Author: Sandy Cairncross; Jeroen Ensink; Tanya Kahawita
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In West Africa cholera has been entrenched since the 1970's. The European Commission's Humanitarian AID Office (ECHO) has been supporting cholera prevention and control measures in Guinea-Bissau and Guinea-Conakry, though International agencies (UNICEF regional offices) and international and local NGO's. In July 2009, the Environmental Health Group at the London School of Hygiene and Tropical Medicine (LSHTM) was asked to evaluate the water, sanitation and hygiene (WASH) interventions that were implemented to prevent and control yearly occurring cholera epidemics.
The evaluation by the LSHTM had three aims: 1) To assess whether the WASH interventions have resulted in an improved understanding of the risk factors and mode of transmission of cholera among the target population, policy makers and those involved in the implementation of the cholera control activities, 2) To assess whether the WASH interventions have resulted in an improvement in water quality, sanitation and hygiene in those households and neighbourhoods affected by the cholera epidemic and 3) To provide recommendations, based on the findings of the field evaluation and a literature review, for the improvement of the current cholera control program.
In order to answer the objectives the LSHTM undertook a systematic literature review on the success and failures of WASH interventions in cholera preparedness and response programs, and during field visits to Guinea-Bissau and Guinea-Conakry conducted interviews with key informants, undertook field investigations and observations at a community levels and in households.
In Guinea-Bissau and Guinea-Conakry different approaches were adopted by the different implementation agencies. In Guinea-Bissau households were informed, and key messages were delivered, predominantly through household visits, while in Guinea-Conakry the predominant mode of message delivery was through health education in local schools. Another strong difference between the programmes in both countries was the mass distribution of soap and bleach in Guinea-Conakry, while this happened only sparsely in Guinea-Bissau.
The absence of any baseline data regarding the prevalence of safe water storage, disinfection and hand washing practices before the interventions in both countries makes it impossible to evaluate whether the interventions have resulted in an improved understanding of cholera risk factors, or improved WASH practices. The evaluation, however, did seem to indicate that the health education classes in Guinea-Conakry were less successful in conveying messages that translated in recommended WASH practices being applied within the household, than the households visits that were part of Guinea-Bissau cholera prevention and control programmes. In addition, although, the mass distribution of sur'eau in Guinea-Conakry did result in the presence of disinfection products in over 60% of visited households, this did not necessarily translate in the presence of free chlorine in household drinking water vessels, as less than 30% of all households were found tohave traces of free chlorine in their drinking. Focus group discussion revealed in both countries that people did understand that chlorine could protect them from cholera and they did know how much chlorine to apply to their drinking water, but also indicated that they would only apply it during the cholera season or when the first cases of cholera were declared within their community.
The study found excellent to good quality drinking water at source, especially in municipal tap water, but also concurrent contamination of drinking water within the household. This combined with the low prevalence of hand washing with soap after defecation suggests that current health education and or door to door household visits are not resulting in a sustainable hygiene behavior change.
The evaluation concluded that the current water supply, sanitation and hygiene situation in both countries facilitates the easy transmission of diarrhoeal disease (including cholera) and in order to fight endemic and epidemic cholera long term planning and investments are needed. The almost exclusive focus on epidemic cholera seems to have created a situation where people will only wash vegetables, or add chlorine to water when the cholera season is upon them, or the first cholera cases are reported. This is likely to be unsustainable and ignores the fact that endemic diarrhoeal disease is on an annual basis responsible for a higher mortality and morbidity than epidemic cholera.
The study therefore recommends the following:
# Strengthen local municipalities and grass root and youth organizations, by providing them with WASH and formative research trainings.
# Conduct baseline surveys before an intervention is to be implemented so that the successes (and failures) of an intervention can be monitored and lessons learn can be applied to future interventions
# Conduct (formative) research before an intervention is planned so that messages and interventions can be tailored to the population at risk
# Cholera prevention and control should be an integrated part of a programme to prevent and control diarrhoeal disease and not stand on its own.
# An increased and equal focus on all cholera transmission pathways, and therefore in the case of Guinea-Bissau and Guinea-Conakry:
o - Increased focus on food quality and safety at local markets/households
# Efforts to improve water availability and reliability (especially in Guinea-Bissau)
# Inclusion of those responsible for water provision (tanker trucks etc) into the cholera working groups in both countries
# Inclusion of staff with experience in implementing WASH interventions in implementation teams
# Identify and target those motivational drivers within the community that can achieve sustainable behaviour change, as health education alone will not bring about a change in behavior!
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