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Safe Water System Manual


10.0
Prepare to implement the behavior change strategy

Tasks:

  • Develop brand name and logo
  • Develop key messages

  • Make detailed plans to implement methods for behavior change
  • Plan training of staff to implement behavior change methods
  • Develop communication materials and training materials
  • List activities and desired outputs (quantities)

  • Arrange use of channels selected
  • Pretest messages and materials
  • Produce and distribute materials
  • Train persons who will implement behavior change methods
  • Plan additional behavior change interventions, if possible

 

Use information from formative research (see 7.1) to develop plans and materials to carry out the behavior change strategy. Effective messages, materials and other behavior change interventions will increase demand, purchase, and use of appropriate water storage vessels and disinfectant. Developing effective materials requires pretesting them with the target audience to find out whether they create the desired effect and revising them accordingly.

Developing an effective behavior change strategy and its components, such as brand name, logo, messages, materials, etc., requires special skills. It is recommended that the project works with specialists to undertake this development. Individuals who have the skills and experience to contribute in this area may be found in HIV/AIDS health education within the MOH, in private firms or advertising companies within the country that have produced effective marketing campaigns, or in NGOs with substantial behavior change activities. In Kenya, for example, CARE hired a marketer who had worked in the private sector. He appreciated the opportunity to apply his skills to a socially useful product.

 

10.1 Develop brand name and logo

Development of the brand name and logo to position the Safe Water System positively for the target population is a very important step. Having a brand name and logo can be very beneficial because it gives people an easy way to identify the products. The best brand names are simple, catchy, and evoke healthy images in the minds of the target population. When the brand name and logo are completed, they should be incorporated in the various promotional and educational materials.

 

10.2 Develop key messages

Use appropriate language, terms and local dialect to ensure that messages are relevant to the audience and can be understood by them. If a new term is needed, it may be necessary to introduce the new term and teach what it means in educational messages. Prepare educational and promotional messages in pictures and words. The pictures should be understandable without the words, so that illiterate people in the target population can also understand the message.

Formative research provides information on:

• local language and terms _ to decide on wording of messages

• current knowledge about diarrhea

• positive perceptions about water disinfection and storage

• negative perceptions and barriers to address in messages

The project must decide which positive perceptions to reinforce and which benefits to emphasize in promotion, according to local circumstances. Some messages may need to address negative perceptions (e.g., about chlorine) or barriers to use of the Safe Water System. Negative messages or warnings tend not to work as well as positive messages. Messages must give information the audience wants and needs but does not know. Promotion can be effective by associating use of the Safe Water System with a status and lifestyle that people aspire to have.

Develop messages that fulfill specific educational and promotional objectives and that are:

• easy to understand _ simple, using appropriate language and local terms

• easy to remember _ simple, conveying only 1 or 2 ideas

• positive — conveying positive benefits of products in a way that encourages use

• specific and action-oriented, not general

• accurate, feasible and relevant

• sensitive to existing cultural beliefs

• attractive and interesting

• conveyed in pictures that can be understood without words (particularly important for messages about how to use products)

The actual messages will depend on findings of the formative research and the behavior change objectives. The box below lists some common messages.

 

Figure 14: Key Messages or Topics for Education and Promotion

Diarrhea

How water is contaminated

• Animal and human feces on the open ground get washed into water sources (surface water, shallow wells)by rain

• Sewage is dumped in surface water sources

• Crossed connections are accidentally made between sewer and water lines

• Cracks or holes in water pipes allow surface contami-nants (animal and human feces) to get into water lines (particularly when there are power outages which shut off pumps and create negative pressure which sucks surface contaminants into the water lines)

• People with fecally-contaminated hands touch water stored in wide-mouthed containers such as buckets

How drinking contaminated water causes diarrhea

• Microbes that cause diarrhea are present in feces. These are ingested when a person drinks contaminated water.

• Microbes are too small to see. Clear water can be very contaminated.

The problem of diarrheal disease in our community

• Use local data that is meaningful, for example, the number of episodes of diarrhea in children under age 5 per month in the community, the percentage of children who die of diarrheal diseases annually

Young children are at particular risk of diarrhea, which can be very severe in infants and toddlers.

You can prevent diarrhea by using the Safe Water System.

Protect your family from diarrhea by using the Safe Water System.

Acquiring vessels and disinfectant
Where to go to get disinfectant and a vessel
Get a safe water storage vessel
What disinfectant is; it is safe
Buy disinfectant and always use it
Prices of the vessel and disinfectant
How long disinfectant lasts in the bottle; when to discard
How to obtain more disinfectant

Treating water
How the intervention works
Disinfectant kills microbes in water within 30 minutes
Storage container keeps new microbes out of water
Cloth filter removes dirt from water so disinfectant is more effective
Allowing water to settle and separating the clear water makes disinfectant stronger.
The correct amount of disinfectant to use in recommended containers.
How to measure and add the correct amount of disinfectant to water
Wait 30 minutes to allow the disinfectant to work and then drink
Always treat water before drinking it, or using it to wash or prepare food

Storing water
Use the vessel correctly to store water and protect it from contamination
Do not put your hands or let anyone else put their hands or utensils into water
Clean the vessel at least once a week

Uses of treated water
Drinking
Washing hands
Washing produce
Cleaning cooking and eating utensils

Storage of disinfectant bottle
Out of reach of children
Indoors, in a dark cool place

Benefits of water treatment and safe storage
Your family, particularly children, will stay healthier and will have less diarrhea if you use disinfectant and a safe water storage vessel.
Shows that you are a better mom
Shows that you are a smart mom
Shows that you are a trend setter

 

10.3 Make detailed plans for implementing the methods for behavior change

Describe the methods selected for behavior change and make detailed plans for each. Plans should include channels and the numbers and types of staff needed to implement the methods. Plan where, when, how often staff will implement the methods, and produce a list or schedule.

For example:

• In both the Central and Northern districts, project will conduct informational meeting for teachers and distribute materials to them by (date). Teachers will do educational activities in the schools at least once weekly.

• Project will distribute promotion and education materials to outlets by (date) in the Central district and (date) in the Northern district. Shopkeepers will do education and promotion on an ongoing basis.

• In the Central district only, house-to-house visitors will be selected, trained in motivational interviewing (specify date, location and trainer), and will make house-to-house visits in their assigned areas according to a schedule developed at their training (to visit each house twice monthly).

• In both districts, posters will be hung in market places and in government offices by (date).

• In the Northern district, a local drama group will be contacted and their help enlisted by (date); local drama group will perform once weekly at market days plus at community mobilization meetings in the towns of Adaba and Cristo on (dates).

• Project will distribute educational and promotional materials to 8 health centers in the Central district by (date) and 4 health centers in the Norther district by (date).

• The project will conduct 4 training sessions for health center staff in the Central district and 2 sessions in the Northern district (specify schedule). Health center staff will teach mothers about the Safe Water System at well-baby clinics each week. Health center staff will teach mothers of children who come with diarrhea about the Safe Water System.

 

10.4 Plan training of staff to implement behavior change methods

Key steps in organizing training in any project are:

• Decide who needs training

• Develop a training curriculum and materials, if not already available

• Identify suitable trainers

• Develop a plan to implement training, and consider whether this training can be integrated into other training activities

 

List the types of staff that will be involved in the project and list the tasks that they should perform. Assess their need for training. Everyone will need to be informed of the tasks that they are expected to do. Some will need further training to provide new skills. Staff will require training for their role in distribution of products as well as their tasks related to behavior change methods. Training may include oral instruction, written instruction, review of reference materials, discussions, demonstrations, practice exercises, and practice on the job.

For effective interpersonal communications, the project must train staff about the Safe Water System and its use, and how to use printed materials. Effectiveness of communications can be greatly increased if staff are trained how to communicate effectively and ensure that messages are understood. For example, a group of community volunteers received training in a behavior change technique known as motivational interviewing (see Annex F for a description of the training). Prior to training, 1% of the target population used disinfectant in their water compared to 2% of a neighboring community. Three months after the community volunteers received training, 78% of the target population had detectable chlorine residuals in their stored water, compared to 4% in the neighboring community.(Quick, unpublished data)

 

10.5 Develop communication materials and training materials

Develop text, artwork and layout for the materials needed. This may include point-of-purchase signs, stickers and cards to identify outlets and sales persons; brochures with instructions on product use and benefits; posters to promote the products and benefits.

Develop video. Video development includes writing a script, filming, editing a film, and adding narration and graphics.

Develop specifications for and list messages that may be included in wall paintings or murals. Then commission community artists to do the paintings.

Write newspaper stories or advertisements.

Design small group activities such as presentations and demonstrations for community meetings, club meetings, etc. This includes writing scripts and instructions, and designing visual aids.

Produce radio spots, including writing scripts, taping a speaker, adding music, and editing.

 

Figure 15: Characteristics of good educational and promotional materials

A good logo

• Simple, not cluttered

• Explicit and not abstract, the audience should understand it immediately

• Related to the key benefits of the Safe Water System, a symbol of the idea

• Positive, uplifting, conveys the idea of results

• Easily reproducible

• Works in different sizes and settings

• Dramatizes the overall tone of the behavior change strategy

 A useful flyer, visual aid or brochure

• Carries the information most likely to be forgotten

• Uses visuals to tell the story, not just words

• Shows people performing key behaviors

• Uses images attractive to the audience

• Concise

• Maintains same tone as overall behavior change strategy

• Organized so that it favors a logical action sequence
• Designed for easy use as a visual aid

• Matches graphic and language skills of specific audience

An effective public poster

• Dramatizes a single idea

• Attracts attention from at least ten meters away

• Uses visuals to carry the message

• Memorable

• Models the behavior whenever possible

• Shows how the product benefits people

• Consistent with tone of overall change strategy

 An effective radio spot

• Presents one idea

• Begins with an attention getter

• Is direct and explicit

• Repeats the key idea at least two or three times

• Asks listeners to take action

• Makes the audience feel part of the situation

• Maintains the same tone as the overall change strategy

 

Training materials may be needed in addition to the educational and promotional materials for the community described above. Training materials should prepare staff to do their specific tasks in the Safe Water System project. For example, shopkeepers may need:

• a description of how they should promote the Safe Water System to customers, including main points to describe

• frequently asked questions and how to answer them

• instructions for keeping records of sales

• instructions for reordering stock of disinfectant and/or vessels.

Training materials may also describe how shopkeepers should display posters and other point-of-purchase materials and suggest how to use the pamphlet when talking with customers.

Training materials are most effective when they are simple and focus just on behaviors that the person is supposed to do.

Some participants in the project will not need written training materials but will be trained by another person. In this case, prepare a trainer's outline of points to address and exercises to do with the group, to show them how and have them practice carrying out their tasks correctly. See Annex I for an example of a plan for a training session.

 

10.6 List the activities related to behavior change and desired outputs (quantities)

List the activities and outputs (quantities) that the project plans to achieve. These should be main activities and level of effort required to achieve the objectives specified in step 2.0. See an example in Figure 16.

 

Figure 16: Sales and Behavior Change Activities to Lead to Achievement of the Objectives

(This example is for illustration only. Actual implementation plans will be much more detailed.)

To achieve the following project objectives:

1.1 - Sell 20,000 bottles of disinfectant in first 3 months

1.2 - Sell 1,000 water storage vessels in first 3 months

2.1 - 70% of target population will recognize the brand name of the Safe Water System products (vessel and disinfectant) after 6 months

2.2 - 30% of households will report use of approved water storage vessel and disinfectant after 6 months

2.3 - 25% of households will have knowledge of correct dose of disinfectant after 6 months

2.4 - 25% of households will have observed safe water storage practices after 6 months

2.5 - 10% of households will have measurable residual free chlorine levels >0.2 mg/liter after 6 months.

2.6 - 10% of households will have no detectable E. coli colonies in stored water

The project will implement the following activities:

Production and Sales

1. Produce 1500 liters of solution per month

2. Produce 100% of batches of solution with hypochlorite concentration >0.5%

3. Train 30 community-based distributors (such as community volunteers)

4. Place disinfectant and vessels in 60 retail shops and demonstrate consistent supply

5. Place disinfectant or vessels in 10 health facilities

Education and promotion

6. Design and produce 20,000 information brochures

7. Hold informational meeting in 10 communities per month

8. Train 10 community health workers to deliver education methods per day

9. Design and broadcast one advertisement on the radio 3 times per day

10. Conduct educational event in 4 schools per month

11. Produce video and show it to 3 communities per week

12. Observe health facility staff providing education to mothers once per week

Community mobilization

13. Establish neighborhood committees in 3 communities in first 3 months

14. Have 3 committees work through participatory process in 3 months

15. Have 3 communities organize themselves for the project in first 3 months

Motivational interviewing

16. Train 10 trainers in first 3 months

17. Each trainer trains 5 additional trainers in 3 months

18. Each of 50 trainers trains 10 volunteers in 3 months

19. Each volunteer conducts motivational interviewing intervention in 10 community households in 3 month period

 

 

10.7 Arrange use of channels selected

Arrange use of channels as planned in step 7.5.

Seek radio time that may be donated by government stations or purchased time from commercial stations. Arrange for air time on stations that the target audience listens to and schedule broadcasts at times the target audience listens.

Arrange for use of a video projection truck. Schedule where and when the truck will visit different communities, markets, businesses, etc.

Arrange with the local newspaper to print advertisements or notices on certain dates.

Arrange for interpersonal communications through health staff, shop keepers, sales persons. This includes distributing materials to them and training them how to communicate the messages (see 10.10 below).

 

10.8 Pretest messages and materials

It is essential to pretest messages and materials with members of the community to be sure they convey the message clearly and have the positive effect intended. Pretest pictures as well as words to be used in promotional messages. Pretesting can avoid expensive and time-consuming mistakes.

Pretesting can be done through in-depth interviews or focus group discussions with a sample of the target audience. It is important that the interviewers listen carefully to the participants' impressions of the materials and NOT tell them what the messages are. If the participants do not understand something, the interviewer should record that and not explain until the interview or focus group is over. This method enables an unbiased assessment of how well the materials convey the intended message. Pretesting should check the following:

Presentation: Do people like the words and pictures?

Attention: Does the message hold the audience's attention?

Comprehension: Does the audience understand the intended messages and products?

Personal relevance: Does the audience perceive the messages to be made for them or made for other people?

Believability: Does the audience perceive the message and its source to be credible?

Acceptability: Is anything (words, pictures, implications) offensive or culturally inappropriate?

Frequently the same material is presented in two or more formats, so that people can choose the one they prefer. Arrange to actually observe people using the materials or products. For example, if a brochure teaches how to add the disinfectant to water, it is best to ask women to actually perform these tasks, using instructions in the brochure. In this way one can observe whether women can actually follow the instructions.

Based on feedback from pretesting, revise the messages and materials. Revision may involve changing text or illustrations, eliminating a particular element such as distracting sound effects in a radio spot, combining parts of two different materials, or actually beginning from scratch with a new idea made evident by the tests. Pretest again with a sample of the target audience to see that the modifications have improved the materials in terms of the audience's comprehension and other criteria listed above. If new materials are developed, they should be pretested before being produced in final form.

In Madagascar, for example, the original draft of an instructional brochure showed a close up of a hand holding a cap of disinfectant and pouring it into a bucket. Mothers were confused by the brochure and could not understand the picture. When this picture was replaced by a drawing of a woman holding and pouring the capful of solution, understanding improved. Also, in this draft brochure, the different steps of treatment were numbered. Step 3 showed the woman pouring a half capful, the recommended dosage, into her container. Several people, when referring to the brochure, poured 3 half capfuls into their containers, mistakenly

interpreting the number 3 as the number of capfuls to use. This problem was corrected by using arrows to point from one step to the next, rather than numbers.

 

10.9 Produce and distribute materials

Estimate the number of copies of different materials needed for distribution to the target population (e.g., brochures, point-of-

purchase displays, posters, videos). Print the needed quantities and distribute them to health facilities and other outlets, health staff, marketing staff, organizations such as neighborhood health committees, and warehouses that will resupply outlets. Also provide sufficient quantities for training sessions.

 

10.10 Train persons who will implement the behavior change methods

To prepare for implementation of the educational and promotional activities:

• Train health staff to use educational materials to teach the target population about products and behaviors.

• Train pharmacists, shopkeepers, volunteers and other persons who will sell products about the messages to tell customers, use of sales brochures and other point-of-purchase materials, procedures for managing money from sales, and procedures for restocking supplies.

• Hire and train promotional workers (e.g., communicators, video projection truck drivers) how to communicate messages, and how to answer likely questions from families.

• If plans include use of motivational interviewing, train the selected staff in those skills (see Annex F).

Training should include information, examples and practice. The trainer should:

• describe the task and give necessary information about it such as tools and supplies needed, when to perform it, and main steps.

• demonstrate himself or show the learners an example of someone doing the task correctly.

• ask the learners to practice the task (or part of the task) so that they gain experience.

• watch carefully and give additional help as needed until every learner can perform the task. People learn better and remember longer how to do a task that they actually perform, as opposed to only hearing about it or seeing someone else perform it.

 

10.11 Plan additional behavior change interventions, if possible

Consider planning additional methods to increase demand for products and behavior change, if possible. Below are some methods used in Safe Water System projects so far:

• use of volunteers for door-to-door sales (Zambia)

• payment of commissions/incentives for sales (Zambia)

• home visits by health workers to reinforce messages (Pakistan, Madagascar, Kenya, Zambia)

• use of Safe Water System in schools to teach school children (Equador, Bolivia)

• branded items such as drinking glasses, cups, t-shirts, stickers and pens to promote awareness of water system project-approved vessels and disinfectant solution.

 

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National Center for Infectious Diseases
Division of Bacterial and Mycotic Diseases
Foodborne and Diarrheal Diseases Branch

 

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