BCC in Emergencies, A Toolkit

BEHAVIOUR CHANGE COMMUNICATION
IN EMERGENCIES: A TOOLKIT
For every child

Health, Education, Equality, Protection
ADVANCE HUMANITY
Cover Photo: UNICEF/HQ/Jeremy Horner
MALDIVES: Rizuana, 11 years old, is among 352 people who lost their homes in
the 26 December 2004 tsunami disaster and are living in a temporary camp for
the displaced in Male, the capital.
© United Nations Children’s Fund

Regional Office for South Asia (UNICEF ROSA), 2006
Parts of this publication may be reproduced or quoted without permission

provided proper attibution and due credit is given to UNICEF ROSA.
ISBN: 99946-896-1-4
For further information and copies, please contact

Regional Programme Communication Advisor
UNICEF Regional Office for South Asia (ROSA)
P.O. Box 5815, Lekhnath Marg
Kathmandu, Nepal
Email: [email protected]
Credits:
Overall technical direction, supervision and substantative editing:
Teresa H. Stuart, Regional Programme Communication Advisor, UNICEF ROSA.
Concept development, field research, co-writer and coordination:

Ulrike Gilbert, Programme Communication Officer, UNICEF ROSA.
Writer and researcher:

Lisa Nicole Woods, Independent Consultant.
Designed & Processed by: WordScape, 5520755
Printed in Nepal
Contents
PART ONE
OVERVIEW
CHAPTER ONE
Introduction 3
CHAPTER TWO
Natural disasters in South Asia 15
CHAPTER THREE
Behaviour change communication in emergencies 27
PART TWO
PROGRAMMATIC AREAS
CHAPTER FOUR
Hygiene promotion 55
CHAPTER FIVE
Promoting breastfeeding 79
CHAPTER SIX
Promoting measles vaccination and vitamin A supplements 101
CHAPTER SEVEN
Promoting safe motherhood 123
CHAPTER EIGHT
Supporting child protection and psychosocial recovery 141

P A R T T HREE
TOOLS
TOOL 1
How to develop SMART behavioural objectives / results 167

TOOL 2
How to develop indicators based on behavioural results 171

TOOL 3
Most significant change technique 189

TOOL 4
Gender checklist 195

TOOL 5
How to conduct a key informant interview 197

TOOL 6
How to use a pocket or voting chart 201

TOOL 7
How to do a ranking exercise 205

TOOL 8
How to facilitate participatory exercises 209

TOOL 9
Monitoring chart 213

TOOL 10
Structured observation checklist for communication skills 215

TOOL 11
Tasks of men and women in the community 217

TOOL 12
A 12- point communication monitoring checklist 219

TOOL 13
Tools to monitor the milestones 221

TOOL 14
How to design a radio spot 231

TOOL 15
How to design print materials 233

TOOL 16
Principles and guidelines for ethical reporting on

children and young people under 18 235
v
FOREWORD
South Asia is a region that is frequently visited by natural disasters - floods,
earthquakes, droughts, tsunamis and other natural phenomena. These have resulted
in large scale loss of lives, devastation and humanitarian crises. This tragic reality
impels us to be better prepared in disaster and risk communication, an area that has
often been neglected in emergencies. Communication preparedness when a
disaster strikes allows us to proactively assist as well as mobilise partner agencies,
families and communities in mitigating the impact of such natural disaster.
Preparing and responding successfully to emergencies require that evidence-based

behaviour change communication strategies become an integral part of emergency
preparedness plans and training. Our communication efforts will result in improved
health, hygiene, protective and caring practices. It will also lead to positive collective
action and informed demand among affected communities for emergency assistance,
supplies and services. All these actions are crucial in protecting and promoting the
well-being of children, women and their families when a disaster strikes.
Experience has shown that affected members of communities can become

effective agents of behaviour change and mobilisers for disaster preparedness and
response. We emphasise the participation of adults, children and young people in
recovery, relief and rehabilitation as integral to any strategic communication action
plan. Participation has proven to promote psychosocial healing and cohesion
among affected community members during times of crises. That affected
communities are too shocked or helpless to take responsibilities for their own
survival and recovery has proven to be a myth. On the contrary, many affected
people, especially the children, find healing and strength and are therefore able to
return to normalcy faster when they participate in helping others during and after an
emergency. This has been proven for example, by the many inspiring stories
shared by both children and adults who were affected by natural disasters in 2004
and 2005 like the tsunami that hit India, the Maldives and Sri Lanka, the floods in
Bangladesh and India, and the earthquake that hit northern India and Pakistan.
We extend our gratitude to the many partners and colleagues who contributed their
time, expertise and experiences into the preparation of this Toolkit. UNICEF ROSA
is pleased to share this Toolkit and invites you to use the many resources it makes
available to guide you in training staff and partners as well as in planning,
implementing and monitoring behaviour change communication that supports
hygiene, health and child protection goals in emergency situations in South Asia.
Cecilia Lotse
Regional Director, UNICEF Regional Office for South Asia
vi IN EMERGENCIES: A TOOLKIT
ACKNOWLEDGEMENTS
We are grateful to the following reviewers for their detailed technical inputs and for
suggesting additional materials, in alphabetical order: Madhavi Ariyabandu, Dr
Benjamin Lozare, Dr Will Parks, Professor Guy Scandlen, Professor Arvind Singhal
and Dr Siraporn Sawasdivorn.
We thank colleagues from UNICEF ROSA who reviewed the drafts and contributed
critical inputs to specific chapters: Bhavna Adatia (psychosocial development),
William Fellows (hygiene promotion), Ian Macleod and Myo Zin Nyunt (HIV/AIDS),
Satish Raj Pandey (safe motherhood and breastfeeding), Serap Maktav and Adele
Khudr (child protection), Soma de Silva (monitoring and evaluation) and Anthony
Raby (emergency planning). Lalita Gurung’s administrative assistance is also
gratefully acknowledged.
We are thankful to Rina Gill at UNICEF NYHQ and colleagues in country offices in
South Asia for their critical comments and suggestions, sharing of experiences,
case studies or reviewing chapters and providing photos: Surangani Abeyesekera,
Susan Aitkin, Geetha Athreya, Judith Borne, Lizette Burgers, Arputhasamy
Devaraj, Paul Deverill, Gopinath Durairajan, Michael Galway, Judith Graeff, Jude
Henriques, Abul Kalam, Alka Malhotra, Suleman Malik, Mirwais Masood, Vinod
Menon, Bo Viktor Nylund, Sharad Ranjit, Sheema Sengupta, Siddhartha Shrestha
and Sinnathamby Vijayapala.
Notwithstanding the extensive and valuable contributions of the above-named

people, UNICEF ROSA assumes full responsibility for any errors or omissions.
Thanks are also due to the UNICEF Division of Communication at New York
Headquarters for providing photographs from the three tsunami affected countries in
South Asia and to Susan Mackay at the East Asia Pacific Regional Office for
collaboration and sharing of a parallel initiative, the CREATE! Toolbox.
Our deepest gratitude goes to the relief workers, service providers, government and
NGO partners and to the many women, men and children who were affected by the
Indian Ocean tsunami on 26 December 2004 for sharing their knowledge, insights
and time with us. This publication is dedicated to those people in South Asia who
lost their lives in emergencies.
UNICEF ROSA gratefully acknowledges the funding provided by the Japanese

Government for the development and printing of this Toolkit and the accompanying
CD ROM.
© UNICEF/ HQ05-0264/Giacomo Pirozzi
CHAPTER- 1
INTRODUCTION
4 IN EMERGENCIES: A TOOLKIT
CHAPTER- 1
INTRODUCTION
INTRODUCTION
WHAT IS IN THE TOOLKIT?
PART I: OVERVIEW
PART II: PROGRAMMATIC AREAS
PART III: TOOLS
WHY WAS THIS TOOLKIT DEVELOPED?
WHO IS THE TOOLKIT FOR?
HOW WAS THE TOOLKIT DEVELOPED?
HOW TO USE THIS TOOLKIT

IN EMERGENCIES: A TOOLKIT 5
INTRODUCTION
INTRODUCTION
This toolkit is a resource for everyone working in emergency situations
caused by natural disasters. It is designed to help programme
managers from UNICEF,
© Shehzad Noorani/UNICEF
UN agencies, NGO
partners and government
personnel to prepare, plan,
implement and monitor
behaviour change
communication initiatives
supporting health, hygiene
and child protection efforts
in emergencies. BANGLADESH: A boy and a girl child carrying her young sibling walk across a
flooded village road in Mymensing.
The toolkit stresses the importance of participation and consultation with affected
individuals, particularly children and young people. Complementary to this toolkit,
UNICEF ROSA has developed an Education in Emergencies Training Package
intended for UNICEF education programme officers at all levels - region, country
and headquarters.
Behaviour change communication (BCC) in emergencies is a consultative process

among communication specialists, technical experts, local change agents and
communities. It addresses the knowledge, attitudes and practices of individuals,
families and communities. It aims to share relevant and action-oriented information
and to motivate programme specialists to work with communication specialists in
preparing strategic communication for disasters - so that if a disaster strikes,
people in affected communities would know what actions to take to maintain and
protect their health and well-being as well as how and where to access emergency
services and supplies. BCC should be planned in close cooperation with a given
programme as an integral part of an emergency preparedness and response plan.
BCC is grounded on the human-rights based and results-based approach to

programme planning and development. It is geared towards facilitating community
mobilisation and participation in preparing and responding to disasters. That

affected communities are too shocked and helpless to take responsibilities for their
own survival has been proven to be a myth. On the contrary, many affected
people, especially children, experience psychosocial healing and are able to return
to normalcy faster when they participate in helping others during and after an
emergency.
WHAT IS IN THE TOOLKIT?

© UNICEF Bhutan
You do not have to be a

communication expert
to use this toolkit. But
you should be ready to
use participatory
approaches which are
proven to influence
people to make
informed decisions,
take action and adopt
positive behaviours.
The toolkit has three parts: an overview section, several programmatic chapters and
many practical tools to plan, implement and monitor a BCC initiative for
emergencies. If you require more technical background information on the different
programmatic areas, please refer to UNICEF’s Emergency Field Handbook or
UNICEF’s Technical Notes: Special Considerations for Programming In Unstable
Situations, or see some of the other literature recommended in the Further Reading
section of the Resource Bank offered at the end of each programmatic chapter.
Part I: Overview
In the overview you will find three chapters. The first maps out the toolkit and will
guide you on your journey to planning an effective behaviour change communication
initiative for an emergency. Chapter 2 introduces you to the rationale for the toolkit
– the abundance of natural disasters in South Asia. You will find some of the most
common emergency situations in South Asia; the direct and indirect humanitarian
consequences on the affected community, the risk factors that emergencies cause on
health and nutrition, hygiene, sanitation and water supply, immunization and vitamin A,
breastfeeding, safe motherhood and child protection. Chapter 3 introduces UNICEF’s
INTRODUCTION
Core Commitments for Children in Emergencies (CCC) – the overarching organisational
framework for UNICEF’s humanitarian response. Finally, you will review the definition
and rationale for behaviour change communication (BCC) in emergency situations; and
principles and action points on how to plan a BCC initiative.
Part II: Programmatic areas

This section has chapters that focus on the following essential programmatic areas
in emergencies:
n Hygiene promotion.
n Promoting measles vaccination and vitamin A supplementation.
n Promoting breastfeeding.
n Promoting safe motherhood.
n Supporting child protection and psychosocial development.
We selected these programmatic areas based on UNICEF's Core Commitments for

Children in Emergencies (CCC). We designed this kit as a starting point for
planning behaviour change communication initiatives for emergencies. You can
apply the basic principles and processes presented in this toolkit to other
programmatic areas in the CCC that are not included in this volume.
The programmatic chapters follow a standard format that offers information on:
n Essentials about the subject

This section provides you a snapshot of the programmatic area, explains the
importance of, for example, hygiene or breastfeeding promotion during
emergencies, and offers some key definitions of terms and concepts. For more
detailed guidance on technical matters, consult UNICEF's Technical Notes: Special
Considerations for Programming in Unstable Situations, UNICEF's Emergency
Field Handbook and other relevant technical guidelines.
n Principles in promoting the subject

This section outlines the core principles in your communication to help you
promote the humanitarian/programmatic area at hand. These principles are derived
from good communication practices and lessons learned in emergencies. In some
topics such as hygiene promotion, there are firmly established tenets for behaviour
change communication. In other areas, the kit offers general principles to fit the
specific issue. These principles are by no means exhaustive - rather, it offers
programme planners and managers like you a foundation for your communication
initiative. Over time and with accumulation of more evidence, you may review and
adapt these principles.
n Doing the groundwork

Formative research, communication analyses and drawing from standard surveys
and rapid assessments are your core elements in the ground work phase. This
should ideally take place as part of emergency preparedness. We selected a few
tools to help you with the communication-related groundwork. You can find more
tools to plan a communication initiative in Part III. Some chapters, e.g., hygiene
promotion, provide sample behavioural results. However, since the development of
your behavioural result(s) depends on the cultural and emergency context as well
as on set priorities and capacities of the affected communities, we have provided a
generic tool in Part III on how to develop behavioural results.
n Getting the message right

This section outlines key messages which you should share quickly in an emergency
situation with different audiences - caregivers, service providers, community leaders,
etc. We referred to Facts for Life in identifying key messages for most of the chapters
in this toolkit. You will need to tailor and test the generic messages to the specific
context and audience. It is essential for you to involve caregivers, communities, service
providers, children and youth and other critical groups in message development,
dissemination and feedback gathering across all programmatic areas.
© UNICEF/HQ05-0216/Tom Pietrasik
SRI LANKA: (Left-right) Grade 2 students

Vidhurshan Amurthan and Prabin
Arulanatham draw and colour in a class in
Thampaddai Government School in the
eastern district of Ampara. The boys'
crayons and the plastic bag bearing the
UNICEF logo that is on their desk are from
a recently arrived shipment of school-in-a-
box supplies. Classes are now being held
in temporary structures set up next to the
Thampaddai Thidal Camp for people
displaced by the tsunami disaster.
The school, whose students are from the
Tamil community, has been at this site
since 20 January 2005. Their original
school, located less than 40 metres from
the sea, was destroyed during the disaster.
UNICEF is also supporting psychosocial
activities, including art therapy for
traumatized children in schools and
camps.
n Communication actions to promote the subject

This section outlines UNICEF’s Core Commitments for Children in Emergencies in
different programmatic areas. We included suggested behaviour change
communication and social mobilisation activities that have proven to be effective
from past experience. You will need to develop the specific communication actions
in partnership and collaboration with relevant government bodies, UN partner
agencies, NGOs, other partners and the affected communities.
INTRODUCTION
n Monitoring milestnes
This section outlines suggested indicators to measure and track if the communication
efforts are contributing to behavioural changes. The final choice of your indicators will
depend on the choice of the behavioural results you want people to manifest.
n Practical examples
This section provides practical experiences from behaviour change communication
and social mobilisation efforts in previous emergencies from South Asian countries
and from other parts of the world.
n Resource bank
This section offers information resources for your further reading, related web sites
you can visit and a short glossary explaining the main terms and concepts.
PART III: TOOLS

This section provides several tools
© UNICEF Pakistan
that are meant to help with the range

of communication planning, rapid
assessment and monitoring activities
that you may need to undertake for an
emergency response. Some tools
may come in handy as guides for
developing print materials, radio
spots, information on ethical issues
and more. The tools are divided into
three sections: planning, assessment
PAKISTAN: A young boy helps his older sister carry a pail
of water to their tent in one of the camps for families and monitoring, and materials
affected by the South Asia earthquake on 8 October 2005.
development.
WHY WAS THIS

TOOLKIT DEVELOPED?
Many communication
efforts launched in
emergency responses,
such as those following
the 26 December 2004
tsunami, tend to focus
on media advocacy and
MALDIVES: At the start of the new school year, boys stand in a queue at the UNICEF- public information.
assisted Qatar School on Gan Island in Laamu Atoll, some 265 kilometres south of
Male, the capital. The school is also receiving children who have been displaced from
nearby Mundoo Island because of the tsunami.
Such communication efforts cater to policy makers, donors and the general public
and are designed for advocacy, fund-raising and public awareness of the general
situation. While this type of communication is indispensable, it is only one
component of a communication response: a holistic communication strategy in an
emergency must cater as much to the communication needs of affected families
through interactive behaviour change communication and social mobilisation.
Behaviour change communication is not a luxury in emergency situations, it is
necessary and urgent for it ensures that the most vulnerable – the children and
women and their families - have access to accurate and instrumental information
about proper practices, available services and supplies that provide sustenance,
prevent disease, harm, abuse and exploitation.
While a tenet of communication is to provide information, past experiences show

that information alone is insufficient to support behaviour change. Influencing
healthy behaviours and creating a supportive social environment in an emergency
situation requires that we stimulate an appetite for learning and participation
through regular dialogue with the affected community, far beyond the initial
response. This type of behaviour change communication and social mobilisation
will work when actions, messages and materials are strategically planned,
managed, monitored with the affected communities – and supported by the
necessary financial and human resources.
We have learned many lessons from the emergency response to the 26 December
2004 tsunami and other natural disasters in South Asia. And we have many
proven strategies and tools to support behaviour change communication and social
INTRODUCTION
mobilisation efforts that can be applied during emergencies. We developed this
toolkit to bridge this critical gap between knowledge and action. We hope that this
toolkit will be a useful resource that would further translate our knowledge and past
experiences into results-oriented communication actions, by allowing us to better
plan, implement and monitor behaviour change communication in emergencies.
WHO IS THE
© UNICEF/ HQ05-0032/Jeremy Horner
TOOLKIT FOR?
This toolkit is developed for
programme managers from
UNICEF, other UN agencies,
government and NGO partners
and humanitarian
organisations who prepare
and respond to natural
disasters in South Asia.
SRI LANKA: A girl washes dishes with other children at a temporary

water point at Al-Arham Vidyalaya School in the Addalaichenai area in
the eastern district of Ampara. The school, whose students are from a
Muslim fishing community, has been relocated to a temporary structure
on rented land. The original school, located less than 40 metres from
the sea, was completely destroyed by the tsunami. Two of its 350
students were killed during the disaster, and 80 percent of the children's
homes were damaged or destroyed. Many of the students have been
traumatized and are afraid to return to the original school site. UNICEF
has provided the materials for a temporary school building, as well as
12 school-in-a-box kits.
We also hope that programme managers in Southeast Asia, Africa, Europe and the
Americas can use or adapt the information in this toolkit, as a complement to their
respective communication initiatives addressed to and involving families and
communities affected by natural disasters.
© UNICEF/ HQ05-0033/Jeremy Horner

HOW WAS THE
TOOLKIT DEVELOPED?
From early May until the end of June
2005, UNICEF ROSA went on several
visits to India Sri Lanka and the Maldives
as part of the regional documentation of
the tsunami response.
MALDIVES: Children and women, formerly displaced,
return to their homes on the island of Diffushi one week
after the tsunami disaster.
In India, site visits were conducted in camps, temporary schools, health centres
and scores of affected communities, including in Nagapattinam, one of the worst
affected districts in Tamil Nadu. Affected caregivers, service providers, community
volunteers, government officials, UNICEF staff and others were interviewed on
behaviour change communication and social mobilization initiatives in various
programmatic areas. In Sri Lanka, service providers, caregivers, community
leaders, government officials, UNICEF staff and other partners were interviewed in
Ampara district and Colombo.
Literature review
Following the country visits, UNICEF ROSA conducted a review of the literature,
including lessons learned, good practices and available monitoring tools. This
process included reviewing current emergency preparedness and response plans of
UNICEF offices in South Asia – and examining how behaviour change
communication and social mobilisation efforts are planned for disasters.
Technical review
We invited a number of international experts in communication and disaster
management to review and provide feedback on the draft toolkit. In addition,
colleagues from UNICEF country offices and the Regional Office for South Asia
reviewed, critiqued and contributed materials for the toolkit.
HOW TO USE THIS TOOLKIT
INTRODUCTION
This toolkit aims to generate ideas and provide some stepping
stones for programmers to get started in planning, managing and
monitoring behaviour change communication for emergencies.
We realize that during an emergency, you do not have the luxury of time to pour
over voluminous material, nor to follow long procedures. You can go through a
selected programmatic chapter separately, according to your priority or area of
interest, and apply only those areas that you deem practical and useful
according to your circumstances.
For example, if your interest lies in Safe Motherhood, you can turn to Chapter 7
and look for what you need without working your way through the other chapters
of the toolkit. However, there are obvious advantages to reading each chapter as
humanitarian issues are cross-cutting and ideas from one programmatic area
can be useful for the others.
PAKISTAN: Boys scouts assist in distributing communication materials bearing hygiene

messages to children and their families displaced by the 2005 South Asia earthquake.
© UNICEF Pakistan
The UNICEF East Asia and Pacific Regional Office (UNICEF EAPRO) produced a
parallel initiative called CREATE!, a DVD collection (“toolbox”) of ready-to-use or
easy to adapt communication materials for emergencies with sample messages on
various programmatic areas, including avian flu.
As you develop the strategic communication plan and implementation protocol for
an emergency using this toolkit as a guide, you can then match the messages
using adapted or modified images and other materials from the CREATE! toolbox to
fit your audience’s socio-cultural and physical contexts.
© UNICEF/ HQ05-0071/Pallava Bagla
CHAPTER- 2
NATURAL DISASTERS
IN SOUTH ASIA
CHAPTER- 2
NATURAL DISASTERS IN SOUTH ASIA

INTRODUCTION
FLOODS
EARTHQUAKES
DROUGHT
CYCLONES, HURRICANES AND TYPHOONS
EXTREME TEMPERATURES
TSUNAMI
RESOURCE BANK
INTRODUCTION
Earthquakes, floods, droughts,

and cyclones are some of the
© : UNICEF/ HQ04-0885/Shehzad Noorani
natural disasters that frequently
NATURAL DISASTERS
IN SOUTH ASIA
strike countries in South Asia,
causing large scale devastation
that affect millions of people.
SRI LANKA: Minhaz Haque, 15, stands in his neighbourhood, now destroyed by the tsunami disaster, in the village of Maruthamunai in the
eastern district of Ampara. Many of Minhaz' friends are missing and his family house is gone. When the tsunami stuck - Sunday, 26 December
2004, when schools were closed - Minhaz was fitting tiles on a roof. He clung to the roof as the water rose, but the house collapsed from under
him. He grabbed first a tree, then a refrigerator that was floating by, then managed to find shelter on the roof of another building. When the water
receded, Minhaz found that his family - both his parents and five siblings - had survived and are now living in a relief centre.
The graph on the Disasters in South Asia byType ( between 2000 - 2005 )
30
right shows the
Drought
number of natural Earthquake
25 Extreme Temperature
disasters by type in Flood
Slides
Wave/Surge
South Asia countries 20 wild Fires
Wind Storm
from 2000 to 2005.
Number of Disasters
15
Natural disasters are

commonly 10
differentiated as
5
rapid-onset
disasters such as
0
storm surges and Source: “EM-DAT: The OFDA/CRED International Disaster Database, www.em-dat.net - Université
earthquakes. These Catholique de Louvain - Brussels - Belgium”, Created on: Nov-8-2005. - Data version: v05.10
calamities can cause

immediate loss and disruption. The other type is called slow-onset disasters
such as droughts. Both types impact on members of the affected community in
many different ways and with varying degrees. This is expressed in terms of
vulnerability – the people’s potential to suffer from harm or loss. Communities
may differ in their vulnerability depending on their location (e.g. shoreline or
proximity to geologic fault lines), stage of development and other characteristics.
Emergency plans may therefore differ accordingly from community to community.
MALDIVES: (Left-
right) Jaushan, 3, and
Shabab, 14, look out
to sea from their seat
on a fallen tree,
amidst flotsam from
the tsunami that has
washed onto the
beach, on Meedhoo
Island in Dhaalu
Atoll, some 145
kilometres south of
Male, the capital.
Emergencies call for a range of responses to effectively assist affected families and
communities to prepare — and recover. These responses include research-based
and experience-based communication activities that enable communities to
prepare for emergencies, avoid risks and create an informed demand for urgently
needed supplies and services and their proper use.
When you plan behaviour change communication (BCC) for emergencies, be sure
to tap on local knowledge and religious practices. Design messages with the
community including children and youth. This way, you are sure that the
messages, materials and methods of dissemination, whether interpersonal, group
or mediated, are socio-culturally acceptable. Closely coordinate with the technical,
service and supply components of the larger emergency plan and the humanitarian
response. This means that you need to work with partners in mobilising
communities with the essential elements of a BCC and social mobilisation initiative
as a way of preparing for or responding to the a disaster.
Below is a brief overview of the frequent natural disasters in South Asia countries
and their common consequences.1 Remember that for all these disasters, the
consequences on children, women, the physically challenged and other
marginalised groups, are likely to be more severe. This is why we must not just
mobilise communities to respond to emergencies, but to educate them on how and
what to prepare for in order to mitigate injuries, suffering and deaths.
©UNICEF/Bangladesh/A.K.M. Mohsin
2
FLOODS
Floods routinely occur in South
Asia leaving thousands displaced
and disrupt public, educational and
health systems. The severity of a
NATURAL DISASTERS
flood depends on the depth and
IN SOUTH ASIA
speed of water, duration, rate of
rise, frequency and season. Floods
are categorised as sudden onset
phenomena and have the following
main classifications:
BANGLADESH: A woman walks with her children through
floodwater looking for shelter in Kamrangir Char, Dhaka, 2004.
n Flash floods
n River floods (mostly seasonal)
n Coastal floods, associated with tropical cyclones, tsunami or storm surges
n Urban floods
Humanitarian consequences
The consequences of floods are felt in the water and sanitation sector because
of disruptions to the water supply and sanitation infrastructure. Water pipes and
tube wells are blocked. Accessible water is commonly contaminated and pose
serious health hazards caused by debris, toxic wastes, chemicals, raw
sewage, or even decomposing bodies of animals and humans. Toilets and
latrines are destroyed. Thus, defecating and bathing in toilets become
unsanitary. Cooking becomes very difficult.
Outcomes can include:

n Drowning
n Grave scarcity of potable water
n Waterborne and vector transmitted diseases
n Hepatitis
n Worm infestation
n Eye and ear infections
n Scabies and other skin infections

n Electroshocks
n Injuries like lacerations or punctures
n Interruption of basic public health services
n Food shortages
n Loss of livelihood and unemployment
n Loan burden is aggravated
n Homelessness/displacement
n Damage to infrastructure, power supply, roads, telecom, and airports
n Disruption of education systems
n Loss of property and support systems
n Negative psychosocial effects on children
n Increased risk of mine injury resulting from movement of landmines by floods
and mudslides
n Separation of children from their primary caregivers
n Increased risk of sexual abuse and exploitation.
© UNICEF Pakistan
EARTHQUAKES
Earthquakes can be defined as the
shaking of the earth, caused by the
movement of waves on and below
the earth's surface. This causes
surface faulting, tremors vibration,
liquefaction, landslides, aftershocks
and/or tsunamis.3 South Asia is
prone to earthquakes as many
countries in the region are situated
PAKISTAN: A school that was damaged by the South Asia earthquake.
on or along fault lines, or are in the
seismic range of earthquakes.
The consequences of an earthquake can vary tremendously, from near-total
devastation of infrastructure in a heavily populated area, to limited destruction of
areas that are sparsely inhabited. Strong underwater earthquakes can cause major
movement of water masses, or tsunamis.

n Internal injuries, crush syndrome and death
NATURAL DISASTERS
n Asphyxia
IN SOUTH ASIA
n Trauma
n Dust inhalation (acute respiratory distress)
n Exposure to the environment (i.e. hypothermia)
n Minor cuts and bruises, fractures
n Burns and electroshocks
n Disruption of food and water supply
n Interruption in basic health care services
n Damage to water and sewer systems
n Diarrhoea and cholera outbreaks
n Homelessness/displacement
n Increased number of children separated from primary caregivers
n Increased risk of sexual abuse and exploitation
n Damage to infrastructure energy lines, roads, telecom, and airports
n Isolation and physical inaccessibility to relief supply sources
n Disruption of education systems
DROUGHT
Drought is a prolonged dry period in a natural climate cycle. It is
a slow-onset disaster caused by too little rainfall combined with
other predisposing factors. Drought leads to water and food
shortages and is likely to have long-term environmental,
economic and health impacts.
Drought can often be anticipated and commonly requires an immediate, long-term
and well-coordinated response. Although warning is possible, a sudden movement
of people to an extremely dry or drought-affected area (because of unrest, conflicts
or other natural disasters) can have great consequences on the health and nutrition
of small children.
Consequences can include:

n Lack of potable household water and agricultural water supply
n Damage to crops and disruption of agriculture-based livelihoods
n Reduced food intake and lack of varied diet
n Protein-energy malnutrition
n Micronutrient deficiency such as iron, vitamin A and C
n Communicable diseases
n Lack of hygiene and sanitation facilities
n Cholera, typhoid fever, diarrhoea
n Acute respiratory infections
n Migration
n Erosion of coping and caring capacities of caregivers
CYCLONES, HURRICANES AND TYPHOONS

Tropical cyclones are among the most
© Farjana Khan/AFP/UNICEF
destructive and fearful natural phenomena.

The impact from cyclones extends over a
wide area, with strong winds and heavy
rains. However, the greatest damage to
life and property is not from the wind, but
from secondary events such as storm
surges, flooding, landslides and
tornadoes. Drowning and catching water
BANGLADESH: Girls traveling by
makeshift raft in the outskirts of Dhaka, 2004
borne and vector-borne diseases
increases if the cyclone is accompanied
by floods and sea surges.4
Humanitarian consequences of cyclones, hurricanes and typhoons can vary
considerably, and relief responses are similar to those for earthquakes and floods.
In most cases, priority is given to health, water and sanitation interventions to avoid
the risk of epidemics, contamination, pollution and disruption of the public distribu-
tion systems.
Outcomes can include

n Trauma
NATURAL DISASTERS
n Injuries and death
IN SOUTH ASIA
n Asphyxiation due to entrapment
n Electroshocks or drowning
n Short and long term mental health effects
n Water borne and vector transmitted diseases
n Damage to health infrastructures and lifeline systems
n Food shortages and interruption of basic public health services
n Loss of property, livelihoods, crops
n Interruption to educational system
n Separation of children from their primary caregivers
5
EXTREME TEMPERATURES
Extreme climate and weather patterns affect communities in many
countries in South Asia. While people adapt to the conditions in which
they live, extremely cold and hot weather can have powerful impacts
on the health and life of families and communities.
Marked short-term fluctuations in weather can cause acute adverse health effects.
In extremely cold temperatures, acute respiratory infections that may lead to
pneumonia are the major risks for children. Extreme cold can also cause
hypothermia, an extreme lowering of the body's temperature and death.

n Extremes of both heat and cold can cause potentially fatal illnesses, i.e. heat
stress or hypothermia, as well as increasing death rates from heart and
respiratory diseases.
n In cities, stagnant weather conditions can trap both warm air and air pollutants -
leading to smog episodes with significant health impacts.
n Damage to crops, land
n Potential food shortages
6
TSUNAMI
Tsunamis are giant sea waves
that are produced by an
underwater earthquake or slope
collapse into the seabed.
Tsunamis can travel thousands of
miles at high speed with very
little loss of energy. They reach
the coast with devastating
MALDIVES: A child's drawing shows the chaos impact on shoreline
caused by the tsunami, with a girl taking refuge on the
roof of a house that is, like the tree beside it, half-
submerged in the water. Both the girl and the house top communities. Successive crests
are depicted in red. The Government's Psychosocial
Support Unit notes that the choice of a particular colour
can be an indicator of stress, with red often denoting can arrive at intervals of every 10
strong emotions. The artwork was created as part of a
Government-sponsored psychosocial programme to
help children recover from the trauma they to 45 minutes and wreak
experienced. Materials from UNICEF-supplied school-
in-a-box kits were used in the project.
destruction for several hours.
The destruction level along the shores affected can be immense, with vast coastal
areas deprived of their infrastructures and entire communities washed away. The
humanitarian consequences are directly proportional to the power of the tsunami,
the geography of the coastline, the level of the infrastructure and the size of the
communities living along the affected coasts.
NATURAL DISASTERS
IN SOUTH ASIA
MALDIVES: Two boys search through debris
Outcomes can include: that has been piled up on a beach on the atoll of
Haraa one week after the tsunami disaster.
n Drowning
n Injuries
n Water borne and vector transmitted diseases
n Outbreaks of communicable diseases
n Poor sanitation, hygiene
n Food shortages
n Interruption of basic public health services
n Disruption to educational systems
n Loss of property, livelihood, crops
n Damage to infrastructure
n Large scale displacement
n Separation of children from primary caregivers
n Increased risk of sexual abuse and exploitation
RESOURCE BANK
Further reading
1 International Federation of Red Cross and Red Crescent Societies, World
Disasters Report, Focus on Information in Disasters, London, 2005.
2 ITDG South Asia, RDPI, Livelihood Centered Approach to Disaster
Management: A policy framework for South Asia, ITDG, Colombo, 2005.
Web sites
1. Asian Disaster Preparedness Centre
http://www.adpc.net/
2. Centre for Hazards and Risk Research at Columbia University
http://www.ldeo.columbia.edu/chrr/
3. Centre for Research on the Epidemiology of Disasters (CRED)
http://www.cred.be/sitemap.htm
4. Emergency International Disaster Database
http://www.em-dat.net
5. Humanitarian Early Warning Service
http://www.HEWSweb.org
6. The International Federation of Red Cross and Red Crescent Societies
http://www.ifrc.org/index.asp
7. The Sphere Project
http://www.sphereproject.org/
8. US Centre for Disease Control and Prevention
http://www.bt.cdc.gov/disasters/
Footnotes
1
Much of the following information has been adapted from
United Nations Children’s Fund, Emergency Field Handbook,
UNICEF, New York, 2005 and World Health Organization,
Floods - Technical Hazard Sheet - Natural Disaster Profile.
2
Adapted from World Health Organization, Floods - Technical
Hazard Sheet - Natural Disaster Profile.
3
Adapted from World Health Organization, Earthquakes -
Technical Hazard Sheet - Natural Disaster Profile.
4
Adapted from World Health Organization, Cyclones -
Technical Hazard Sheet - Natural Disaster Profile
5
Adapted from World Health Organization, Climate and health
Fact sheet, July 2005.
6
Adapted from World Health Organization, Climate and health
Fact sheet, July 2005.
© UNICEF/Afghanistan 00239S/Roger Lemoyne
CHAPTER- 3
BEHAVIOUR CHANGE
COMMUNICATION IN EMERGENCIES
CHAPTER- 3
BEHAVIOUR CHANGE
COMMUNICATION IN EMERGENCIES
UNICEF'S CORE COMMITMENTS FOR CHILDREN IN EMERGENCIES
BEHAVIOUR CHANGE COMMUNICATION PRINCIPLES FOR EMERGENCIES
STEPS IN DEVELOPING A COMMUNICATION PLAN
COMMUNICATION STRATEGIES IN EMERGENCIES
USING APPROPRIATE COMMUNICATION CHANNELS
PRACTICAL EXPERIENCE
SPECIAL NOTE ON CHILDREN'S PARTICIPATION IN EMERGENCIES
RESOURCE BANK
UNICEF'S CORE COMMITMENTS

FOR CHILDREN IN EMERGENCIES
© UNICEF Pakistan
UNICEF's support for behaviour

change communication in
emergencies is guided by the
Core Commitments for Children
COMMUNICATION
in Emergencies (CCC), which
BEHAVIOUR CHANGE
HYGIENEIN PROMOTION
provide the overarching
organisational framework for a
humanitarian response.1
EMERGENCIES
Core Commitments for
Children in Emergencies The two fundamental tenets
UNICEF's Core Commitments for Children supporting all UNICEF
in Emergencies are not merely a mission operations are:
statement - they are a humanitarian n The Convention on the Rights of
imperative - in health and nutrition, water, the Child, and
sanitation and hygiene, protection, n A commitment to a human-rights
education, HIV/AIDS and programme based approach to programming.
communication or behaviour change
communication. Emergencies particularly in South Asia have grown increasingly
complex, and their impact is especially devastating on the most vulnerable. In the
midst of these crises, children and women are not only incidental victims, but
increasingly are often targets of wilful violence and abuse. In many cases, they
are denied access to basic services and essential relief supplies. The CCC
provides a framework from which to work with partners from the government, United
Nations and non-governmental sectors.
The commitments outline UNICEF's role in providing protection and assistance to

children and women. They make a clear distinction between life-saving interventions,
which should be carried out immediately - within the first six to eight weeks of any
crisis - and the broader spectrum of essential activities that may be added beyond
the initial response. Although this distinction is clear for sudden onset emergencies,
the logic of the CCC should apply to all humanitarian crises: focus first on
interventions proven to be essential for immediate survival and protection.
UNICEF adheres to the following key principles in fulfilling its Core Commitments
for Children in Emergencies:
n Children in the midst of armed conflict and natural disasters such as droughts, floods
and earthquakes have the same needs and rights as children in stable conditions.
n UNICEF's response will recognise the priority of humanitarian action while assuring
safe access to affected populations, and the safety and security of staff and assets.
n The emergency response will build on existing activities and partnerships
developed through the country programme of cooperation.
n The response will be based on nationally defined priorities and UNICEF's
comparative advantage.
B ehaviour change communication plays an essential, albeit often

neglected, part in any emergency. In the past, many emergency
responses in South Asia tended to focus on providing supplies and
setting up services. Little attention was paid to addressing risky
practices, poor habits and communication needs based on the
existing knowledge, beliefs, attitudes and practices of the affected
individuals and families. Also insufficiently addressed was creating
awareness and demand for emergency supplies, services and
assistance among affected families and communities.
Experiences from the tsunami response in South Asia showed that

communication preparedness for emergencies, risk communication
and behaviour change communication (BCC) initiatives that benefit
affected individuals and communities were not always adequately
given importance, funding, and thus were not coordinated, planned,
managed or monitored well. Fulfilling the Core Commitments for
Children in Emergencies, however, requires that BCC initiatives
become an integral part of preparing and responding to emergencies.
The following section offers you an overview of the basic communication related principles
to help you prepare for and respond to in an emergency. It outlines the essential steps you
need to take in developing a rapid communication action plan. It points out some issues
you need to consider when designing appropriate communication messages and channels
with the affected communities during emergencies.
BEHAVIOUR CHANGE
COMMUNICATION
PRINCIPLES FOR
EMERGENCIES
Keep in mind the following basic
principles for your BCC initiatives.
These principles are built around
COMMUNICATION
the CCCs and thus contribute to
© UNICEF Bhutan
BEHAVIOUR CHANGE
HYGIENEIN PROMOTION
overall efforts to prepare and
respond to emergencies.
EMERGENCIES
Before an emergency strikes:
n Prepare accordingly
Planning and preparation for BCC are vital steps that must take place long
before an emergency strikes. UNICEF country offices have the responsibility to
identify and develop 'Emergency Preparedness and Response Plans' (EPRP) for
potential natural or man-made disasters. Based on experience and evidence
from past emergencies, define what kinds of results, that is, behaviours, in
terms of specific knowledge, attitudes and practices your intended audience
groups need to develop, perform or reinforce, and sustain. You need to also
define what kinds of communication support and resources your team of
partners would need so that the BCC response would support the overall
humanitarian response.
n Invite different partners to come together to plan jointly

BCC initiatives are prepared with partners from different sectors, including
government, UN agencies, NGOs and humanitarian agencies. Keep in mind that
communication efforts, to influence positive behaviours, have to be closely linked
to other programme, service and supply plans for an emergency. Therefore, you
will need to ensure that you establish a sustained collaborative arrangement with
relevant partners.
n Engage communities in preparing and planning for emergencies

The human rights-based approach to programming stresses participatory
approaches that engage communities in planning, implementation and monitoring
processes. This means that we should build on what people already know and that
we recognize their social and cultural strengths. However, communities are not
homogeneous. Keep in mind that vulnerabilities related to age, gender
inequalities, ethnicity, caste, socio-economic status and disability, are factors that
may affect people's ability to take part in decision-making processes.
n Invest in communication research

Communication research addresses the critical information gaps that you need
to fill to enable you to adequately prepare and plan for emergencies.
Conducting communication research will be a wise investment for it will save
you time and resources later. Ensure that you disaggregate data from such
research by sex, age and other variables which can impact on people's
behaviours, such as ethnicity and income levels. In the face of an emergency,
when information from previous communication research is not available, the
best alternative is to conduct a rapid communication assessment. Prepare a
monitoring and evaluation (M&E) plan as well. M&E enables you to track your
progress and impact at given periods of the emergency response in terms of
message and channel reach, resource use and most of, all in terms of desired
behaviour results.
n Prepare action oriented communication materials

Be ready with sample messages and materials that have been pre-tested such
as those on maternal health, nutrition, immunization, disaster-related stress,
water and sanitation, and child protection. This will save you precious time and
resources. Countries with landmines will also need mine-risk education
materials in advance. Having a central website with downloadable files ready for
printing will be useful preparations for an emergency. It will also be handy to set
up a database of available writers, editors, designers, printing houses, and radio
and TV producers so that contracts could be quickly drawn up.
n Develop a communication protocol and partnerships that will

collaborate in communication efforts
During an emergency, information overload and confusion is likely to happen,
especially when the impact is large scale and if there is little coordination
among different actors providing assistance. Agree with key partners and have
a plan which outlines how communication efforts will be coordinated, with
clearly defined roles and responsibilities. Agree on how information will be
managed. This should also help to prevent and manage rumours and
misinformation, two unwanted results that often happen during emergencies.
n Train service providers in interpersonal communication skills

In times of stress and trauma caused by a disaster, health workers and other
service providers need to possess and maintain good interpersonal
communication skills to inform, motivate, counsel and encourage people
affected by emergencies. They also need to know how to deal with the distress
and anxiety experienced by people who come for assistance as well as among
themselves.
n Test the communication plan by drills and exercises

Many BCC plans for emergencies fall short when they clash with harsh
COMMUNICATION
realities. You need to test your assumptions and nurture positive mindsets and
skills that can be harnessed when everything is in chaos. Test your
BEHAVIOUR CHANGE
HYGIENEIN PROMOTION
communication approaches. Carefully test and review them with affected
people, to ensure that these are practical and feasible under the circumstances
of the emergency. This also implies that your BCC plan should help build the
necessary confidence and skills among staff and partners to overcome fear,
EMERGENCIES
stress and anxiety.
If an emergency strikes
n Establish a central health education and communication coordination centre
Partners from government, UN agencies, NGOs, religious communities, media,
children and youth groups and others need to coordinate, plan, manage and
monitor communication initiatives with affected communities during the
emergency response. This will avoid duplication, misunderstanding, rumours
and misinformation and maximize communication efforts.
n Participate in sectoral assessments

When health, water and sanitation, child protection and education
assessments are conducted in the initial phase of an emergency, it is critical
that the different sectoral assessments also identify any high risk practices that
have implications for behaviour change communication among affected
caregivers and communities. This information is critical to map out the detailed
emergency responses for different sectors.
n Conduct a rapid appraisal of communication channels and resources

Assess the availability and reach of media and other communication channels.
Determine media access among affected communities. Are media and other
communication channels (e.g., national, provincial and community based radio)
still functioning? What about commercial as well as university based radio
stations, are they ready to support BCC in an emergency? Can they be
mobilized, for instance, for hygiene promotion, disease prevention and the
protection of displaced/unaccompanied children? What logistical requirements,
as well as gaps and problems could you anticipate? What appropriate, low-tech
communication channels could be urgently set up that would work without
electricity? As the response unfolds, look out for new as well as existing
opportunities for persuasive interpersonal channels that existing or newly set up
community communication channels could support - for example, the Military,
Red Cross workers, children and youth groups like Girl Guides, Boy Scouts,
Child Clubs, other community-based channels - for communicating quickly with
affected populations.
n Focus on re-establishing existing behaviours and norms

In the initial emergency phase, concentrate on re-establishing positive behaviours
that existed prior to the emergency. Focus not only on individual behaviours and
actions, but seek to re-establish positive social and cultural values that are
temporarily disrupted. However, depending on the situation, be aware that
emergencies might also provide opportunities to promote new behaviours.
n Forge alliances
Build alliances to include relief workers, service providers, journalists and others
so that they are able to support directly desired behaviours of affected people.
n Facilitate community and children's participation

Be pro-active in creating opportunities for affected caregivers and communities,
including children and young people, to participate in determining issues and
solutions in the emergency response. Take particular care to include especially
vulnerable groups, whether this requires inviting representatives from children and
young people's organisations, women representatives, religious leaders, asking
vulnerable populations to nominate spokespersons or advocating with camp
management and local authorities to consult affected communities.
n Follow humanitarian imperatives

Humanitarian needs should always take precedence over political and other
agendas. In our communication efforts, we also might have to advocate for
cross boundary cooperation, support and compassion.
n Have a detailed communication plan

Based on your emergency preparedness plan, develop with your team and
partners the details of the communication initiative(s) for the different phases of
an emergency. In the following section, you can gain from an overview of the
essential steps in developing a communication plan.
STEPS IN DEVELOPING
A COMMUNICATION PLAN
Developing a communication plan to
influence behaviour change or
reinforcement does not have to take long.
But it is an essential component of the
COMMUNICATION
overall emergency plan. A plan is
necessary to ensure greater behavioural
BEHAVIOUR CHANGE
HYGIENEIN PROMOTION
impact. It allows you to get the most out of
your budget, to measure any changes, to
© UNICEF Pakistan
EMERGENCIES
motivate people to achive intended results
– and is just plain good management.
When you develop a behaviour change communication plan, design each step to
be as participatory as possible. Participation in all steps of the process allows
community representatives to participate in decisions, develops a sense of
ownership and helps affected communities achieve a sense of normalcy in their
disrupted system.
If an emergency strikes, usually the exact details of a communication plan will

have to be outlined - often under pressure and with little time. Here are some
essential steps you can follow when developing the details of a communication
plan for an emergency.
Step One
Bring all stakeholders together: Work with the various stakeholders together
(from a given programme or related sectors at a time, e.g., health and hygiene)
from government, UN agencies, NGOs and community representatives as quickly
as possible to determine:
n What behaviour results should your communication plan for this programme or
sector achieve in the rescue and survival phase; in the recovery phase; and the
rehabilitation and development phase of the emergency?
n What are the roles and responsibilities of the different partners?
n How will the plan be funded, implemented, monitored, documented and

reported?
n How will the monitoring results be used in the different phases of the emergency?
Step Two
Plan and conduct a rapid communication assessment based on an
appropriate combination of tools and applying the next steps below.
(Please see also Part 3: Tools)
Step Three
Determine your audience/s and define SMART behavioural objectives and results.
Based on the rapid assessment and on data from any pre-existing communication
research, determine who your audience groups are among the affected population.
Define the specific desired behavioural objectives or results you would like to achieve
from your communication plan. These behavioural results may vary for the different
phases of an emergency response. Define behavioural results so that they are:
1. Specific in terms of an issue (a behaviour, a skill, knowledge, attitudes), of a
specific group and of the geographical location.
2. Measurable in such a way that changes in people's behaviour can be
measured, either quantitatively or qualitatively.
3. Achievable in that the behavioural results correlate to a target that can
feasibly be attained by the programme partners with UNICEF and others'
support, and that all necessary resources are identified and budgeted.
4. Relevant so that the planned behavioural result(s) represent a milestone in the
results chain, and will contribute to the achievement of commitments for the
emergency response.
5. Time-bound in that a time frame has been set within which change is
expected to happen.
Keep in mind that behavioural results have to contribute to the overall results - health
and nutrition, child protection, education, water and sanitation - in the emergency.
Step Four
Based on the specific intended behavioural results, determine the details of
the communication plan:
n Which combination of communication strategies to use: advocacy, BCC, social
mobilization?
n Which groups of people to involve as partners, to mobilise, orient or train?
n What specific training needs and orientations are required, for which group/s for
the plan to be carried out quickly?
n Which communication activities, main messages and materials? Where can

you obtain examples of messages and materials that you can quickly adapt?
n What mix of communication channels (e.g. mass media, interpersonal
communication, community media, etc) by which phase of the emergency?
n What is the dissemination plan for the communication messages and
materials?
n What is the timeline for communication activities during different phases of the
emergency?
n What is the monitoring (including indicators and means of verification),
evaluation, documentation and reporting plan?
COMMUNICATION
n What is the total budget?
BEHAVIOUR CHANGE
HYGIENEIN PROMOTION
Step Five
When implementing the plan, keep the following in mind:
n Pre-test messages and materials with representative groups from different
EMERGENCIES
affected communities;
n Conduct the training early on, which may include training of interpersonal
communicators such as animators, peer educators, health workers, teachers
and young people;
n Orient and involve journalists in your efforts;
n Mobilise partners and communities to support and implement the plan.
Step Six
Establish a monitoring system
Manage and monitor communication activities as part of the overall emergency
programme monitoring effort. Ideally, use community monitoring systems among
affected population groups. Based on the monitoring data, adjust activities and
materials accordingly. Programme and service delivery data, such as immunization
drop out, decrease in diarrhoea rates, also serve as monitoring information and
should be used to modify communication activities or messages.
Step Seven
Evaluate and re-plan: Based on the desired behavioural results, assess outcomes
and if possible any behavioural impact. Disseminate results to partners - including
affected community members. Determine the need for follow-up and for continued
support to shape behaviours, and for communication support in the recovery and
rehabilitation phase of an emergency. In evaluating impact, contributions that can be
linked to communication efforts should be an integral part of a programme evaluation
rather than a separate evaluation of communication initiatives.
COMMUNICATION STRATEGIES
IN EMERGENCIES
Communication initiatives are
© UNICEF/ HQ05-0491/Ami Vitale
not a 'luxury' in an emergency.

It is a necessary component of
efforts to ensure the survival,
health, development, protection
and psychological recovery of
INDIA: A woman and a girl draw water from a pump set up in a tent camp an affected population.
for people displaced by the tsunami in the seaside village of Mudtukadu,
near Chennai, capital of the southern state of Tamil Nadu, India.
In past emergencies, many relief and humanitarian aid workers relied on IEC
(information, education and communication) materials alone without the benefit of
strategic planning with relevant partners and affected communities based past
evidence or on a rapid assessment. Posters and pamphlets were churned out
without clearly defined behavioural results and without a communication plan in
place. This was done with the hope that behaviours would change if the affected
people receive the "right" information as quickly as possible. While providing
information to affected populations is essential, it is only one ingredient in the
larger process of behaviour and social change in an emergency.
We need to keep in mind that effective communication strategies for emergencies,

as for stable situations:
n Are grounded on concepts that range from social psychology, learning theories,
role modelling through audience-appropriate combinations of mass media and
interpersonal communication approaches, and the proper use of advocacy and
social mobilisation.
n Are informed by the policy and legislative environment.
n Are evidence-based and results-oriented.
n Never work in isolation. Communication initiatives must be planned, based on
evidence, coordinated and implemented in close synchrony with the
programmatic, service and relief supply components of an emergency response.
n Are based on dialogue with and active participation of affected community
members, including the children.
n Are based on close collaboration and networking with partners to synchronize
messages, materials and channels, and to scale up communication efforts.
UNICEF engages three strategic communication approaches: behaviour change

communication, social mobilisation and advocacy. The following figure illustrates
how the three distinct dimensions of communication are united through the
planning and management continuum (represented by the arrow on the left). The
figure shows how communication is integral to programmes and affirms the
importance of linking communication activities to service delivery.
Strategic communication model2

Communication approaches: some definitions
COMMUNICATION
BEHAVIOUR CHANGE
HYGIENEIN PROMOTION
EMERGENCIES
Remember that information alone, using IEC materials, is not enough to influence
sustainable healthy behaviours and to create a supportive social environment in an
emergency situation. If your strategy is dominated by one-way information
dissemination, it may result in increased awareness but may have limited impact on
improving behavioural and social norms. It is critical for you to stimulate shared
learning through dialogue, participation and discussions with members of the
affected communities in emergencies. Involving affected families and communities
allows them determine among themselves what needs to be done, and by whom in
the long run, thus establishing a sense of ownership of the processes in the
different phases of their recovery. To support such positive behaviour and social
changes, you need to employ three interrelated, interdependent and interactive
strategic communication approaches in emergency situations.
Behaviour change communication

Behaviour change communication (also referred to as programme communication
in UNICEF) attempts to bridge the gap between information, a person's knowledge,
attitudes and subsequent behaviour. This approach addresses the knowledge,
attitudes, practices and skills of individuals, families and communities as they
relate to specific programme goals. Within a participatory communication framework,
individuals and communities gain knowledge, appreciations and skills that motivate
them to develop positive, healthy and protective practices. BCC requires a sound
understanding of the audience(s) and the use of an appropriate mix of communication
channels - interpersonal, group, community and mass media. It also recasts the role
of the "communicator" as facilitator rather than "expert". Behaviour change
communication has proven to be more effective when complemented by well-planned
and implemented advocacy and social mobilisation strategies.
Social mobilisation
The purpose of social mobilisation is to bring together relevant inter-sectoral
partners to determine needs and raise awareness for a particular objective in an
emergency response. It involves the identification of organisations, institutions,
groups, networks and communities who can contribute their efforts and resources.
It involves facilitating their participation to realise the goals of an emergency
response. Social mobilisation helps build the capacity of these mobilised groups in
the process, so that they are able to mobilise resources, plan, implement and
monitor programme activities with the community or camps as the case may be.
This approach should support actions and priorities identified by communities,
especially the most vulnerable groups whose rights tend to be consistently denied.
Social mobilisation activities should stem from community action, but must receive
support and coordination services.
Advocacy
Advocacy is directed at different levels of decision makers - people who have the
power to create policies, programmes and structures and to allocate resources.
By persuading decision makers to decide in favour of a cause, advocacy seeks to
develop, change or modify an existing law, policy and/or administrative practice that
would enhance the emergency response. It is a continuous and adaptive process of
gathering, organising and transforming information into arguments. These
arguments are then communicated to decision makers, to influence their choices
to raising resources (human and financial), or demonstrate political or social
leadership and commitment to an emergency response. A goal of advocacy is to
influence leaders and decision makers at different levels to make it easier for
affected communities, families and individuals to make healthy choices for their
own physical and social well-being, and ultimately to protect the rights of children.
USING APPROPRIATE
COMMUNICATION CHANNELS
In the initial relief phase of an emergency you must find ways to reach as
many affected people as fast as possible with your messages. During
this phase, communications systems may be temporarily out of
commission. Low cost and low-tech
COMMUNICATION
communications systems are often
BEHAVIOUR CHANGE
the most practical and effective
HYGIENEIN PROMOTION
during such difficult circumstances.
Megaphones, car battery-operated
EMERGENCIES
public address systems, community
radio (also powered by battery or
generators) are good ways to quickly
disseminate messages to affected
families and communities. Properly
organised public gatherings and
community or camp meetings
INDIA: With the aid of a mobile loudspeaker system UNICEF
animators demonstrate how to prepare Oral Rehydration Salts
provide further opportunities to
(ORS), part of a health campaign in relief centres for tsunami-
affected displaced people, in the Union Territory of Pondicherry. The
teams are promoting the use of ORS and good hygiene practices to
quickly share information.
prevent and treat diarrhoea and other water-related diseases.
Choose more than one communication channel to help reinforce the information.
Beyond using mass and small media, interpersonal and participatory community
based media are indispensable channels to lead communication efforts aimed at
improving or changing behaviours and in sustaining such behaviours.
To choose the right mix of channels in the different phases of an emergency

response, consider the following:
n How do affected families and communities seek information?
n How do affected families and communities share information?
n Who are trusted and respected spokespeople in the community or relief camp?
n Which groups have access to generators, mobile phones, megaphones, public
address systems, radio or TV? Which groups among the affected population do
not have access to any media?
n What traditional, telecommunications and mass communication channels are
available? If available, using these in an emergency is often easier and more
efficient than setting up new ones.
n Which groups can you reach via community-based group channels such as
social or religious functions?
Example of mixing communication channels

UNICEF India supported the following post-tsunami child protection initiatives in
Tamil Nadu using a mix of different channels and strategies:
n Government officials attended a conference with multi-media presentations
designed to educate them on the importance of preventing child abuse,
trafficking and other harmful practices to children.
n A child protection awareness campaign was initiated where booklets, posters
and banners with information on abuse and trafficking were printed along with
phone numbers of a helpline to report child trafficking cases.
n Posters with relevant messages and Child Line hotline phone numbers were
printed and distributed to schools and child care centres.
n Several hundred community "watch dog" committees were set up and trained to
identify and report child abuse and trafficking cases.
n A state level action plan was drafted to respond to trafficking issues and
commercial sexual exploitation of children and women.
S oon after the tsunami that hit on 26 December 2004, UNICEF Maldives
collaborated with the Health Education Unit of the Ministry of Health to produce,
approve, pre-test and disseminate a new package of materials on the proper disposal
of dead fish and dead bodies, on mosquito control, diarrhoea prevention and treatment
guidelines. This was done via fax and emergency supply channels. Videos were also
produced and aired as TV spots and shown in hospitals and health centres that were
equipped with Closed Circuit Television (CCTV). Radio spots were also produced and
aired by the Voice of Maldives, the state-run station.
In the Maldives, 24 hours after the resumption of telecommunications services, TV

transmissions were available on almost all the islands that have a high penetration of
TV and radio signals. The director-general of health services delivered messages on
how to prevent and control diarrhoeal diseases and on personal hygiene and
sanitation via his daily TV address.
Useful communication channels in an emergency

Mass media
The mass media include print, radio, television and cinema. When operating during
an emergency, these media can reach large numbers of people in a short time. The
mass media are most effective when coupled with other communication approaches
through which the affected community can talk about the new information with
someone whom they trust, such as community opinion leaders.
Consider these points when you use mass media in an emergency:3
COMMUNICATION
n Depending on the consequences of an emergency, the mass media can reach a
substantial number of people.
BEHAVIOUR CHANGE
HYGIENEIN PROMOTION
n Enjoys credibility.
n Can be important channel for advocacy as it can reach and get the attention of
policy-makers, senior officials and community leaders.
EMERGENCIES
n Not participatory in nature.
n Messages may tend to be for general consumption, not taking into account the
unique needs of the affected community.
n Might reinforce gender based stereotypes (e.g. portraying women as helpless
victims)
n The affected population may not have access to radio or TV.
Small format community media

Small format community media are often the most practical, useful and effective in
reaching affected people during an emergency. These media include community
radio (generator or battery-powered FM transmitters), community bulletins or flyers,
and loudspeakers or megaphones - stationary (e.g., those in mosques) or itinerant
(connected to vehicles). In an emergency, you can use these types of small
community media to quickly disseminate information to a camp or affected
community. With community coordination
and support, you can plan, conceptualise,
produce and disseminate messages with
affected community members. U NICEF India used the
loudspeakers from mosques to
broadcast news about the measles
Points to consider in using small and vitamin A campaign in the
format media in an emergency: tsunami camps of Nagapattinam.
During the first two days, more than
n Participatory in nature, involving all
14,000 children were immunized
possible community groups.
and given vitamin A.
n Requires how-to knowledge, therefore
you need to engage participants in
basic training.
n Easy to set up.

n Needs oversight to make sure it is not abused or exploited by political factions.
Interpersonal communication channels

Interpersonal communication (IPC) refers to face-to-face communication. IPC can
either be one-to-one or in a small group. IPC makes it possible for people to exchange
information, express their feelings and obtain immediate feedback, respond to
questions and doubts, convince and motivate others to adopt certain behavioural
practices. IPC requires listening skills, the ability to empathise and be supportive. IPC
in a crisis situation is particularly useful in counselling approaches such as through
hotlines, clinic consultations, in training service providers and community volunteers as
peer educators, through pep talks by specialists, and for facilitating group meetings
where the affected community can share and discuss the issues at hand.
Peer educators
Peers are persons who belong to the same age group and social cultural
background. In addition to promoting healthy behaviours, we can build local
capacity by training peer educators in effective communication and participatory
approaches. Even after the end of a emergency communication initiative, these
individuals can continue to pass on messages through casual conversations with
friends, family members and their wider peer group.
Points to consider in tapping peer educators in an emergency:

n They can be easily organised in emergencies but you must invest in training
which takes time.
n They need supportive supervision.
n Affected individuals can both give and receive information.
n Does not need to be costly.
n If planned and supported well, can be an effective way to motivate people.
n Affected people may not have a lot of time in an emergency to participate in
meetings.
n Sharing personal information may not
be culturally acceptable in some
affected communities and will require
Through the community-based
approach, UNICEF Sri Lanka
worked with partners to train
time to establish trust. individuals within villages to identify,
n Messages spread via word-of-mouth assist and refer other community
may diminish message accuracy. members who may need psychosocial
support. UNICEF reported that an
Participatory drama estimated 43,000 children participated
Participatory drama is an important aspect in and benefited from this effort.
in the preparedness and recovery phases.
This type of communication method allows the affected community to be directly

involved in the drama itself. This gives individuals greater control, and helps them to
explore issues and possible solutions. Participatory performance emphasises
working with and from the affected community's own reality, and choosing their own
modes of expression. Local people replace outside scriptwriters, illustrators,
editors, directors and actors and become actively involved in creating and exploring
solutions to a real life situation. Through participatory drama, you can encourage
participation in the decision-making, implementation, monitoring and evaluation
phases of relief and recovery projects.4
COMMUNICATION
Points to consider when using participatory drama in an emergency:5
n Stimulates critical thinking, stresses process rather than outcomes.
BEHAVIOUR CHANGE
HYGIENEIN PROMOTION
n Community can prioritise their needs.
n Develops a sense of community ownership.
n Offers a creative approach to deal with distress and trauma and thus supports
healing among affected community members.
EMERGENCIES
n Can be time consuming for the initial emergency response because of need to
raise consciousness through IPC and relationship-building while it promotes
sustainability.
n Castes, class, gender and other social variables can create different realities for
some members of the affected community. Be sensitive to the cultural and
gender-based specifics and act accordingly, by resorting to locally appropriate
and innovative means of achieving equal participation.
n Community members may lack the commitment to the process if there are no
perceived benefits.
Local folk media

Local folk media can include music, local art forms, local theatre, puppetry,
drawing or dance. Many affected communities have their own traditional media
forms to express themselves. Local ways of communicating are powerful avenues
to stimulate psychosocial healing, return to normalcy and motivate affected families
and communities to practice healthy behaviours.
Points to consider for an emergency:

n Information can be presented in the most culturally appropriate forms.
n Messages can be adapted to suit the needs of the affected community by local
as well as imported experienced performers.
n Most folk media are entertaining and hold the attention of the audience,
allowing them to be temporarily distracted from the realities at hand.
n It takes time to research on which folk media are acceptable to the affected
community.
n Local participants need to be identified and trained on the messages to be shared.
n Technical information can be difficult to communicate.

n The actors may not be able to ad-lib or be spontaneous in acting out the local
art forms.
Information, education and communication (IEC) materials

IEC materials with prepared messages can be conceptualised as part of a
communication preparedness plan before a disaster strikes. You can easily adapt
and produce these as part of your BCC programme provided messages, design and
presentation are duly pre-tested with the intended audience groups. Once a disaster
strikes, producing and disseminating IEC materials can be a quick way to reach a
large number of affected people. This form of communication typically leads to
'awareness raising' of an issue, and serves to reinforce existing knowledge and
practices, such as the importance of hand washing, but
this may not necessarily lead to changes in behaviour.
IEC materials include radio public service
announcements in print form, posters, leaflets,
brochures, videos, flip charts, banners, and promotional
items like T-shirts and badges.
Points to consider when using IEC materials in an emergency:

n Generic messages addressed to and pre-tested with specific audience groups,
for example, on hygiene, can be conceptualised, researched, tested and
printed before a disaster strikes.
n Easy to do in initial response.
n Good way to get information out fast.
n Awareness of message does not equal action.
n Messages disseminated can easily be ignored, forgotten or cause confusion.
n Each message needs repetition and reinforcement through other
communication channels.
When you decide on the communication channels to
T o prevent loss of lives

due to landmines that
might have been unearthed
use in an emergency situation, keep in mind to mix
media and interpersonal communication channels
based on audience realities to achieve better results.
by the tsunami, UNICEF Sri
Numerous communication research studies have
Lanka launched a land mine
documented that individuals are particularly
awareness campaign. A
total of one million school
influenced to adopt new or improved practices
timetables with mine risk through interpersonal communication with their peers
education messages were or with opinion leaders. The studies have shown that
produced and included in using communication materials tend to reinforce the
the school-in-the-box. effectiveness of interpersonal communication.
47
47
PRACTICAL EXPERIENCE
Community Based Disaster Preparedness: A life saving strategy using
interpersonal communication6
A community based disaster preparedness (CBDP) programme was praised as a life
and livelihoods saving intervention in the 2004 West Bengal, India floods. The project
was launched by the Inter Agency Group (IAG)7 and the Government of West Bengal
after the 2000 floods affected over 22 million people in the state. In 2004, the project had
reached more than 1,500 villages in four districts of the state.
COMMUNICATION
"CBDP saved our lives and our livelihoods" said Sujit Kumar Roy, Gram Pradhan of
Bahirgachi Gram Panchayat (GP), which has about 6,000 families. When the project
BEHAVIOUR CHANGE
HYGIENEIN PROMOTION
team visited one of the worst affected villages of the GP, community women said that
during the previous flood, they were very afraid. All of them reported that this time they
were not fearful of the floods because they were better prepared.
EMERGENCIES
Significant outcomes of the Bahirgachi Gram Panchayat CBDP programme:
n Water supply was not affected because community raised the level of hand
pumps and disinfected tube wells.
n Hardly any disease outbreak occurred.
n There were no food shortages as each family stockpiled food for 7 to 10 days to
meet their immediate needs.
n No reports of children losing textbooks.
n Two deaths in the GP occurred (which were not due to floods).
n No loss of cattle; practically no loss of poultry.
n No families reported any loss or damage to their documents.
This is a marked difference from the aftermath of the 2000 floods where 11 people died;
700 cattle and 10,000 poultry were lost; nearly 3,000 families lost some/all of their
valuable documents; and more than half of children's textbooks were lost or damaged.
"CBDP really made a difference in the lives of the flood-affected community" said Rajesh
Pandey, District Magistrate. "Besides preventing loss of life, CBDP greatly reduced the
loss of livelihoods of people by saving their cattle and poultry. More importantly, the
CBDP made the community more resolute and better organised in tackling floods. It
also brought about community togetherness in that all elected representatives
belonging to the different political parties worked hand in hand with the community to
minimise the risk arising out of the flood situation."
The process
Using Participatory Learning and Action (PLA) tools in their emergency preparedness
communication initiative, each community prepared an action plan for their village.
48
1. Produced a village vulnerability map that identified the safe places, low risk areas,
highly vulnerable areas and the estimated number of families residing in each of
these zones.
2. Catalogued the number and location of the vulnerable groups such as the elderly,
disabled, lactating mothers, pregnant women, seriously ill persons and small
children in their village. Information related to the number of persons belonging to
each of these categories was also collected.
3. Described history of earlier floods and elaborated in detail the damage that
occurred in the 2000 floods. The plan also mentioned the key elements at risk such
as life, health, property, livestock and livelihood, the resources required/at hand for
bringing down the level of risk.
4. Listed key activities that the community would do before, during and after the flood.
The key activities identified before the flood were flood warning, household
readiness regarding the positioning of family survival kits and safe keeping of
valuables and important documents, formation of different task forces, training on
health and first aid, water and sanitation, and rescue and relief.
5. Identified key local resources such as bamboos, banana plantations, and so on,
for use in the preparation of machans (temporary shelters) and local rafts. The
community also identified hand pumps that needed to be raised above the flood
level to protect their source of water.
6. Stated the specific places where the affected community would go along with their cattle
to take shelter in event of a flood. Some of them also acquired the technology to
construct small boats, life jackets and other materials for successful rescue operations.
7. Specified the roles of different stakeholders, quantitative and time schedule for all
activities including mock drills. Overall the activities were prioritised and thus
requirements became more realistic.
SPECIAL NOTE ON CHILDREN’S

PARTICIPATION IN EMERGENCIES
Emergencies push children to discover new roles for themselves in the face of difficult
and unstable situations. The Convention on the Rights of the Child provides the basic
principle that should guide UNICEF's programming in child and adolescent
participation in emergencies - that children and adolescents have the right to
appropriate information, the right to be heard and the right to have a meaningful
involvement in the emergency response, according to their best interests.
From a November 2005 discussion in Thailand among child-focused NGOs, UNICEF

and with tsunami affected children from, India, Indonesia, Sri Lanka, the Maldives and
Thailand9 who were involved in various ways in the tsunami response, here are some
arguments put forward in favour of children's participation in emergency situations:
n Children and their associations – child clubs, child ‘parliaments’, children’s unions,
etc. make important contributions to relief, rehabilitation and reconstruction efforts, for
example in health and sanitation services and in the distribution of relief supplies;
n Children’s participation can make the delivery of relief more effective. They can
identify who needs what, where, how;
n Children can be effective communicators in their families and among their peers
n Children have strong connections and networks among themselves and can
become effective agents of behaviour change in the community;
n Children’s views and concerns differ from those of adults. Rapid emergency
assessments are of better quality if they are also based on information from children.
COMMUNICATION
n Children who are informed about relief efforts are better able to survive and to
protect themselves;
BEHAVIOUR CHANGE
HYGIENEIN PROMOTION
n Children provide emotional support in their community. Their participation has
proven to promote psychosocial healing;
n Children provide valuable feedback on relief efforts;
n Children know their communities and have access to some information and
EMERGENCIES
knowledge that adults may not have;
n Children are a large segment of the community;
n Children are willing to help, to participate and to mobilise others;
n They can foster cohesion among affected community members during times of crises.
n Children can save and care for other children;
n Children are best placed to build rapport and trusting relationships with other children;
n Children can be more resilient than adults – they can bounce back faster;
n Children are less concerned with social and economic divisions in their
communities than adults. They are more inclusive;
n Children are less attached to material things than adults; and
n Children find it easier than adults to understand other children.
Save the Children offered some recommendations in involving children as social

actors in emergencies and transition phases:10
n Involve children as social agents or “social entrepreneurs” in their own
right, with the capacity to influence their situation and their communities
in a positive way. Supporting children’s wellbeing requires the perspective not
just that children need special protection, but that they have valid insights into
their well being, valid solutions to their problems and a valid role in implementing
those solutions for their own benefit and that of their communities.
n Approach children with a focus on their competencies and strengths, on
regenerating resiliency as understood by those children and their
elders. Through participatory approaches, educators and development workers
can be encouraged to learn about children’s own perspectives and
understandings of adversity and their own ideas about coping and resilience.
© UNICEF/Afghanistan 00212S/ Roger Lemoyne
AFGHANISTAN: Adolescent
girls raise their hands in class
at a girls' high school in
Faizabad, capital of the north-
eastern province of
Badakhshan -- part of the less
than 10 per cent of the country
not controlled by the Taliban.
n Focus on rebuilding a sense of community through the restoration of

normal every day routines and activities. Where possible, such strategies
could include rebuilding family and community networks, re-establishing
productive capacity, providing opportunities for recreation and play, developing
mechanisms for justice and retribution, among other interventions.
n Understand that relief and reconstruction efforts have a psychosocial
dimension, where needs are defined by local people and reconstruction efforts
engage the people to meet their own basic needs and recreate the necessary
social spaces for social healing to take place.
n Recognize that psychosocial needs are long-term, and therefore it is
essential to give attention to participatory processes to address issues of
sustainability. Ensure that all efforts contribute to the promotion of girls’ and
boys’ ongoing and long-term development in the best ways possible.
n Base relief, emergency and development processes on an accurate
assessment of capacities and vulnerabilities with full participation of girls,
boys, women and men of the affected communities. All information should
be disaggregated according to gender, age, as well as other social variables.
n Ensure efforts are non-discriminatory. No child should be discriminated
against due to gender, ethnicity, caste, religion, disability, or nationality.
Monitoring efforts should include a focus on which children are included or
excluded in relief and emergency efforts.
n Engage with girls, boys, women and men from the target population as
agents of their own recovery, so that relief efforts do not increase the
recipients’ feelings of powerlessness and dependence.
n Include a focus on capacity building - training, mentoring, resources - for
local caregivers to work with children, rather than sending foreign psychosocial
workers to work directly with war-affected children for short-term missions.
n Encourage opportunities for girls and boys to express issues which

concern them and involve them in discussing issues of immediate local
concern. This will help them to learn problem-solving skills and to gain a sense
of control over their lives. Sharing grief with others may help children to
overcome their sense of loss.
n Maximise opportunities which make use of space for creative forms of
expression such as art, drama, story telling, play, poetry, music,
puppetry and other cultural art forms.
n Develop child protection approaches which build upon local resources
and local understanding of girls, boys, women and men.
COMMUNICATION
n Promote programmes which encourage children’s active participation
in decision-making, problem-solving, team building and peer mentoring
BEHAVIOUR CHANGE
HYGIENEIN PROMOTION
to reinforce individual attributes in children that contribute to self-
esteem, self-efficacy and coping.
n Encourage cultural activities, games, sports and recreational activities which
enable children to relax, to have fun and to cooperate with one another.
EMERGENCIES
n Provide safe spaces for interaction with peers and promote positive
opportunities for girls, boys and youth to come together and to organize
themselves and their own programmes. There is considerable evidence that
social support from peers can enhance children’s resilience. Furthermore,
through collective organization, children can learn the art of self-protection, self-
representation and self-advocacy.
n Promote and support peace and respect for human rights.
n Cooperate, coordinate and integrate work with other agencies
n Take every opportunity to promote efforts by other agencies which
respect children as competent social actors, and validate self-efficacy
and decision making ability of girls, boys, women and men in the
affected communities.
RESOURCE BANK
Further reading
1. Bhatti A, Ariyabandu M.M., Disaster Communication, A Resource Kit for Media
ITDG Sout Asia, Duryog Nivaran, Islamabad, 2002
2. Burke, A., Communications and Development. A practical guide, DFID, London, 1999.
3. McKee, N., et al., (editor), Involving People, Evolving Behaviour, UNICEF,
Penang, 2000.
4. Oxfam, Guidelines for Public Health Promotion in Emergencies, Oxfam UK, 2001.
5. Parks, W., et al., Planning Social Mobilisation and Communication for Dengue
Fever Prevention and Control, WHO, Geneva, 2004.
6. Rogers, Everett M., Diffusion of Innovations (4th edition), New York, Free Press, 1995.
7. United Nations Children’s Fund, ROSA, Strategic Communication for Behaviour
and Social Change in South Asia, UNICEF, Kathmandu, 2005.
8. World Bank, Strategic Communication for Development Projects: A toolkit for
task team leaders, Washington, D.C., 2003.
Web sites
1. Center for Communication Programs (CCP)
http://www.jhuccp.org
2. Development Gateway
http://www.developmentgateway.org
3. Duryog Nivaran: South Asian Network for Disaster Mitigation
http://www.duryognivaran.org
4. IDS Participation Group Page
http://www.ids.ac.uk/ids/particip/index.html#pghome
5. InfoDev http://www.infodev.org/
6. Janathakshan.org http://www.janathakshan.org
7. The Communication Initiative http://www.comminit.com
Footnotes
1
United Nations Children’s Fund, Core Commitments for Children in Emergencies, UNICEF, New
York. 2005.
2
UNICEF ROSA, Strategic Communication for Behaviour and Social Change in South Asia,
Kathmandu, Nepal, 2005, p. 7.
3
Adapted from McKee et al., op.cit., pp. 50-51.
4
Waisbord, S., Family Tree of Theories, Methodologies and Strategies in Development
Communication, (unpublished paper), Rockefeller Foundation, pp. 20-21.
5
Adapted from UNICEF ROSA, Strategic Communication for Behaviour and Social Change in
South Asia, p. 28.
6
Source: Jude Henriques, Programme Communication Officer, UNICEF Office for West Bengal
and Assam.
7
The IAG consists of the members of the international organisations such as UNICEF, DFID,
CARE, OXFAM, CRS, CASA, CARITAS, Rama Krishna Mission, LWS, MCC, SCF, WBVHA and
Children International, USAID, Action Aid, CINI (GOAL), World Vision, SPADE and ABCD.
8
Additionally, ATI, GOWB, DFID, CARE, CARITAS, CRS, WBVHA, OXFAM and other agencies
participated in the monthly review meetings and provided technical assistance.
9
Based on a paper by Joachim Theis, EAPRO Youth and Partnership Officer, presented during
the Children and Young People’s Participation in the Tsunami Forum and Fair, Phuket, Thailand,
November 2005.
10
From a paper entitled “Responding to Children as Social Actors in Emergency Relief Response”
by Claire O’Kane, Project Co-ordinator, “Children, Citizenship and Governance” Save the
Children Alliance (South and Central Asia), October 2001
© UNICEF/AFGHANISTAN00900D/Asad Zaidi
CHAPTER- 4
HYGIENE PROMOTION
CHAPTER- 4
HYGIENE PROMOTION
WHY PROMOTE HYGIENE IN EMERGENCIES?
PRINCIPLES OF HYGIENE PROMOTION
DOING THE GROUNDWORK
GETTING THE MESSAGE RIGHT
COMMUNICATION ACTIONS FOR HYGIENE PROMOTION
MONITORING MILESTONES
PRACTICAL EXPERIENCES
RESOURCE BANK
WHY PROMOTE HYGIENE

IN EMERGENCIES?
Hygiene is the practice
© UNICEF Pakistan
of keeping oneself and
one's surroundings
clean, especially in
order to prevent illness
or the spread of
disease. Emergencies
create an environment
in which germs flourish: PAKISTAN: A mother washes her daughter’s hands with soap and water near their
temporary shelter.
over crowding,
traumatised immune systems, poor (or no) access to facilities,
latrines, safe water and exposure to disease pathogens - all of which
HYGIENE PROMOTION
endanger people's health and survival.
Research shows that hygienic practices

can have an equal or greater impact on
Common myths in hygiene disease prevention than water supply and
promotion that you can avoid. sanitation facilities. Modern thinking
1. People are empty vessels into suggests that the two must go hand-in-
which new ideas can simply be hand to effectively combat disease and to
poured. boost healthy, sustainable hygienic
2. People will listen to me because behaviours.
I'm medically trained.
3. People can learn germ theory in a What is hygiene
few sessions at the health centre. promotion?
4. Health education can reach large Hygiene promotion empowers people to
populations. prevent disease. It is the process of
5. Knowing means doing. influencing people’s knowledge, attitudes
and practices, and an agency’s knowledge
Source: Curtis, V.5
4
F-DIAGRAM:
and HOW
resources DO PEOPLE
which CATCH
together DIARRHOEA?
enable family members to avoid risky behaviours
related to water use, waste and excreta disposal and cleaning habits.1
The key ingredients to effective hygiene promotion are:

n A mutual sharing of information and knowledge.
n Mobilising communities for concerted action.
n Providing essential supplies and facilities.
We can group hygiene promotion into three categories:2

n Reducing high-risk hygienic practices.
n Promoting appropriate use and maintenance of facilities.
n Promoting participation in programmes.
Such a multi-pronged approach should enable the affected community to practice

hygienic behaviours and stay healthy.
The role of hygiene promotion in emergencies

Preventing diarrhoeal infection by promoting hygienic practices should be your
communication priority Number One in an emergency situation. In camp situations,
diarrhoeal diseases can account from 25 to 40 percent of deaths in the acute phase of an
emergency. More than 80 percent of the deaths usually occur in children under 2 years.
The F-diagram below illustrates the different routes diarrhoea microbes take from faeces
to a person. Interrupting the transmission chain, thus, should be your first priority.
F-diagram: How do people catch diarrhoea?4
Fluids
Fingers
Faeces Food New host
Flies SB
PB: Primary barrier

Fields SB: Secondary barrier
PB SB Adapted from Kawata, 1978
© UNICEF/NEPAL/Martin Chamberlain
PRINCIPLES OF
HYGIENE PROMOTION
In emergency situations, you have to
coordinate closely with all agencies
involved in relief work on a small
number of hygiene messages of
proven public health importance.
NEPAL: Teaching proper hand washing
techniques in Pumdi Bhumdi, 2004.
Coordination of programme
communication activities avoids
duplication of efforts and wasting of time and resources - both of
the programmes and of the affected community. Apply the following
essential principles to hygiene promotion:
HYGIENE PROMOTION
1. Focus on a small number of risk practices
To control diarrhoeal disease, your messages should highlight the priority hygiene
practices: hand wash with water and soap, or when not available use ash after
contact with faeces; and safe disposal of adults’ and children’s faeces to prevent
infection and contamination – i.e. clear scattered faeces, control open defaecation
and shallow trench latrines, repair toilet facilities and/or build temporary family or
communal latrines.6
2. Involve specific participant groups

Involve fathers, mothers, children, older siblings, opinion leaders and other
influential persons and groups in the affected community. Public health promoters
need to identify primary child caregivers and those who influence and make
decisions for them. Involve these influencers in the different stages of a health
promotion initiative.
3. Identify the motives for adopting

positive behaviours
By working with the various participant groups from affected
communities you can discover individual views of the benefits of
safer hygiene practices. This insight can provide the basis for a
motivational strategy.
4. Keep hygiene messages positive

People learn best when they laugh and pay attention longer if they
are entertained. Programmes that attempt to frighten the audiences
will tend to alienate them. Therefore, avoid the mention of death in
hygiene promotion programmes.
A special word on female hygiene

Provisions for female hygiene have often been neglected in hygiene
promotion programmes. Recent lessons from emergency responses
in South Asia clearly show that many girls and women find it difficult
to practice female hygienic behaviours because of one or more of
the following constraints:
n Unavailability of underwear and sanitary napkins.
n Inaccessibility to sanitary napkins; and/or the manner in which
sanitary napkins are distributed in the camps and affected
areas.
n Lack of clean water and soap for washing and laundering.
n Lack of privacy to change and wash, launder underwear and
menstrual rags (in the absence of disposable sanitary napkins).
n Inappropriate positioning of female latrines.
n Social taboos attached to menstruation.
n Lack of knowledge or sensitivity among camp managers and relief
workers to hygiene and sanitation-related needs and requests.
These issues make a strong case

© UNICEF Pakistan
for the need of a gender-sensitive

emergency response team in the
camps/affected areas. These also
call for sensitivity training for male
camp managers, government
officials and health workers to
ensure that the needs of women
and girls are provided for.
A case in point
In the 1998 Bangladesh floods, adolescent girls reported perineal rashes and urinary
tract infections because they could not properly wash themselves, and launder and dry
menstrual rags in private. They also lacked access to clean water. The girls said they
wore the still damp clothes because they did not have a place to dry them.
Women and girls of reproductive age must have access to appropriate materials for
absorption and disposal of menstrual blood. Hygiene promoters should advocate for
providing private facilities for girls and women to wash themselves, wash and dry
underwear and sanitary clothes, and properly dispose of women’s sanitary napkins.7

Doing the groundwork for your hygiene emergency response depends on
how well you were prepared in the first place, what data and capacities
HYGIENE PROMOTION
exist, and which partnerships and networks you work with - whom you can
quickly tap. When you do your ground work (rapid communication
assessment), keep in mind to build on what people already know rather
than importing ideas from people the community regards as “outsiders”.
This should be the basis for any hygiene promotion programme.
The following diagram shows how your planning team should work together
with representatives of the affected community in the rapid communication
assessment, which is also a formative research process. Your aim is to
answer four main questions: Which specific practices are placing the people's
health at risk? What messages are most crucial? What or who could (serve
as effective channels) motivate them to adopt new practices? Who should be
targeted by the hygiene promotion initiative? And how can we communicate
with these groups effectively?
Assessment stages RAPID COMMUNICATION ASSESSMENT

FOR HYGIENE PROMOTION 8
In an emergency situation one of
the first steps to doing the
groundwork is the rapid
assessment. There are different
stages involved in the doing the
assessment. These stages help
you to plan, monitor and adjust
your hygiene promotion
programme according to
behavioural results and feedback
from affected community groups,
health and relief workers, camp managers and other stakeholders.
Stage I: You can do an initial rapid assessment using tools such as exploratory or
transect walks and interviews with key informants from the camps or affected areas,
as the case may be, in order to identify priority issues. You need to do this in the
first few days after a disaster, working with the emergency rapid assessment team.
Stage II: Use the initial data from Stage I in group discussions with camp
managers and dwellers, as appropriate, with assessment tools such as mapping,
network analysis, focus group discussions and household observation. This could
be undertaken between weeks two and four after a disaster.
Stage III: Obtain a deeper understanding of what people know, do and think, by
using tools such as matrix ranking, seasonal calendars, three pile sorting, pocket
charts and gender analysis (see below), also as appropriate and feasible. You can
choose to do this after you have collected the initial data.
Assessment tools
Please refer to Part III of the toolkit for further participatory assessment and
planning tools. You can also use the two simple examples below to help you
understand the hygiene practices and beliefs of the affected community.
Ranking exercise
In a ranking exercise, ask participants to rank their health needs and priorities on a
numerical scale that you would have prepared earlier. A facilitator then guides a
discussion with the participants on the relevance and appropriateness of their
choices. Ranking provides a quick way to assess the affected community’s
hygiene and sanitation practices and gets them involved in the initial stages of a
hygiene promotion programme. Please see Tool 7 in Part III of the toolkit.
© UNICEF Pakistan
PAKISTAN:
Women and
children who
were displaced
by the South
Asia earthquake
in October 2005
fetch water from
a water tank
provided by
UNICEF.
Focus group discussions

You can do focus group discussions (FGDs) in an emergency situation even
among a few participants, say three to five. FGDs help you determine what
motivates people in the affected community to adopt safe practices and barriers for
HYGIENE PROMOTION
doing so. It is more productive to group the older women, young women,
adolescent girls, men, etc., separately. By so doing, you can elicit uninhibited
responses. The qualities of the facilitator and the democratic manner in which the
discussions are conducted are critical to your effectiveness in eliciting reliable
information. Consider that most hygiene-related information is personal in South
Asian cultures and affected groups may share this information only with trusted
and/or respected persons, among peer groups or in private.
Note on focus groups:

You can make arrangements for an FGD at any stage of an initiative. You can also
use it to share new information with affected community members, while learning
about their practices and beliefs. Please See Tool 8 in Part III of the toolkit.
Developing behavioural objectives

Once you have completed the initial rapid assessments, you can then develop
SMART behavioural objectives for your hygiene promotion programme. The
behavioural objectives depend on many factors including the severity of an
emergency, pre-existing knowledge and practices, access to and availability of
water and sanitation facilities. Please see Tool 1 in Part III of the toolkit.

Be mindful that in emergencies, having
© UNICEF/Nepal
too many messages can create
confusion. The only way to make a
sensible choice is to know the main risk
factor for disease and death - diarrhoeal
infection - and to know what practices are
common among the affected families and
communities. Messages also need to
reach the emergency and camp
managers and health workers to ensure
that the required supplies, facilities and
services are available to the affected
NEPAL: A young girl fetches water from deep well.
community groups.
While there are many factors that

can help prevent diarrhoeal infection, What is the correct
evidence suggests that the two main way to wash hands?
factors are:
Use at least 0.5 litres (8 ounces) of
1. Hand washing with soap or ash
water, and soap or ash, and rub your
after contact with faeces. hands in at least three different
2. Safe disposal of adults' and directions.
children's excreta.
Note: Use locally understood
These are the two most important measursements!
practices that you need to promote
to prevent diarrhoeal infection in the Source: The sustainability of hygiene behaviour and the
effectiveness of change interventions.9
initial emergency response.
The key-hygiene related messages

for all family members, including Building a local lexicon
children are:
Discovering local names for diseases
n Wash your hands thoroughly
helps the affected community link
with water and soap, or, if soap
illnesses with causes, preventions and
is not available, water and ash,
cures; and it allows programmers to tailor
after contact with faeces and the messages.
before touching food or before
feeding children. In Zaire, people use 6 names to describe
n Dispose of all faeces safely. illnesses that are accompanied with
The best way is to use a toilet loose stools. A survey found that more
or (pit or trench) latrine, or other than 50 percent of the respondents used
appropriately safe alternatives. ORS to treat kuhara, but less than one-
sixth of the respondents used ORS to
When diarrhoeal infection is not the treat lukungga and kilonde ntumbo - all
diseases with diarrhoea symptoms.
most important risk factor
Programmers adjusted the messages to
anymore, address the range of
promote ORS use for each of the six
other risk factors through good
diseases separately rather than using a
hygiene practices like drinking safe general term such as diarrhoea.
water, clean food preparations and
safe disposal of household refuse. Source: Strategic Communication for
Development Projects10
HYGIENE PROMOTION
Key messages can include:
Keeping water clean and safe

n Use only water that comes from a safe source or is purified.
n Boil water until the bubbles appear.
n Drink only safe water.
n Use clean containers with lid/cap to store water.
n Use a clean cup for drawing water from the container, making sure your hands
are clean too.
Handling food safely

n Wash hands with soap or ash before preparing food.
n Always cover cooked food.
n Keep kitchen and cooking utensils and water containers clean.
n Keep rubbish bin away from food and cooking.
Safe household refuse disposal

n Put rubbish in bin with lid.
n Empty your rubbish in a collective pit.
n When full, cover rubbish in collective pit with soil.
n If you have a problem with your rubbish, contact:

1. Camp management.
2. Municipal council.
3. Urban council.
Developing and choosing the right and appropriate local variations of these basic
messages depends on (1) your knowledge of the main risk factors for disease and
death in the emergency situation, and (2) your knowledge of which practices are
common among the affected families and communities.
COMMUNICATION
© UNICEF Pakistan
ACTIONS FOR
HYGIENE
PROMOTION
UNICEF’s response to emergencies
is guided by the Core Commitments
for Children in Emergencies (CCC),
which provide the overarching
organisational framework in a
humanitarian response (see Chapter
3). The table below outlines
UNICEF’s Core Commitments for
PAKISTAN: Children wait for their turn to use the latrine in one of the
camps for people displaced by the South Asia earthquake. Children in Emergencies in the
areas of Water, Sanitation and
Hygiene. We included suggested BCC and social mobilisation activities that have
shown evidence to improve hygiene situations in an emergency. Remember to plan
your risk communication and social mobilisation actions with the participation of the
affected community, the children, youth and your partners, and to carefully monitor
and evaluate the programme.
When you choose the mix of communication actions remember that a key aspect to
hygiene promotion is to target a small number of risk practices only. For this reason,
it is important for you to plan the activities in stages rather than trying to tackle all
risky behaviours at once.11 Your mix of hygiene promotion actions depends on the
impact of the disaster; identified priorities; cultural and socio-economic contexts of
the affected community; availability of facilities; and existing partnerships and
capacity – both human and financial.
TABLE: UNICEF’s CCC in the areas of Water, Sanitation and

Hygiene and corresponding BCC and social mobilisation support
FIRST SIX TO EIGHT SUPPORTIVE BCC AND

WEEKS SOCIAL MOBILISATION ACTIONS
1. Ensuring the n Make sure that those who are providing water
availability of a supplies are in dialogue with women and girl
minimum safe representatives to determine the best modes,
drinking water times, locations and/or distribution points for
supply taking into water supplies.
account the privacy,
dignity and security
of women and girls.
2. Providing bleach, n Make sure the affected community and service

chlorine or water providers receive information on the importance
purification tablets, of and how to use bleach, chlorine or water
including detailed purification tablets – i.e. through loudspeaker
user and safety announcements, printed materials, and IPC.
instructions in the n Train motivated and interested people who live
local language. in or near the camp to provide group
HYGIENE PROMOTION
demonstrations on how to use bleach, chlorine
and water purification tablets.
n Enable service providers through
communication skills and counselling training
to communicate with and motivate affected
individuals and families to use bleach, purify
water with chlorine or water purification tablets.
n Mobilise and engage community volunteers to
monitor changes.
3. Providing jerrycans, n Assess the level of knowledge on hygiene

or an appropriate aspects in the different populations of the
alternative, including affected community (since it can vary widely)
user instructions and remembering that this is an area where most
messages in the related activities are carried out by women and
local language on girls.
handling of water and
disposal of excreta
and solid waste.
TABLE: UNICEF’s CCC in the areas of Water, Sanitation and Hygiene

and corresponding BCC and social mobilisation support Contd..

n Ensure affected community receives information

on importance of and how to handle safe water,
dispose of excreta and solid waste – i.e. using
a combination of loudspeakers, IEC materials,
community radio, and/or peer educators.
n Enable hygiene promoters, facilitators, peer
educators, animators to provide one-to-one or
small group participatory hygiene education.
Ensure they can handle questions and clarify
doubts.
n Enable service providers to communicate with
and motivate affected individuals and families to
wash hands, handle safe water, and dispose of
excreta and solid waste.
n Engage motivated school-aged children or other
interested groups to observe and share
information on the handling of safe water,
disposable of excreta and solid waste.
4. Providing soap and n Establish and train a team that is familiar with
disseminating key local practices and social structures.
hygiene messages n Use local languages or pictograms if possible.
on the dangers of n Work through existing social structures to:
cholera and other ensure affected communities receive soap and
water- and excreta- information on benefits of hand washing,
related diseases. cholera prevention and the prevention of other
excreta-related diseases.
n Ensure that affected communities, especially
primary caregivers, know how to wash hands
with soap, and how to prepare ORS to prevent
dehydration, by giving demonstrations on hand
washing and how to make ORS/ORT.
n Train female communication agents, including
community health workers, volunteers and Girl
Guides to ensure women’s and girls’ access to
basic health and hygiene information.
TABLE: UNICEF’s CCC in the areas of Water, Sanitation and Hygiene

and corresponding BCC and social mobilisation support Contd..

n Train motivated school-aged children or other

groups to demonstrate proper hand washing
techniques, and for them to observe community
practices as part of monitoring.
5. Facilitating the safe n Make certain that affected community receives

disposal of excreta information on importance of and how to keep
and solid waste by human (including infant) faeces from public and
providing shovels or living areas, the importance of using latrines –
funds for contracting i.e. using IEC materials (including flip charts),
local service demonstrations on how to dispose of infant
companies; faeces/diapers.
spreading messages n Engage positive deviants or people who bury
on the importance of infant faeces and dispose solid waste properly,
keeping excreta as positive role models.
(including infant n Enable service providers to communicate with
HYGIENE PROMOTION
faeces) buried and and motivate affected individuals and families to
away from safely dispose of excreta and solid waste,
habitations and safely dispose of human and animal corpses,
public areas; and the use of trench/pit latrines.
disseminating n Train motivated young people to be “link
messages on leaders” between camp residents and
disposal of human government officials – i.e. to report on broken
and animal corpses; and unsanitary facilities, observe facility
and giving maintenance and use; and help with monitoring.
instructions on, and
support for,
construction of
trench and pit
latrines
In the initial response of an emergency, many activities are likely to be

led by programme staff, relief workers and government officials with the
assistance of a rapidly mobilised task team of community volunteers. It
is essential that you only implement the basic immediate actions this
way. Be sure to plan, implement and monitor all long-term aspects of
the programme in partnership with affected community groups and other
relevant stakeholders.12
BEYOND INITIAL SUPPORTIVE BCC AND SOCIAL

RESPONSE MOBILISATION ACTIONS
1. Making approaches
and technologies
used consistent with
national standards,
thus reinforcing long-
term sustainability.
2. Defining UNICEF’s
continuing
involvement beyond
the initial response
by:
n Establishing, n Make sure the affected community has the

improving and knowledge of how excreta contaminates water
expanding safe and contributes to the spread of diarrhoeal
water systems for disease, and the relation between unsafe water
source and cholera – i.e. through group discussions,
development, children volunteers, loudspeakers, community
distribution, radio, community theatre and IEC materials.
purification, storage n Mobilise the community to keep water safe – i.e.
and drainage, train camp residents as water source attendants
taking into account who encourage people not to defecate near water
evolving needs, sources; train support workers to chlorinate all
changing health wells and test for residual chlorine levels.13
risks and greater n Train health workers and other service providers on
demand. specific cholera, diarrhoea prevention methods.
Enable them to motivate affected community to
handle safe water, purify water through boiling,
chlorination or water purification tablets.

n Providing a safe n Strengthen community knowledge of handling
water supply and safe water and importance of and how to wash
sanitation and hand hands with soap, using latrines – i.e. through IPC
washing facilities at like animators, IEC materials, etc.
schools and health n Train educators, health workers, school-age
posts. children and camp/community residents to
demonstrate proper hand washing techniques.
n Empower service providers with tools and
information to motivate school-age children and
community to use latrines and to wash hands
with soap or ash after defecation.
n Observe pump and latrine maintenance and
promote hand washing practices at schools and
health posts as part of monitoring.
n Supplying and n Involve the community in the design,

upgrading sanitation implementation, and maintenance of sanitation
facilities to include facilities so that the facilities are culturally
semi-permanent appropriate, private, child-friendly, accessible by
HYGIENE PROMOTION
structures and the disabled – and in line with the Sphere
household Standards, which can be reviewed at http://
solutions, and www.sphereproject.org.
providing basic n Enable service providers to motivate the affected
family sanitation community to use sanitation facilities and basic
kits. family sanitation kits.
n Specifically enable female service providers or
community health volunteers to communicate
with girls and women about female hygiene.
n Ensure that girls and women have access to
appropriate materials for absorption and disposal
of menstrual blood, that facilities allow the
disposal of women’s sanitary napkins or provide
the necessary privacy for washing themselves
and for drying sanitary clothes.

n Train motivated school-age children and
interested groups to attend and monitor latrines –
i.e. report on broken or unsanitary latrines and
water pumps, observe facility/latrine use for
monitoring purposes, and put up motivational IEC
materials with hygiene messages, e.g. posters.
n Establishing regular n Identify main risk practices to adjust your

hygiene promotion hygiene promotion initiative in affected areas.
activities. n Ensure that affected individuals and communities
understand good hygiene practices – i.e. by
using a mix channels like street plays, traditional
folk media, video showings, and other appropriate
art forms that draw out local talents.
n Provide supportive supervision to ensure that
hygiene promoters are discussing ways to
prevent diarrhoea, cholera and other excreta-
related diseases with affected communities – i.e.
by advocating hand washing with soap or ash
and the use of latrines and by organising training
sessions for community and opinion leaders on
ways to reduce risk of diarrhoea, malaria or
cholera cases/outbreaks. 14
n Mobilise community to monitor any changes –
i.e. hold community meetings to discuss and
share monitoring findings. Jointly decide on how
the initiative can be improved.
n Planning for long- n Facilitate water-related discussions on making

term solid waste safe water available. Clearly identify the
disposal. relationship between safe water, waste disposal
and disease and relate those factors to action –
both in the preparedness and emergency
phases.
n Engage affected communities in planning safe
ways to dispose of solid waste – i.e. by involving
them in identifying solutions and developing
monitoring plans.
One of the main aims of a hygiene promotion initiative in an
emergency situation is to ensure that all populations of the affected
community know and adopt the priority hygiene practices to protect
their health. The following section presents the key indicators to
measure hygiene practices related to excreta disposal.15 Tool 13 in
Part III lists possible sources of information to help you
measure the indicators.
Key indicators for good hygiene practice

n People use the toilets available and children’s faeces are disposed of
immediately and hygienically.
n People use toilets in the most hygienic way, both for their own health and for the
health of others.
n Household toilets are cleaned and maintained in such a way that they are used
by all intended users and are hygienic and safe to use.
HYGIENE PROMOTION
n Parents (mothers and fathers, or other primary caregivers) demonstrate
knowledge of the need to dispose of children’s
© UNICEF Pakistan
faeces safely.
n Families and individuals participate in a family
latrine programme by registering with the agency,
digging pits or collecting materials.
n People wash their hands after defecation and
handling children’s faeces and before cooking and
eating.
n People demonstrate correct hand washing and
know when to engage in this behaviour.
Key indicators for the design

and implementation of your
hygiene promotion programme
Ideally, you should base your hygiene promotion
activities on the specific vulnerabilities, needs and
preferences of all populations in the affected
PAKISTAN: A woman cleans a latrine in one of
the temporary camps for people who were
displaced by the South Asia earthquake.
© UNICEF Pakistan
PAKISTAN:
Adolescent girls
cooking outside
their family tent in
one of the camps
for earthquake
affected families.
communities. These are often influenced by factors like displacement, age,

gender, ethnicity, disability and socio-economic status. Take note of the following
key indicators for measuring the design and implementation of your hygiene
promotion programme:16
n Key hygiene risks of public health importance are identified.
n Programmes include an effective mechanism for representative and participa-
tory input from all users at all phases, including the initial design and location of
facilities – making sure that latrines accommodate the disabled; are well-lit and
designed to protect women from sexual molestation; and provide girls and
women the privacy to cleanse themselves, wash underclothes and sanitary
rags.
n All groups within the affected community have equitable access to the
resources or facilities needed to practice or continue the proper hygiene
practices.
n Hygiene promotion messages and activities address key behaviours and
misconceptions and reach all participant groups. Representatives from these
groups participate in planning, training, implementation, monitoring and
evaluation.
n Participants take responsibility for the management and maintenance of
facilities as appropriate, and all populations of the affected community
contribute equitably.
Note: Plan the behavioural monitoring and set indicators from the start and
encourage follow-up action. In other words, encourage your staff, partners and
affected communities to do something with the results of monitoring. In planning
the monitoring and evaluation indicators, you need to be concerned about
information for action rather than “information to be more informed”.17
75
75

INDIA: (Second from left) UNICEF
Programme Officer Geeta Athreya
briefs a team of UNICEF animators
before they visit relief centres for
tsunami-affected displaced people,
in the Union Territory of
Pondicherry. The teams are
promoting the use of ORS and good
hygiene practices to prevent and
treat diarrhoea and other water-
related diseases. Team members
are wearing T-shirts bearing the
UNICEF logo.
College students trained to promote hygiene in tsunami relief camps, India

As UNICEF worked to provide and install water storage tanks in Nagapattinam and
other tsunami-affected districts in India, one of the priority goals was to prevent an
outbreak of diarrhoea. With thousands of homeless huddling in 200-odd camps, the
threats from diarrhoea, dysentery and dehydration loomed.
HYGIENE PROMOTION
Just one week after the tsunami hit, UNICEF in partnership with a social marketing
agency, trained 140 college students and cadets to deliver ORS demonstrations. A team
consisted of three student animators, supervisors and UNICEF staff. They travelled by
van, from camp to camp to the worst-hit areas.
One such team stopped at the Shakuntaladevi Ramaswami Kalyana Mandapam – a

reception hall for marriages cum temporary home – to some 300 people. The
animators, supervised by UNICEF’s Geeta Athreya, talked about how diarrhoea breaks
out in crowded, unsanitary conditions; the importance of washing hands with soap and
water after defaecation, before handling food and feeding children. They organised hand
washing demonstrations; trained community volunteers to show others how to prevent
diarrhoea and recognise the symptoms of dehydration. They instructed the affected
individuals on how to prepare ORS.
This experience shows that even in the initial response, group communication approaches
can be used to influence participants to adopt healthy practices. In this case live
demonstrations occurred simultaneously with flyer and pamphlet distribution. Posters
displaying messages about diarrhoea prevention and ORS were also tacked in public areas.
By engaging a mix of communication channels, the hygiene promotion team was able to
increase the possibilities of hygiene messages being heard, remembered and applied.
RESOURCE BANK
1. Almedom, A.M., Blumenthal, U., and Manderson, L., Hygiene Evaluation
Procedures: Approaches and methods for assessing water and sanitation-
related hygiene practices, Herndon IT Publications/Stylus Publishing,
London, 1996.
2. Aubel, J. ‘Participatory Monitoring and Evaluation for Hygiene Improvement -
Beyond the Toolbox: What else is required for effective PM&E?’
Environmental Health Project, Strate.g.,ic Report No. 9, Washington, D.C.,
2004.
3. Curtis V., Cairncross S. and Yonli R. ‘Domestic Hygiene and Diarrhoea:
Pinpointing the problem’, Tropical Medicine and International Health, 5(1),
pp. 22-32.
4. Department for International Development, Guidance Manual on Water
Supply and Sanitation Programmes, DFID, London, 1999.
5. Ferron, S., et al., Hygiene Promotion: A practical manual for relief and
development, Intermediate Technology Publications London on behalf of
CARE International, 2000.
6. Huttly, S., et al., ‘Prevention of Diarrhoea in Young Children in Developing
Countries,’ Bulletin of the World Health Organization, 75(2), WHO, Geneva,
2000, pp.163-174.
7. Narayan-Parker, D., ‘Participatory Evaluation: Tools for managing change in
water and sanitation’, World Bank Technical Paper 207, The World Bank,
Washington, D.C., 1993.
8. Sawyer, R., et al., PHAST Step-by-Step Guide: A participatory approach for
the control of diarrhoeal disease, WHO, Geneva, 1998.
9. Shordt, K., Action Monitoring for Effectiveness: Improving water, hygiene
and environmental sanitation programmes, IRC, Delft, 2000.
10. Srinivasan, L., Tools for Community Participation: A manual for training
trainers in participatory techniques, PROWESS/UNDP- World Bank Water
and Sanitation Program, Washington, D.C., 1993.
11. Sukkary-Stolba, S. ‘Oral Rehydration Therapy: The behavioural issues’,
Behavioural Issues in Child Survival Programs, Monograph Number One,
International Health and Development Associates, Malibu, 1990.
12. United Nations Children’s Fund, Happy, Healthy and Hygienic: How to set
up a hygiene promotion programme, UNICEF, LSHTM, 1998.
13. United Nations Development Program - World Bank Water and Sanitation
Program South Asia Re.g.,ion, Improving User Participation to Increase
Project Effectiveness: Community action planning in an adaptive project -
NWFP community infrastructure project, 1998.
Web sites
1. Global Public-Private Partnership for Handwashing with Soap
http://www.globalhandwashing.org/
2. Health Communication Partnership

http://www.hcpartnership.org/mmc/
3. HealtheCommunication
http://www.comminit.com/healthecomm/index.php
4. HORIZON Communications
http://www.solutions-site.org/artman/publish/
5. IRC International Water and Sanitation Centre

http://www.irc.watsan.net
6. PHAST Step-by-Step Guide: A participatory approach for the control of

diarrhoea
http://www.who.int/water_sanitation_health/hygiene/envsan/phastep/en/
HYGIENE PROMOTION
7. United Nations Children’s Fund
http://www.unicef.org/wes/index.html
8. WELL
http://www.lboro.ac.uk/well/
9. World Health Organization

http://www.who.int/water_sanitation_health/en/
Footnotes
1
The Sphere Project: Humanitarian charter and minimum standards in disaster response, The
Sphere Project, Geneva, 2004.
2
Harvey, P., et al., Emergency Sanitation: assessment and programme design, London, 2003, p. 164.
3
World Health Organization, South East Asia Re.g.,ional Office, Communicable Disease Profile
for Tsunami Affected Area - Indonesia, Communicable Disease Team, WHO Aceh/Indonesia,
WHO/SEARO, Communicable Disease Working Group on Emergencies, 2005.
4
Adapted from Kawata as cited in Harvey et al., op cit., p. 58.
5
Curtis, V., ‘Hygiene Promotion,’ WELL technical brief, Water, Engineering and Development
Centre, Loughborough University, 1999.
6
Harvey et al., op cit., p. 86.
7
Adapted from World Health Organization, ‘Gender and Health in Disaster’, Gender and Health, WHO
Department of Gender and Women’s Health, 2002, p. 2.
8
United Nations Children’s Fund, ‘Towards better programming, a manual on hygiene promotion,’
Water, Environment and Sanitation Technical Guidelines Series, No. 6, UNICEF, New York,
1999, p. 10.
9
IRC, Sustainability of Hygiene Behaviour and the Effectiveness of Change Interventions,
Booklet 1,Delft, 2004.
10
Verzosa, C., Strate.g.,ic Communications for Development Projects: A toolkit for task team
leaders, World Bank, Washington, D.C., 2002, p. 18.
11
Harvey et al., op. cit., p. 172.
12
Ibid., p.265.
13
Adapted from Guidelines for Public Health Promotion in Emergencies, p. 47.
14
Adapted from Guidelines for Public Health Promotion in Emergencies, p. 47.
15
The Sphere Project: Humanitarian charter and minimum standards in disaster responses,
The Sphere Project Geneva, 2004, pp. 60-61.
16
Humanitarian Charter and Minimum Standards in Disaster Responses, pp. 60-61.
17
Parks, W., Final Report on Behavioural Monitoring Workshop, UNICEF, Dhaka, June 2005.
© UNICEF Bhutan
CHAPTER- 5
PROMOTING BREASTFEEDING
CHAPTER- 5
PROMOTING BREASTFEEDING
WHY PROMOTE BREASTFEEDING IN EMERGENCIES?
PRINCIPLES OF BREASTFEEDING PROMOTION
COMMUNICATION ACTIONS FOR BREASTFEEDING
SPECIAL CONSIDERATIONS
RESOURCE BANK
© UNICEF/AFGHANISTAN 00766p/ Roger Lemoyne

WHY PROMOTE
BREASTFEEDING
IN EMERGENCIES?
In nearly all contexts, breastfeeding
is the most beneficial form of infant
feeding for both mother and baby.
Infant feeding is an important issue
in emergencies because:
AFGHANISTAN: Children and women wait to be attended to at a therapeutic
feeding centre for displaced persons run by the international NGO Medecins Sans
Frontieres, on the outskirts of the western city of Herat, capital of the province of
the same name. Most of the displaced are from the drought-affected provinces of
Badghis and Ghor, north-east of Herat, as well as from conflict areas.
§ Nutrition is closely linked to an infant’s health and survival in the short

and long-term.
§ A child’s early nutrition will affect his/her later growth, health and mental
development.
§ Infant feeding practice offers the first bonding between mother and baby.
PRINCIPLES OF
BREASTFEEDING PROMOTION
An emergency is an ever-evolving situation that creates challenges
and opportunities to promote exclusive breastfeeding. The following
principles should guide your breastfeeding communication initiative:1
BREASTFEEDING
PROMOTING
1. All infants, including those born into populations affected by emergencies

should normally be exclusively breastfed for the first six months.
§ The beneficial effects of colostrum in breast milk, particularly in building the
infant’s immune system, are especially important. Infants should be breastfed
on demand from birth, within the first hour after birth.
§ Every effort should be made to identify ways to breastfeed infants whose
mothers are absent or incapacitated.
§ Re-lactation should be attempted before the use of infant formula is considered.
10 steps to successful
2. Every effort should be made to breastfeeding: 2
create and sustain an environment Every facility providing maternity
that encourages exclusive services and care for newborn
breastfeeding for the first six infants should:
months, and continued frequent
breastfeeding thereafter up to two 1 Have a written breastfeeding
years. policy that is routinely
3. The quantity, distribution and use of communicated to all health care
BMS at emergency sites should be staff.
strictly controlled, using the 2 Train all health care staff in skills
following guidelines: necessary to implement this
§ Nutritionally adequate infant formula policy.
(BMS), fed by cup, should be 3 Inform all pregnant women
available to infants who do not have about the benefits and
access to breastmilk. management of breastfeeding.
§ Those responsible for feeding BMS 4 Help mothers initiate
should be adequately trained and breastfeeding within half an hour
equipped to ensure its safe of birth.
preparation and use. 5 Show mothers how-to
§ Feeding infant formula to the breastfeed, and how-to maintain
minority of children who cannot be lactation even if they should be
breastfed should in no way interfere separated from their infants.
with protecting and promoting 6 Give new-born infants no other
breastfeeding for the majority who food or drink other than
can. breastmilk, unless medically
§ The use of infant feeding bottles indicated.
and artificial teats in emergency 7 Practice “rooming-in” to allow
settings should be actively mothers and infants to remain
discouraged and cup feeding together 24 hours a day.
promoted instead, as cups are 8 Encourage breastfeeding on
much more hygienic and easier to demand.
keep clean. 9 Give no artificial teats or pacifiers
(dummies or soothers) to
Note: breastfeeding infants.
Recognise a mother’s right to make 10. Foster the establishment of
and implement decisions regarding breastfeeding support groups
infant feeding, and acknowledge the and refer mothers to them upon
actual and potential role of family discharge from the hospital or
members, and the affected community clinic.
in influencing those decisions.

Your communication initiative to promote breastfeeding will depend
much on which pre-emergency partnerships you have established, for
instance with healthcare providers, community groups, community
health workers, maternity caregivers, school and youth groups,
government agencies and other relevant stakeholders. It will also
depend on how much you know about the affected community’s pre-
existing knowledge, attitudes and practices regarding infant feeding.
This, along with rapid assessments, will give the information needed
to set SMART behavioural results (Please see Tool 1 in Part III of
the toolkit) and design effective breastfeeding promotion strategies.
Doing the groundwork will ensure that your breastfeeding
communication actions, messages and materials are based on an
adequate understanding of the key factors that influence a woman’s
decision to breastfeed.

Experiences from past emergencies show that common barriers and disincentives
to breastfeeding can include following:
§ are mothers believing that they do not have sufficient milk;
§ women not breastfeeding prior to the emergency;
§ breastfeeding practices changing during the emergency;
§ some breastfed infants appearing malnourished;
§ unacceptability of wet nursing due to cultural taboos or HIV prevalence;
BREASTFEEDING
§ separated or orphaned infants;

PROMOTING
§ and/or bottle feeding is the norm.3
Focus group discussions are useful to examine barriers and disincentives

regarding infant feeding in detail, and to educate women and service providers on
the importance of exclusive breastfeeding. See Tool 10 in Part III of the toolkit.
84
FOCUS GROUP DISCUSSION

IN NAGAPATTINAM
A s part of the Indian emergency response to the tsunami, several focus group
discussions were organised to probe into women’s infant feeding beliefs and
practices in Nagapattinam district, located in the State of Tamil Nadu. Besides getting an
inside view on why women in this community chose bottle feeding over breastfeeding,
the FGDs also provided opportunities to clarify myths and doubts and to counsel women
on optimal infant feeding practices and other maternal child health aspects.
Separate focus group discussions were organised with adolescent girls, newly married
couples, and antenatal and postnatal mothers in an attempt to gain information across
the board. A common finding, however, was the strong influence of traditional beliefs and
cultural values on women’s attitudes and practices towards infant feeding. Another
common finding was the need to increase women’s understanding of maternal and
child health.
Specific findings from the FGD included:

§ Many mothers believed that bottle feeding was a harmless and hygienic
practice.
§ Several mothers did not recognise the traditional practice of giving infants
mercury drops immediately after birth as harmful to the infant. They believed this
would avoid skin rash.
§ Some mothers regularly gave their infant “rubber nipples” or pacifiers.
Dr. Durairajan Gopinath, UNICEF Health and Nutrition District Coordinator in

Nagapattinam, explains that the FGDs brought out the following important lessons:
Lessons Learned
1. Prevent or stop the supply of BMS and bottles as a form of relief to mothers.
2. Encourage the supply and use of properly cleaned stainless steel spoons and
cups for artificially fed infants.
3. Gain a thorough understanding of the affected community’s cultural beliefs and
traditions before launching a breastfeeding promotion initiative.
4. Develop clear and precise messages such as:
§ Only breastmilk from birth until 6 months.
§ Stop bottle feeding (unless an exceptional case).
Common myths about
© UNICEF/AFGHANISTAN 00580S/ Jeremy Hartley

breastfeeding in
emergencies
MYTH: Women under stress cannot
breastfeed.
TRUTH: Women under stress CAN

successfully breastfeed.
AFGHANISTAN: A woman is feeding solid food to her baby.

Milk production is stable; but milk
release (let down) can be affected by
Pocket chart stress. The treatment for poor milk
A pocket chart can be used to explore release and for low production is
or examine the affected women/ increased suckling and social
community’s infant feeding preferences support. The most effective support
for a breastfeeding woman comes
and practices more closely. This
from other breastfeeding women.
exercise can also be used as a means
of information exchange – to protect, MYTH: Malnourished women don’t
support and promote breastfeeding – by produce enough milk.
increasing knowledge and engendering
supportive attitudes across all sections TRUTH: Malnourished women DO
of the affected community. See Tool 6 produce enough milk.
in Part III of the toolkit
It is extremely important to
Setting behavioural distinguish between true cases of
results insufficient milk production (very
rare) and mistaken perceptions. Milk
Once you have identified the incentives
production remains relatively
and barriers to breastfeeding in unaffected in quantity and quality
emergencies, you can easily develop except in extremely malnourished
SMART behavioural results. Some women. Malnourished women and
BREASTFEEDING
points to consider when setting children are best served by feeding

PROMOTING
behavioural results are the cause and the mother and letting her
severity of the disaster, the affected breastfeed the infant. By doing so,
community’s pre-existing infant feeding you protect the health of both mother
practices, and social taboos and and child. Giving supplements to
misconceptions about breastfeeding infants decreases suckling and so
and wet nursing. Please see Tool 1 in can reduce milk production.
Part III of the toolkit.
GETTING THE
MESSAGE RIGHT T he treatment for insufficient milk
production–real or perceived–is to
increase suckling frequency and
When developing breastfeeding duration, ensure the mother has
sufficient food and liquids, and offer
promotion messages, remember reassurance from other breastfeeding
that women, mothers and women.
primary caregivers are often the MYTH: Breastmilk substitutes are

needed during an emergency.
main audience for behaviour
change in an emergency, as TRUTH: Usually, breastmilk substitutes
are NOT appropriate.
humanitarian workers are
There are appropriate guidelines on
communicating messages for the use of breastmilk substitutes and
diarrhoea prevention, measles other milk products in emergencies.
They include the WHO International
vaccination, and other hygienic Code of Marketing of Breastmilk
Substitutes (May 1981), the UNHCR
practices to keep children and guidelines on the use of milk
adults alive and well. substitutes (July 1989), and the World
Health Assembly resolution 47.5 (May
1994). Under the Code, donors must
Consider three main ensure that any child who receives a
breastmilk substitute is guaranteed a
factors to getting the full, cost-free supply for at least six
message right: months.
1. It is important to only focus on a
few messages that are vital to Health workers may need training on
influencing women to exclusively how-to help women who have difficulty
breastfeed. Use participatory breastfeeding because of incorrect
communication methods such as positioning, cracked nipples or
group meetings with primary engorgement. A mother’s fear that she
caregivers, peer educators and one- “may not have enough milk” is often a
cause of early termination of
to-one counselling to discuss these
breastfeeding. This (mis)perception
vital infant and child health related
may be intensified by the stress of an
messages. emergency situation.
2. You may have to counter some Health workers should encourage

harmful messages and optimal breastfeeding behaviours.
advertisements regarding the use of

BMS with positive ones that MYTH: General promotion of
reinforce the benefits of breastfeeding is enough.
breastfeeding.
TRUTH: Breastfeeding women
3. Different groups of women, families NEED assistance; general
and communities in an emergency promotion of breast-feeding is
NOT enough.
are likely to have unique infant
feeding beliefs, practices and
Most health practitioners have little
challenges that we have to
knowledge of breastfeeding and
understand before launching a lactation management. Women
communication initiative. Note that who are displaced or are in
the emergency may lead to a emergency situations are at
breakdown of internal family increased risk of breastfeeding
support systems – partners, problems. They need help, not just
mother, mother in law, sisters, motivational messages. Health
aunts – and other people in the workers may need to be trained to
family who traditionally influence give practical help to women who
and support mothers’ infant feeding have difficulty breastfeeding
because of incorrect positioning,
choices.
cracked nipples or engorgement.
Keep in mind: A mother’s fear that she “may not

Past emergencies have revealed two have enough milk” is often a
main behaviours that keep babies alive cause of early termination of
and healthy: breastfeeding. This
1. Women that can breastfeed do so (mis)perception may be
exclusively for the infant’s first 6 intensified by the stress of an
months. emergency situation. Health
2. Women that cannot breastfeed workers should encourage
have access to an adequate optimal breastfeeding behaviours,
even if they require selective
amount of appropriate BMS, can
feeding of lactating women.
safely prepare it, and cup-feed their
BREASTFEEDING
infants.
PROMOTING
Policies and services which
undermine optimal feeding, such
In the initial response of an emergency, as giving food supplements to
the above mentioned are the two most infants less than six months and
important infant feeding practices that using bottles for Oral Rehydration
should be promoted. Salts (ORS) delivery, should be
avoided.
What do we
need to know? Priorities of alternatives for infant
The following messages cover a range feeding in emergencies
of information on what different 1. Breastfeeding
audiences (adolescent girls, pregnant/ 2. Wet nursing*
lactating women, mothers, health 3. Breastmilk from Milk Bank
workers and other service providers) 4. Generically packaged infant
need to know. formula
5. Locally purchased branded
Breastfeed exclusively for the formula
first 6 months4 6. Stop-gap home made
§ Almost every mother/woman can recipes
*The practice of wet nursing may be
successfully breastfeed.
unacceptable or inappropriate in
§ Breastmilk alone is the only food situations of high HIV prevalence
and drink an infant needs for the where testing, support and
first six months.1 counselling are not available.
§ Breastfeeding helps protect babies
and young children against Source: UNICEF Technical Notes
dangerous illnesses, and creates a
special bond between mother and
child.
§ Stress doesn’t necessarily prevent
a mother from producing milk.
§ Continue breastfeeding babies who
have diarrhoea.
§ Frequent breastfeeding stimulates
milk flow.
Minimise the dangers of artificial breastfeeding

§ Bottle-feeding can lead to illness and death.
§ Use safe water to prepare BMS.
§ Use clean cups to feed BMS; never use bottles.
Create an enabling environment for women who breastfeed

§ Help breastfeeding women with food preparation, childcare.
§ Ensure that lactating women eat nutritious food and take supplements.
§ Establish “safe havens” and support groups for pregnant and lactating women to
help reduce stress.
§ Provide breastfeeding women with special rations, water and supplements, and
provide re-lactation support if needed.
© UNICEF/ Sri Lanka

Healthcare workers are key to breastfeeding promotion
§ Initiate breastfeeding within 30 minutes of birth to stimulate milk flow.
§ Help mothers return to exclusive breastfeeding by increasing frequency of feeds
and ensuring “emptying” of breasts.
§ Re-stimulate lactation where milk production has been affected by stress.
Prevent solicitation of unnecessary donations of powdered milk

and powdered formula, and help prevent unsolicited donations
from being delivered to the camp, shelter or affected community
§ Breastmilk keeps infants in an emergency alive and well.
§ BMS are not affordable to most women in developing countries, and may be
hard to obtain once the emergency stabilises.
BREASTFEEDING
PROMOTING
COMMUNICATION ACTIONS
FOR BREASTFEEDING
UNICEF's emergency response is guided by the Core Commitments
for Children in Emergencies (CCC) that provide the overarching
organisational framework in a humanitarian response (see Chapter
3). The table below outlines the CCC in the areas of Health and
Nutrition related to infant feeding. Included are suggested behaviour
change communication (BCC) activities that have proven to improve
infant feeding in an emergency. Remember to plan your
communication and social mobilisation actions with the involvement of
the affected community and your partners, and to carefully monitor and
evaluate the programme.
TABLE: Extract from UNICEF's CCC in health and nutrition and

corresponding BCC and social mobilisation support.
FIRST SIX TO EIGHT WEEKS SUPPORTIVE BCC AND SOCIAL

MOBILISATION ACTIONS
1. Based on rapid assessments, § Ensure that affected women receive
provide child and maternal information on the importance of
feeding: support infant and feeding newborns colostrum and
young child feeding and exclusive breastfeeding for the first 6
therapeutic and supplementary months – i.e. group meetings/
feeding programmes with the discussions, IEC materials, flip charts
World Food Programme that explain benefits of exclusive
(WFP) and NGO partners. breastfeeding, audiovisual
demonstrations.
§ Make sure that health workers and
other service providers understand the
importance of breastfeeding and are
able to communicate it to women, by
involving government and health
FIRST SIX TO EIGHT SUPPORTIVE BCC AND SOCIAL

WEEKS MOBILISATION ACTIONS
associations in training and

supporting service providers in giving
advice and support to women in
choosing the appropriate feeding
methods.
§ Provide health workers, peer
educators, and breastfeeding
counsellors training and support to
increase the breastfeeding ability of
lactating women; guarantee that
women know how to breastfeed in a
way that stimulates milk production,
make sure that women who cannot
breastfeed know how to safely prepare
BMS and cup feed; give accurate
information and correct breastfeeding
misconceptions; introduce
breastfeeding women to each other in
the camp; and increase awareness on
the benefits of colostrum.
§ Mobilise the community to support
breastfeeding women by facilitating
mother-to-mother support networks,
“safe havens” for pregnant/lactating
women, women’s groups, etc.
§ Advocate and mobilise support with
the local government, camp
management, private sector, and
humanitarian agencies to increase
BREASTFEEDING
knowledge on the dangers of

PROMOTING
unnecessary, unsolicited and

inappropriate BMS in emergencies,
and promote compliance to the
International Code of Breastmilk
Substitutes regarding the prevention of
the marketing of BMS among health
and aid workers.
FIRST SIX TO EIGHT SUPPORTIVE BCC AND SOCIAL

WEEKS MOBILISATION ACTIONS
2. Introduce nutritional monitoring § Facilitate participatory monitoring and

and surveillance. evaluation methods – i.e. monitoring
chart, ongoing FGDs – to
systematically monitor the nutritional
status of children and women.
Communication interventions that span beyond the initial response should build
upon those implemented pre-emergency and during the initial response. Besides
increasing knowledge and optimal infant feeding know-how, community
participation and advocacy efforts are central in protecting, promoting and
supporting breastfeeding.
BEYOND THE INITIAL SUPPORTIVE BCC AND SOCIAL

3. Support infant and young child § Ensure that health workers,

feeding, complementary community volunteers are trained to
feeding, and when necessary provide support to breastfeeding
support therapeutic and women – i.e. ongoing advice, and
supplementary feeding encouragement at health centres and
programmes with World Food homes through motivational talks, flip
Programme and NGO partners. charts, one-to-one counselling;
motivating breastfeeding women by
sharing with them how they can
produce enough milk and providing
assistance, if needed.
§ Provide supportive supervision (and, if
needed, further training) to health
workers, peer educators, and
breastfeeding counsellors to increase
the breastfeeding ability of lactating
women; guarantee that women know
how to breastfeed in a way that
stimulates milk production, make

sure that women who cannot
breastfeed know how to safely
prepare BMS and cup feed; give
accurate information and correct
breastfeeding misconceptions;
introduce breastfeeding women to
each other in the camp; and
increase awareness on the benefits
of colostrum.
§ Mobilise the community to support
breastfeeding women by facilitating
mother-to-mother support networks,
“safe havens” for pregnant and lactating
women, women’s groups, etc.
§ Ensure that the affected mothers,

4. Provide health and nutrition community and service providers
education, including know the health and nutrition
messages on the importance benefits of colostrum and
of breastfeeding and safe breastfeeding and other safe
motherhood practices. motherhood practices; know how to
breastfeed and how to safely
prepare BMS and cup feed – i.e.
through interpersonal
communication channels such as
individual and/or group counselling,
community health education,
cooking demonstrations, mother-to-
mother support networks, activities
BREASTFEEDING
in women’s groups/clubs, trials of

PROMOTING
new feeding practices - depending

on the duration of the emergency -
and positive deviance approaches.6
§ Train health workers, peer
educators, breastfeeding
counsellors, TBAs, midwives and
other relevant stakeholders on how

to communicate health and nutrition
education messages to mothers in a
way that motivates them to feed infants
colostrum, exclusively breastfeed, and
adopt nutritious habits (including taking
vitamin A supplements).
§ Advocate and mobilise support with
local authorities, camp management
and other relevant stakeholders to
provide women a safe place to
breastfeed, prevent the solicitation of
unnecessary donations powdered milks
and formulas, and help prevent
unsolicited donations from being
received into the camp.
One of the main goals of breastfeeding promotion is to improve infant
survival and decrease risks of malnutrition, diarrhoea and other
diseases. Your communication initiative has to support this goal.
The following are some key indicators to monitor whether our communication
initiative is on track (Tool 13 in Part III lists possible sources of information to
help you measure the indicators):
§ Health workers, peer educators, birth attendants, midwives and other relevant
service providers are trained on infant and child feeding practices, and can
communicate and motivate affected women to exclusively breastfeed and safely
prepare appropriate BMS and cup feed (in exceptional cases).
§ Women with newborns know the benefits of colostrum and the importance of/
how-to breastfeed. Women who cannot breastfeed know how to safely prepare
appropriate BMS and cup feed. The affected community is mobilised to support
breastfeeding women via, mother-to-mother support networks, “safe havens”,
trials of new feeding practices, activities in women’s groups, etc.
§ Infants less than six months are exclusively breastfed, wet nursed (where
acceptable), or in exceptional cases, have access to an adequate amount of an
appropriate BMS.
§ Local governments, humanitarian agencies, camp management and other

service providers know the international guidelines on the marketing of BMS,
the appropriate use of BMS in emergencies, and are supplying it to artificially-
fed infants without undermining the breastfeeding population at the camp.
Advocacy helps Maldivian mothers

breastfeed after tsunami
D uring the aftermath of the 26 December tsunami which affected 11 Indian

Ocean countries, many private sector companies and individuals flooded
camps and affected communities with infant formula. This gesture – perhaps rooted
in good will, but doing more harm – was aimed at feeding orphans and babies
whose mothers were believed to be too stressed to breastfeed.
The following example from the Maldives demonstrates the effect of quick-and-high
level advocacy with the government; the importance of having guidelines on
breastfeeding promotion in emergency situations and the need to train health
workers in breastfeeding promotion and counselling skills. BREASTFEEDING
In the Maldives, prior to the 26 December Tsunami, breastfeeding practices were
PROMOTING
generally good and the use of breastmilk substitutes (BMS) was not widely
practiced. After the tsunami, many affected mothers felt that they could not
properly breastfeed their babies. This was coupled with the sudden widespread
availability of BMS, which prompted many to switch to the bottle. What’s more,
when the tsunami hit, many community health workers were unaware that they
should encourage mothers to continue breastfeeding – even in emergencies. Many
health workers didn’t know how to handle the deliveries of BMS and supported
bottle feeding in the initial response.
96
It was only after UNICEF shared the international infant feeding guidelines with the
government – which in turn educated health workers – that they realised the
benefits of exclusive breastfeeding in emergencies. Subsequently, health workers
started to promote and support breastfeeding to affected mothers via one-to-one
talks and counselling. Follow-up reports show that many of the health workers
would have an added benefit of interpersonal communication and counselling
training to promote breastfeeding beyond the initial response.
The Maldives experience illustrates the positive impact that swift advocacy can
have. This is a reminder that messages on the importance of breastfeeding, and
the guidelines on the use of BMS should be easily accessible and quickly shared
in emergencies. It also highlights that information is necessary but not sufficient on
its own to influence positive behavioural change. It was through advocacy,
education and health worker training that mothers learned to engage in optimal
infant feeding practices. We should remember that health workers are necessary
and valuable partners in breastfeeding promotion. Our communication initiatives
should include training them with the necessary communication skills to protect,
promote and support breastfeeding in emergencies.
Lessons Learned
1. Breastfeeding promotion works best when it is a joint-effort between health
workers, camp managers, government officials and other humanitarian workers.
2. Don’t assume that health workers have knowledge on best breastfeeding

practices in emergencies, or are aware of the international standards on the
use of adequate and appropriate breastmilk substitutes.
3. Include health worker training as part of the emergency preparedness and

recovery phases of your breastfeeding promotion initiative.
4. Be sure to quickly share knowledge with all relevant sectors of the concerned
humanitarian and government organisations in an emergency, to ensure that
breastfeeding messages are harmonious and disseminated to the intended
audiences.
SPECIAL CONSIDERATIONS:
BREASTFEEDING AND HIV
© UNICEF/Pakistan
In South Asia, where HIV prevalence is
still considered relatively low, promoting

and supporting exclusive breastfeeding is
vital to significantly reduce the risk of a

newborn's death - which diarrhoeal
infections can easily cause - and

exclusive breastfeeding can just as
easily prevent.
However, where HIV rates are known to be high, it is important that we standardise
HIV and infant feeding messages so that women and their partners are not
confused on the issue of breastfeeding and the possibility of mother-to-child
transmission (PMTCT). Admittedly, communicating these facts to mothers may be
difficult; dialogue and pictorial aids will often be needed. In addition, partner and
family involvement, if feasible, and depending on the consequences of the
emergency, will be crucial. It may be possible to draw a risk analogy that is based
on cultural knowledge and traditions. This, however, should be carefully researched.
In an emergency, the following information must be taken into account before an

appropriate infant feeding and communication strategy is developed:
§ Assessment of the prevalence of HIV in the affected population – using
secondary sources (including pre-emergency estimates) and relevant
information from health information systems; whether it is a high HIV prevalence
BREASTFEEDING
PROMOTING
country of South Asia (pre-emergency) or not? This is particularly important
before we can recommend wet nursing.
§ Assessment of the knowledge of HIV status: Were voluntary counselling and
testing facilities available pre-emergency? Are there such services available
now?
§ Are there any relevant policies on infant feeding and HIV, from the host and/or
home countries?
RESOURCE BANK
Further reading
1. Almedon, A., Socio-cultural Consideration for Infant Feeding in Emergencies:
A discussion paper, Health Promotion Sciences Unit, Dept. Public Health &
Policy, London School of Hygiene & Tropical Medicine, London, 1994.
2. Brownlee, A., ‘Breastfeeding, Weaning and Nutrition: The behavioural issues’,
Behavioural Issues in Child Survival Programs, Monograph Number Six,
3. Brownlee, A., ‘Growth Monitoring and Promotion: The behavioural issues’,
Behavioural Issues in Child Survival Programs, Monograph Number Six,
4. Carter K., Feeding in Emergencies for Infants Under Six Months: Practical
guidelines, OXFAM Public Health Team, Oxfam, London, 1996.
5. Geneva Infant Feeding Association, ‘Breastfeeding in refugee situations’,
Breastfeeding Briefs, No. 21, GIFA, Geneva, 1995.
6. Ockwell, R., Assisting in Emergencies: A resource handbook for UNICEF field
staff, UNICEF, 1986.
7. McGrath, M., et al., Meeting the Nutritional Needs of Infants During
Emergencies: Recent experiences and dilemma, report of an international
workshop, Institute of Child Health, SAVE UK, London, 1999.
8. Robertson, A., et al., How to Breastfeed During an Emergency: A guide for
mothers, WHO, Copenhagen, 1997.
9. Sokol, E., The Code Handbook: A guide to implementing the international code
of marketing and breastmilk substitutes, International Code Documentation
Centre and IBFAN, 1997.
10. United Nations Children’s Fund, Facts for Life, New York, UNICEF, 2002.
11. HIV and Infant Feeding Guidelines for Decision Makers, UNICEF, UNAIDS,
WHO and UNFPA, Geneva, 2003.
Web sites
1. Baby Friendly Hospital Initiative
http://www.babyfriendlyusa.org/eng/01.html
2. Breastfeeding.com
http://www.breastfeeding.com
3. CDC Breastfeeding Page
http://www.cdc.gov/breastfeeding/index.htm
4. Department of Nutrition for Health and Development (NHD)
http://www.who.int/nut
5. International Baby Food Action Network (IBFAN)

http://www.ibfan.org/
6. La Leche League International (LLLI)
http://www.lalecheleague.org/
7. The Academy of Breastfeeding Medicine
http://www.bfmed.org/
8. The Emergency Nutrition Network
http://www.ennonline.net
9. The Linkages Project
http://www.linkagesproject.org
10. UNICEF
http://www.unicef.org/nutrition/index.html
11. Wellstart International
http://www.wellstart.org/
12. World Alliance for Breastfeeding Action (WABA)
http://www.waba.org.my/
Glossary
Breastmilk Substitutes (BMS) Any food being marketed or otherwise
represented as a partial or total replacement of breastmilk, whether or not suitable
for that purpose; in practical terms this includes milk or milk powder marketed for
children less than 2 years and complementary foods, juices and teas marketed for
children less than 6 months.
Colostrum The thick, yellowish milk the mother produces in the first few days
after birth. It is very nutritious and helps protects the baby against infections by
building the baby’s immune system.
Exclusive breastfeeding Only breastfeeding or breastmilk feeding and no other

foods or fluids (no water, no juices, no tea, no pre-lacteal feeds), with the exception
of drops or syrups consisting of micronutrient supplements or medicines.
BREASTFEEDING
PROMOTING
Infant An infant is a child under 12 months. For the purpose of breastfeeding

promotion, however, where prime concern is for the period of the infant’s life when
milk feeding is essential, the term infant is used for those below 6 months only.
This age coincides with the period for which exclusive breastfeeding is
recommended by the World Health Assembly (WHA) in Resolution 47.5, 1994.
International Code of Breast-milk Substitutes The International Code of

Marketing and Breast-milk substitutes was adopted by the World Health Assembly
(the policy-setting body of WHO) in 1981. The aim of the code is to contribute to
the provision of safe and adequate nutrition for infants, by the protection and
promotion of breastfeeding, and by ensuring the proper use of breastmilk
substitutes, when these are necessary, on the basis of adequate information and
through appropriate marketing and distribution.
Optimal infant and young child feeding Exclusive breastfeeding for the first
six months of life, followed by continued breastfeeding with adequate
complementary foods for up to two years and beyond.
Re-lactation The re-establishment of breastfeeding after the breastmilk supply

has stopped, or is reduced.
Spill-over The feeding behaviour of new mothers who either know that they are
HIV-negative or are unaware of their HIV status – they do not breastfeed, or they
breastfeed for a short time only, or they mix-feed, because of unfounded fears
about HIV or of misinformation or of the ready availability of breast-milk substitutes.
WHA resolutions Since 1981 the World Health Assembly has passed a number
of Resolutions all of which have equal status with the Code. The Code and
subsequent Resolutions aim to ensure that information on infant feeding is not
influenced by commercial considerations, and that marketing practices do not
undermine breastfeeding. The Code and Resolutions are therefore important
safeguards for health workers, parents and infants, including those in emergency
and relief situations.
© UNICEF/AFGHANISTAN 00774P/ Roger Lemoyne
CHAPTER- 6
PROMOTING MEASLES
VACCINATION AND VITAMIN A
SUPPLEMENTS
CHAPTER- 6
PROMOTING MEASLES VACCINATION

AND VITAMIN A SUPPLEMENTS
MEASLES VACCINATION AND VITAMIN A ESSENTIALS
PRINCIPLES IN PROMOTING MEASLES VACCINATION AND

VITAMIN A
DOING THE GROUND WORK
COMMUNICATION ACTIONS TO PROMOTE MEASLES

RESOURCE BANK
MEASLES VACCINATION AND

VITAMIN A ESSENTIALS

Measles is a highly contagious
© UNICEF/AFGA00791P/ Shehzad Noorani
respiratory viral infection that is

commonly identified by its distinctive
skin rash. It can be quickly transmitted
through airborne droplets from person
to person. The highest fatality rates
are usually among children under five,
AFGHANISTAN: A health worker gives an oral polio vaccination to a

and up to 20 percent of infants who
six-week-old held by his mother, in a health clinic in the New Nasir
Bagh camp for Afghan refugees -- also called 'Camp-e-Noa -- in the are less than a year old. Children who
city of Peshawar. The camp's population fluctuates frequently with the
ongoing movement of refugees in and out of neighboming Afghanistan.
Estimated at well above 14,000, the camp's inhabitants have recently catch measles may suffer lifelong
received notices from local authorities to move, but with no indication
as to where they should go.
disabilities such as brain damage,
blindness and deafness. Measles remains the leading vaccine-
preventable disease that causes child deaths in the world.
Malnourished children are especially at risk of complications and
death following an acute attack of measles.
Measles is common and especially dangerous in emergencies because of the
following factors:4
§ Populations are displaced and live in overcrowded conditions.
§ Sanitation and shelter are poor.
§ Food and safe water are in short supply.
During an emergency situation, especially if the affected community is displaced, the

existing expanded programme on immunization (EPI) operations may become
disrupted, leaving the youngest and most vulnerable children unprotected. In
emergencies, priority must be given to preventing measles outbreaks and efforts must
be made to immunize all young children as completely and as quickly as possible.5
This could mean that in the initial emergency response, your first measles vaccination
communication action will be in support of an emergency measles vaccination
campaign conducted by the Ministry of Health and other concerned organisations.
Measles vaccination and vitamin A “Protecting more children against measles

supplementation go hand-in-hand as will make a significant contribution to
vitamin A deficiency is particularly reducing child deaths – a key millennium
potent as a co-factor in severe development goal.”
measles. Deficiency in vitamin A
Ann M. Veneman, Executive Director
increases the likelihood that a child will
UNICEF.
die from the viral disease. We know
that not enough vitamin A can lead to Did you know that -
blindness. But even before blindness § In conflict or emergency areas, WHO
occurs, a child deficient in vitamin A and UNICEF have a commitment to
faces a 25 percent higher risk of dying ensure that, at a minimum, measles
from measles, malaria or diarrhoea.6 vaccine and vitamin A supplements1
vitamin A deficiency (VAD) is are administered?
associated with increased incidence, § Along with the measles vaccine and
duration and severity of measles, vitamin A, children in temporary
diarrhoea and respiratory infections. shelters can also be given other vital
health interventions such as
Vitamin A supplementation is a simple insecticide-treated mosquito nets to
measure with wide-reaching and long- prevent malaria and anthelminthics for
lasting impact on the health of children. deworming?
Ensure that children get enough vitamin
A, especially in emergency situations. Did you know that –
This increases their likelihood of § The measles virus remains active
surviving poor living conditions in a and contagious in the air or on
camp or emergency site. infected surfaces for up to two hours?
§ It can be transmitted by an infected
Successful measles and vitamin A individual from four days prior to the
campaigns require well planned, onset of the rash to four days after the
coordinated and managed onset?
communication and social mobilisation § If one person has the disease, it's
activities. This will gain the trust of highly possible that those who come
caregivers, community leaders, into close contact with them will also
children and youth groups and other become infected?
critical groups; help them to § The highly contagious nature and
understand the importance of the severity of measles makes vigilant
vaccination campaign; and motivate immunization promotion, education
them to support and participate in the and social mobilisation imperative to
efforts to prevent, control and treat ensure the health and protection of
measles and vitamin A deficiency.7 the population?
105
105
Saving Orissa’s children

Bright saris and stifling crowded rural rooms. These are India’s mind-boggling

logistics: postering every wall, training hundreds of helpers, supplying the remotest

communities. What happens here is played out 19, 000 times today in each “booth”:
children standing in long lines, receiving polio drops, having liquid vitamin A
spooned into their mouths.
What makes Orissa’s National Immunization Day 1999 so special? It’s the first
Indian state to combine vitamin A supplementation and polio immunization. All day
long... by sunset images blur together: bright green fields, white-clad village
teacher, young children in siblings’ arms, fathers with infants, a child with measles,
the maps, the ice boxes, the palpable determination of health workers and
volunteers to reach all targeted children in the entire state – that’s over 4 million – in
just three days.
One week later, in October 1999, a massive cyclone hit Orissa, devastating its
homes, villages and roads. Its vitamin A distribution just days before may have
helped participant children stave off the infection and disease which followed.
Source: UNICEF ROSA, Micronutrient Deficiencies: Combating vitamin A deficiency.
PRINCIPLES IN PROMOTING MEASLES

You can learn more about the technical principles for an emergency
vaccination campaign - such as planning and organising vaccines,
vaccination teams and supplies, storage conditions, vaccination
cards, etc. in UNICEF’s Technical Notes.8
Keep in mind the following key principles in PROMOTING an emergency
vaccination campaign, i.e. creating informed demand, support and action at the
household and community level for the campaign. The main vaccination
communication principles tell us to:
1. Closely plan, coordinate and monitor the communication and social
mobilisation initiative with the service components of the vaccination
programme, particularly if there is a measles outbreak.
2. Ensure that caregivers receive timely and accurate information about vaccination
– the venue, date and time; the warning signs of measles and where to seek
treatment.
3. Address possible inequalities in access to vaccines by employing social

mobilisation efforts and health education specifically for the most vulnerable and
‘hard-to-reach’ groups.
4. Involve caregivers, community leaders, children and youth groups and other
critical groups to garner understanding, participation and support for the
emergency vaccination campaign.
5. Pro-actively address possible myths and doubts. Many cultures in South Asia
may believe that it is necessary to withhold food and fluid when a child is ill or
is known to have measles – a belief which can prove fatal for a sick and
dehydrated child.
6. Be prepared for possible adverse events following immunization (AEFI). During
a vaccination campaign, a clustering effect of AEFI might occur and, with it, a
heightened public and media interest in vaccine and related issues.
7. Mobilise partners and the community to use all available means of
communication (radio, loudspeakers, community meetings, etc.) and
organisational structures (government bodies, NGOs and community based
groups) to quickly reach the affected population.
DOING THE GROUND WORK

An emergency vaccination campaign programme is likely to have two
major components:9
§ Measles outbreak response.
§ Measles prevention.
Groundwork for measles outbreak control

If there is a measles outbreak you will not have much time to do groundwork. You
will have to quickly mobilise community volunteers and other groups to provide
accurate health education to caregivers and community leaders.
Groundwork for a measles prevention response

When you are doing the ground work for an emergency vaccination programme, you
will most likely have to look at the following factors to get your communication
initiative off the ground:
§ What are the pre-emergency routine vaccination rates?
§ Who are the hard-to-reach population groups and what are the main reasons
these groups are hard to reach? Remember, emergencies usually have the worst
effect among the disadvantaged groups

of the population. These groups’ pre-

emergency vaccination rates are often

below the national average.
§ Do the healthcare providers
and vaccinators have the communica-
tion and people skills to impart the
advantages of measles vaccination and
vitamin A supplementation? Can they
answer questions or clarify doubts?
§
© UNICEF/AFGHANISTAN
What is the availability of

community volunteers, faith-based
organisations and other partners who
can be quickly mobilised for health-
education campaigns and social
mobilisation activities?
§ What are common beliefs, attitudes, practices and barriers regarding vaccina-
tion and vitamin A supplementation?
This, along with rapid health and immunization assessments, will help you develop
SMART behavioural results and develop the communication actions for an
immunization initiative. By adeptly doing the groundwork (using findings from
formative research, communication analysis and immunization assessments), you
ensure that all communication strategies, messages and materials are based on
an adequate understanding of the key factors that influence a caregiver’s decision
to have his/her child receive the measles shot and vitamin A supplements.
Consider some common barriers

One of the main reasons caregivers do not bring children for vaccination is that the
child has a fever, cough, diarrhoea or some other illness on the very day of the
vaccination. However, it is your role to influence health workers and other local
opinion leaders to proactively communicate to mothers that it is safe to vaccinate a
child who has minor symptoms of illness.
Sometimes a health worker advises against vaccinating a child who is disabled or

malnourished. You must make health workers understand that this advice can
yield negative consequences. A measles vaccination can save a malnourished
child from death as the infection can be extremely dangerous to children in this
fragile state. Not only is the vaccination safe, but it is key to boosting the immune
system of a malnourished child – especially if the malnutrition is severe.10
Consider also that a child in the affected community may have had a bad reaction to a
measles shot. Or, caregivers who may have heard negative rumours about vaccinations
may become apprehensive and prevent their child from getting vaccinated.11
Message development: using culture as strength
N ot presenting children for measles vaccination and vitamin A supplementation,

along with a host of other health-related issues are sometimes rooted in an
affected community’s traditions that are entrenched in political, social, cultural and
economic structures.
In Health and Culture: Beyond the western paradigm, Nigerian professor Collins
Airhihenbuwa advises health educators not to assume that culture always
represents an obstacle. He divides cultural traditions into three categories: positive,
neutral, and negative. Cultural traditions such as breastfeeding and transmission of
important messages through song and dance are positive building blocks for health
education. Beads tied around a child’s wrist to ward off evil spirits offer no threat to
health. But gender inequity, female circumcision, and withholding fluids during
diarrhoeal episodes have negative consequences. He recommends building on the
strengths of the culture to reinforce the positive and gently undermine the
negative. While we should aim to develop culturally appropriate messages, we
cannot, in good conscience, promote messages that are contrary to the best
interests of the child. When an affected community’s culture conflicts with best
practices, we must negotiate and advocate with respected community members
leaders to help bring about positive change in the attitudes and beliefs. This also
calls for creativity on the part of communicators who may have to dig deeply into the
culture to find traditions that support positive behaviours.
Ethnologist Dwight Conquergood illustrates this approach in his work in a Hmong

refugee camp. After an outbreak of rabies in the camp, a mass dog vaccination
campaign failed to produce a single dog for inoculation, and Conquergood, who
lived with the Hmong, was asked to design a better campaign.
He organised a Rabies Parade led by Hmong who played important characters in

their own folktales—the tiger danced and played a traditional instrument; the dab (a
spirit who lives in the jungle and causes epidemics when disturbed) sang and
banged a drum; while the chicken, known for its power of predictions, explained what
must be done to avoid rabies. The next day, the health centre was overwhelmed by
Hmong men and women bringing their dogs for vaccination.
Source: Health and Culture: Beyond the Western Paradigm12 and, The Spirit Catches You and You Fall Down13
Understanding and responding to common beliefs and practices among caregivers

and health workers is an important element when doing your ground work.

Formative research will help you to determine these barriers, and enable you to

develop communication strategies, messages and materials to quickly supply
children in emergencies with the vaccine and vitamin A supplements.
Some tools to do the groundwork

Rapid assessment tools
In emergency situations rapid assessment (RA) techniques can be appropriate
tools in finding out the practices and beliefs of an affected community with regard
to vitamin A, measles and other vaccine preventable diseases. In the initial
response of most emergencies may not be feasible to carry out a wide range of RA
techniques – or to mobilise the community to fully participate in the groundwork.
While it may be possible to facilitate some basic ranking exercises, in practice,
only two main rapid assessment procedure tools are feasible to yield the baseline
data and information needed to launch an emergency vaccination communication
effort. These are the semi-structured interviews and direct observation.14
Semi-structured interviews with key informants

Semi-structured interviews involve one-to-one talks or discussions with three
groups: the affected primary caregivers; the local health authorities; and the relief
staff. Interviewing in emergencies call for great sensitivity on the part of the
interviewer, as the affected population is often in an unfamiliar, chaotic and stressful
environment. The affected participants may be unable to speak with the confidence
level that they possessed prior to the disaster, may not have a complete
understanding of the issue at hand, or may give the answer that they believe the
interviewer wants to hear. Please see Tool 5 in Part III of the toolkit.
Direct observation
Direct observation is a data gathering approach that allows you to obtain firsthand
information on the affected community’s actual vaccination processes and practices.
Your aim would be to focus on the most important aspects, rather than writing down
what you observe. Therefore, you need to develop an observation checklist with the
key attitudes, skills and practices that you want to observe. Then mark the specific
characteristics by indicating with a check whether the knowledge, attitude, skills
and/or practices are present. You will find a sample checklist for observing specific
skills (e.g. communication) in Part III of the toolkit. Please see Tool 10.

Messages should be
© UNICEF/Nepal/ Martin Chamberlain

culturally sensitive,
appropriate and create an
informed demand and
support for emergency
measles vaccination and
vitamin A supplementation.
They should clearly
communicate the benefits of
immunization and vitamin A
– as a morbidity and
mortality prevention strategy.
Involving the key populations NEPAL: Female Community Health Volunteer in a meeting with village leaders, Kalika
in Kaski district, 2004.
in the affected community in
developing, fine-tuning and choosing the right mix of messages will boost your
communication effort. Coordinate messaging with partners. Remember that messages
have to be consistent with those of the other partners involved in the campaign.15
Messages for a measles outbreak16

If a measles outbreak is declared at a camp or emergency site, there is likely to be
widespread public concern and media attention. It is important to keep the affected
families and communities informed about the outbreak and the response. We can
communicate via interpersonal and mediated channels - workers, vaccinators,
community meetings loud speakers, community-based radio stations, health.
During an outbreak, disseminate messages that remind caregivers the importance
of getting the measles vaccination at this crucial time, and where to get appropriate
treatment for children who are sick. This will also help to allay fears. Reinforce IPC
with pre-tested, pre-produced printed and audio-visual media - posters, banners,
radio-TV public service announcements, spots and plugs, etc., and use community
and mass media, as appropriate and feasible.
During a measles outbreak, prepare localised messages that:

§ Provide accurate information on the natural history of measles infection, the
symptoms that should prompt a parent to seek expert advice, and the
appropriate care of a child with measles.
§ Encourage parents whose children have had a recent onset of rash and fever to
notify health workers.
§ Convey clear information on the ages for immunization, the location and time-
schedule for the vaccination and vitamin A supplementation.

Your messages should convey to all caregivers why, when, where and how
many times the child should be immunized. Remind caregivers that it is safe to
immunize the child even if he or she is malnourished, ill, or disabled.17
Generic messages for primary caregivers may include:18

§ Disease can spread quickly when people are crowded together. All children
living in congested conditions have to be immunized immediately, especially
against measles, to protect them from dangerous illnesses.
§ Measles vaccination and vitamin A protect children and are safe for children,
including those who have a minor illness, disability or are malnourished.
§ Vitamin A helps children fight infection and malnutrition and prevents blindness.
§ If your child has a fever, cough, rash, runny nose or red eyes that lasts for three
days or more, immediately seek help from a trained health care provider.
§ Children who are sick or recovering from measles are at risk of dehydration and
need adequate food and water.
§ Continue to breastfeed babies with measles.
A special note:
Since women are commonly the primary caregivers of children, most messages
will be directed at them. This is OK as long as we don’t forget to develop
messages and activities that inspire the entire community to participate in averting
or controlling a measles outbreak.
Messages for service providers may include:19

§ All children aged six months to 14 years have to be immunized against
measles in an emergency situation. Infants who have been vaccinated at 6
months should be vaccinated again at 9 months.
§ As diseases such as measles spread quickly, a child with measles should be
isolated from other children and examined by a trained health worker.1
§ Measles vaccination is a golden opportunity to promote vitamin A.
§ A new or sterile needle and syringe must be used for every child vaccinated.
§ It is safe to immunize a child who is malnourished, has a minor illness or disability.
§ After an injection, the child may cry or develop a fever, a minor rash or a small
sore. This is normal. However, if you observe more serious side effects, report
these immediately to the district health/medical officer or your supervisor.
§ Promote immunizations by encouraging and praising caregivers who present
their children for the vaccination, and by treating them and their children kindly.
COMMUNICATION ACTIONS TO
PROMOTE MEASLES VACCINATION
AND VITAMIN A
organisational framework in a humanitarian response (Please see
Chapter 3). The table below outlines the CCC in health and nutrition
areas related to measles vaccination and vitamin A supplementation.
We have included some suggested behaviour change communication
(BCC) and social mobilisation activities that have proven effective.
Remember to plan your communication and social mobilisation
actions with the participation of the affected community and your
partners, and be mindful about gathering feedback, monitoring and
evaluating your BCC initiative.
TABLE: Extract from UNICEF's CCC in health and nutrition and corresponding
suggested BCC and social mobilisation support.
FIRST SIX TO EIGHT WEEKS SUGGESTED BCC AND SOCIAL

1. Vaccinate all children between § Launch a public awareness campaign
6 months and 14 years of age via mass media. In affected
against measles; at minimum communities, low-tech media are
children from 6 months to 4 usually the most practical -
years of age must be loudspeakers, megaphones, etc.
immunized. Provide vaccines Work with community-based radio
and critical inputs such as stations where they are operational.
cold-chain equipment, training Distribute and post printed and audio-
and social mobilisation visual materials – posters, banners,
expertise and financial support etc. as appropriate. Through these
for advocacy and operational community media, you can share with
costs. Along with the affected families and communities the
vaccination, provide vitamin A what, why, when and where to go
supplementation, as for the vaccination and vitamin A
required.21 supplementation.


§ Mobilise community volunteers and
service providers to personally tell
primary caregivers the details of the
emergency vaccination campaign, and
the benefits and safety of vaccination
and vitamin A supplementation.
§ Make special efforts to reach
vulnerable and hard-to-reach
communities with information and
vaccination services.
§ Distribute basic messages that would
help caregivers recognise measles
symptoms and complications to help
reduce measles mortality.
§ Involve community and faith leaders in
the planning of the emergency
vaccination campaign, if possible. At
a minimum, ensure that they know
when, where and why the vaccination
campaign will take place.
§ Build the capacity of health workers
and vaccinators with the necessary
communication skills to talk about the
advantages of immunization and are
able to handle questions and clarify
doubts.
§ Use camp registration points as a
communication channel to provide
information on the measles
vaccination and vitamin A. Children
can receive vaccination here and
adults can learn when and where to
go to receive the health services.
§ Train volunteers to visit temporary and
roving schools to share with
principals, teachers and students vital
information on measles vaccinations
and vitamin A.

§ Employ child-to-child methodologies –
i.e. children singing songs related to
immunization, so that they can
become informal promoters by, for
instance, singing the lyrics in the
community or at public events.
§ Engage motivated school-aged
children, boy scouts and girl guides,
or other local children’s groups, eg,
Child Clubs in Nepal and local
Children’s Parliaments in India, as
“calling parties” the day before and
during vaccination and
supplementation to remind caregivers
of the date and venue. This is also a
creative way to get children involved in
their own health.
§ Train and deploy community
volunteers throughout the camp to
meet with caregivers and to discuss
child health related issues, including
the severity of measles, the need to
protect children from disease, the
safety of the vaccine and injection,
and the need to continue with routine
immunization.
§ Invite and engage people who have
lost children to measles as peer
educators, counsellors as they can be
strong advocates because they have
witnessed the virility and
consequences of the disease.
§ Monitor any immunization coverage
and shifts in the community’s attitude
regarding immunization.
115
115
Measles song
C hildren learn ‘measles songs’ from their teachers; teachers tell the children to
bring their younger siblings to get immunized; children march through the streets or
in a camp in parades, holding up signs and singing to let everyone know about the

importance of vaccination.22

I am measles, killer disease

Take your child for immun-I-zation….
November XX
November XX
November XX
Take the shot for immun-I-zation….
From the age of six months
To the age of fourteen years
Our parents work hard
MALDIVES: A baby is vaccinated against polio on Kudahuvadhoo Island in
Take your child for immun-I-zation….
Dhaalu Atoll, some 150 kilometres from Male, the capital. An immunization Immun-I-zation everywhere
campaign against measles and polio, aimed at all children under age two, is
under way following the tsunami disaster. Immun-I-zation everywhere
Immun-I-zation everywhere
Take your child for immun-I-zation…
Indicators are needed to measure and demonstrate whether or not
our communication initiatives are meeting the behavioural results. But
advocacy and communication activities alone can not improve
emergency vaccination efforts. This also depends on service delivery
factors and disease control efforts. Most communication indicators
are therefore process-oriented and measure inputs and outcomes of
activities conducted. Indicators are most effectively measured and
monitored at district and community level through a combination of
qualitative and quantitative methods (i.e. focus group discussions, exit
interviews with caregivers, observation of vaccination and community
mobilisation sessions and so on).
The impact and outcome of communication efforts is tied to other EPI indicators
and must therefore be measured within that context. Listed below are a range of
indicators.23 Tool 14 in Part III lists possible sources of information to help
you measure the indicators.
Input indicators include:

§ Presence of a communication component for EPI in the emergency
preparedness and response plan.
§ Amount of funds allocated for the communication component to support the EPI
programme in an emergency situation.
§ Number of planned outreach activities in the affected communities and camps.
§ Number of materials produced.
§ Percentage of communication plans that map resistant or difficult groups,
including “zero-dose” children, and proposed strategies for reaching them.
Output indicators include:

§ Percentage of emergency vaccination programme budgets used for a)
broadcast media, b) print materials, and c) strengthening interpersonal
communication skills.
§ Percentage of planned activities to reach the hard to reach population groups
actually conducted.
§ Number of materials disseminated, made visible and used in health facilities.
§ Number of health workers and mobilisers trained in immunization
communication. What is the number of training sessions conducted?
§ Number of meetings held with community and faith leaders.
§ Percentage of health workers/vaccinators/care-givers who know how to
recognise measles and where such a case should be reported.
Outcome indicators (linked to EPI indicators) include:

§ Percentage of health workers/vaccinators providing key messages during
immunization sessions.
§ Percentage or caregivers with vaccination cards.
§ Percentage of caregivers who know where to go for vaccination and vitamin A
supplementation.
§ Percentage of caregivers who know where to take a sick child for treatment.
§ Percentage of households in affected communities/camps visited by
community health volunteers/mobilisers.
§ Percentage of budget spent on communication activities according to the plan.
Impact indicators (EPI indicators) include:

§ Percentage of children vaccinated with measles.

§ Percentage of children who received vitamin A supplements.

§ Percentage of drop-out rates.
§ Percentage of planned outreach sessions actually conducted.
§ Percentage of reduced measles incidents among the child population from date
A to date B.
Uganda Red Cross mobilises community to promote measles immunization
W hile a measles communication initiative should not rely strictly on campaigns,

stickers and posters – a mass vaccination campaign may be the first line of
defence in an emergency situation. In a disaster, one of the top health priorities is to give
the measles shot to all children in the camp/affected area who are between 6 months
and 14 years of age. Overcrowding, poor sanitation, diarrhoea and malnourishment are
conditions that make it easy for a measles outbreak to occur.
Be mindful that in emergencies the affected community may be busy doing household
chores, searching for work, standing in lines for food/humanitarian assistance,
gathering fuel or water, recovering lost items, or caring for the family. This will prevent
them – particularly women with children – from attending public events, standing in long
lines for immunization/health services, or pay much attention to matters that don’t seem
urgent to them.
The Ugandan Red Cross communicated with such hard to reach populations through a
mix of communication channels including interpersonal communicators, mass media,
volunteers, and community theatre in its November 2001 measles campaign. One of the
behavioural results was to ensure that every mother or primary caregiver in a particular
district understood the need for their children to be immunized, and subsequently took
them to the health centre for the shot. Red Cross workers recruited volunteers from the
communities that were targeted for the campaigns, educated and trained the volunteers
on the process, and gave them the necessary resources to carry out their mission.
Supplies included costumes to put on plays, vests for identification, brochures, and
money for the volunteers’ lunches, posters, banners, and other items.
Volunteers – travelling by whatever method available – met with the primary caregivers,
usually the mothers, to communicate the importance of protecting children against
measles; the safety of the vaccination process; and the need to follow-up and keep up
with the immunization schedules. The volunteers made lists of children in each
household who were eligible for vaccination; then cross-referenced the names with the
list of children who had received the vaccination. This method helped them confirm if
any child had been missed.
Clearly this type of measles communication initiative takes planning. You can most
effectively mobilise the community during the emergency preparedness phase of your
BCC programme, and also beyond the initial response. While emergencies usually
result in widespread social disruption, it is to your advantage to partner with the leaders
of the affected community who have the ear, mind and heart of the people – religious
leaders, traditional healers, TBAs, tribal chiefs, teachers, clan leaders and other relevant
stakeholders – to gain support for the measles vaccination. You should also be
prepared to deal with misconceptions, myths and past adverse events related to the
measles shot. In this particular Ugandan district, a local anti-government radio station
was advising parents against immunization, saying the vaccine would kill their children,
not save them. Red Cross activated more volunteers to counter this message with
positive ones to help allay parents’ fears.
Don’t neglect to tap into your most precious resources in emergencies: motivated young
people can be quickly mobilised to spread the immunization message. If the education
system is still in place (or if a temporary one has been established), educators can
teach schoolchildren the ‘measles songs’, and tell students to bring their younger
siblings for the vaccination. In Uganda, one schoolgirl in the Pallisa district looked
sternly at the crowd as she sang the measles song, shaking her finger at the crowd
during the verse, “take your child for immunization.”
Source: Adapted from the Measles Initiative24
Lessons Learned
1. Be aware of the affected community’s pre-existing beliefs about the cause of
measles and its cure before the disaster occurs.
2. Engage traditional healers, religious leaders, health workers, key informants,
volunteers and other respected community leaders to support a measles
vaccination initiative.
3. Enlist motivated school-aged children, boy scouts, girl guides and children’s
organisations to promote the measles shot to the affected community and
parents.
4. Don’t use fear to motivate parents; but, inform them of the consequences of not
vaccinating their child.
5. Be prepared with positive information and communication actions to counter
misperceptions and myths surrounding measles vaccinations.
RESOURCE BANK

Further reading
1. Center for Disease Control, Famine-affected, Refugee and Displaced
Populations: Recommendations for public health issues, MMWR, Atlanta,
1992.
2. Children’s Vaccine Programme, Immunization and Child Health Materials
Development Guide, PATH, USA, 2001.
3. Heggenhougen, K. and Clemens, J., ‘Acceptability of Childhood Immunization:
Social science perspectives’, EPC Publication No.14, London School of
Hygiene and Tropical Medicine, London, 1987.
4. International Vitamin A Consultative Group, ‘Guidelines for the Use of vitamin A
in Emergency Relief Operations’, IVACG Technical Guide Series, 1988.
5. Pillsbury, B. ‘Immunization: The Behavioural Issues: Behavioural issues in child
survival programs’, Monograph Number Three, International Health and
Development Associates, Malibu, 1990.
6. Salama, P, et al., ‘Reaching the Unreached with Measles Vaccination’, Lancet,
Vol. 366, 2005, pp-787-788.
7. Smith, T., et al., Helping Young People Become Youth Advocates for
Immunization, Bill and Melinda Gates Children’s Vaccine Program at PATH,
2000.
8. Toole, M.J., et al., ‘Measles Prevention and Control in Emergency Settings’,
WHO Bulletin, 67, WHO, Geneva, 1989, pp. 381-388.
9. United Nations Children’s Fund, Building Trust in Immunization: Partnering with
the media, UNICEF, New York, 2004.
10. United Nations Children’s Fund, Building Trust and Responding to Adverse
Events Following Immunization in South Asia: Using strategic communication,
UNICEF, ROSA, Kathmandu, 2005.
11. United Nations Children’s Fund, Combating Antivaccination Rumours: Lessons
learned from case studies in East Africa, UNICEF Eastern and Southern Africa
Regional Office, Nairobi, 2002.
12. United Nations Children’s Fund, Getting to the Roots: Mobilizing community
volunteers to combat vitamin A deficiency disorders in Nepal, UNICEF ROSA,
Kathmandu, 2003.
13. US Agency for International Development, Immunization Essentials: A practical
field guide, USAID, USA, 2003.
Web sites
1. Agency for Toxic Substances and Disease Registry
http://www.atsdr.cdc.gov/HEC/primer.html
2. Allied Vaccine Group
http://www.vaccine.org
3. Centre for Disease Control and Prevention: Communication at CDC
http://www.cdc.gov/communication/
4. GAVI Advocacy Resource Kit http://www.vaccinealliance.org/Task_Forces/
Advocacy_Task_Force/Documents/other_materials_2.php
5. Global Alliance for Vaccines and Immunization (GAVI)
http://www.vaccinealliance.org
6. Gates Children’s Vaccine Program at PATH
http://www.childrensvaccine.org/html/resources.htm
7. Immunization Resources from The Media/Materials Clearinghouse (M/MC) at
Johns Hopkins University
http://www.m-mc.org/
8. Polio Eradication Initiative
http://www.polioeradication.org
9. Safe Injection Global Network (SIGN)
http://www.injectionsafety.org
10. The Communication Initiative
http://www.comminit.com
11. The Measles Initiative
http://www.measlesinitiative.org/
12. The Vaccine Page
http://www.vaccines.org
http://www.unicef.org
http://www.who.int/vaccines
Glossary
Adverse event following immunization (AEFI) is a medical incident that takes
place after immunization which causes concern and is believed to be caused by
the immunization.
Adverse reaction is an undesirable outcome caused by a vaccine (or drug) where

there is evidence suggesting a causal relationship. The difference between adverse
events and adverse reactions is that adverse events may coincide with (i.e. occur
at the same time), but not necessarily caused by, vaccine administration.

Cluster are two or more cases of the same or similar adverse event related in time,
geography (e.g. at a health unit or immunization outreach post), vaccinator and/or
vaccine administered.
Epidemic an outbreak of a contagious disease that spreads rapidly and widely
Mass vaccination vaccinations of large numbers of people at the same time,

usually when several cases of a disease have been reported, causing concern that
there may be a general outbreak of the disease
Measles is an acute viral illness caused by a virus in the paramyxovirus family. As

a respiratory disease, measles virus normally grows in the cells that line the back
of the throat and in the cells that line the lungs. Measles is a human disease with
no known animal reservoir.
Vitamin A deficiency causes Xerophthalmia, blindness and death. Eye signs: poor
vision in dim light, dryness of conjunctiva or cornea, foamy material on the
conjunctiva or clouding of the cornea itself. These signs may appear after several
months of an inadequate diet, or following acute or prolonged infections, particularly
measles and diarrhoea.
Footnotes
1
Information taken from Measles Initiative, http://www.measlesinitiative.org.
2
World Health Organization, State of the Art New Vaccinations: Research and development,
WHO, Geneva, 2005, p. 3.
3
WHO estimates for 2002.
4
United Nations Children’s Fund, Technical Notes: Special considerations for programming in
unstable situations, UNICEF, New York, 2003, p. 28.
5
Technical Notes, p. 26.
6
Adapted from United Nations Children’s Fund, Ending Vitamin A Deficiency: A challenge to the
world, UNICEF, New York, 2001, p.3.
7
Technical Notes, p. 38.
8
Technical Notes, p.28.
9
World Health Organization and United Nations Children’s Fund, Measles, Mortality Reduction
and Regional Elimination Strategic Plan 2001–2005, WHO/UNICEF, Geneva, 2003, p.24.
10
United Nations Children’s Fund, Facts for Life, UNICEF, New York, 2002, p. 71.
11
Adapted from Ending Vitamin A Deficiency, p.39.
12
Slim, H., et al., Rapid Assessment Procedures: Qualitative methodologies for planning and
evaluation of health related programmes, ‘The application of RAP and RRA techniques in
emergency relief programmes’, International Nutrition Foundation for Developing Countries
(INFDC), Boston, 1992, Section 18.
13
Adapted from Sphere Project: Humanitarian charter and minimum standards in disaster
response, The Sphere Project, Geneva, 2004, p.264.
14
World Health Organization, Guidelines for Epidemic Preparedness and Response to Measles
Outbreaks, WHO, Geneva, 1999, p. 8.
15
Adapted from Airhihenbuwa, C., ‘Health and Culture: Beyond the western paradigm’, Sage
Publications, Inc., Thousand Oaks, 1995, pp. 25-43, as cited in Murphy, E., ‘Promoting Healthy
Behaviour’, Health Bulletin No.2, Population Reference Bureau, Washington D.C., 2005, p. 12.
16
Adapted from Fadiman, A., The Spirit Catches You and You Fall Down, Straus and Giroux,
New York, 1997, pp. 35-37, as cited in Murphy, E., ‘Promoting Healthy Behaviour’, Health
Bulletin No.2, Population Reference Bureau, Washington D.C., 2005, p. 12.
17
Adapted from Facts for Life, p.66.
18
Adapted from Facts for Life, pp.68-73.
19
20
Facts for Life, p. 73.
21
York, 2005, p. 7.
22
Measles Initiative, Measles Song, http://www.measlesinitiative.org.
23
Adapted from Shimp, L., Strengthening Immunization Programs: The communication
component, BASICS II for USAID, USA, 2004, pp. 14-15.
24
‘Uganda Red Cross Mobilises Community to Promote Measles Immunisation’, Measles Initiative,
http://www.measlesinitiative.org.
13
Adapted from Sphere Project: Humanitarian charter and minimum standards in disaster
response, The Sphere Project, Geneva, 2004, p.264.
14
World Health Organization, Guidelines for Epidemic Preparedness and Response to Measles
Outbreaks, WHO, Geneva, 1999, p. 8.
15
Adapted from Airhihenbuwa, C., ‘Health and Culture: Beyond the western paradigm’, Sage
Publications, Inc., Thousand Oaks, 1995, pp. 25-43, as cited in Murphy, E., ‘Promoting Healthy
Behaviour’, Health Bulletin No.2, Population Reference Bureau, Washington D.C., 2005, p. 12.
16
Adapted from Fadiman, A., The Spirit Catches You and You Fall Down, Straus and Giroux,
New York, 1997, pp. 35-37, as cited in Murphy, E., ‘Promoting Healthy Behaviour’, Health
Bulletin No.2, Population Reference Bureau, Washington D.C., 2005, p. 12.
17
Adapted from Facts for Life, p.66.
18
19
20
Facts for Life, p. 73.
21
York, 2005, p. 7.
22
Measles Initiative, Measles Song, http://www.measlesinitiative.org.
23
Adapted from Shimp, L., Strengthening Immunization Programs: The communication
component, BASICS II for USAID, USA, 2004, pp. 14-15.
24
‘Uganda Red Cross Mobilises Community to Promote Measles Immunisation’, Measles Initiative,
http://www.measlesinitiative.org.
© UNICEF/ Sri Lanka
CHAPTER- 7
PROMOTING
SAFE MOTHERHOOD
CHAPTER- 7
PROMOTING SAFE MOTHERHOOD
WHY PROMOTE SAFE MOTHERHOOD IN EMERGENCIES?
PRINCIPLES OF SAFE MOTHERHOOD PROMOTION
COMMUNICATION ACTIONS FOR SAFE MOTHERHOOD
MONITORING MILESTONES: TRACKING BEHAVIOUR RESULTS
SPECIAL CONSIDERATIONS: SAFE MOTHERHOOD AND HIV
RESOURCE BANK
WHY PROMOTE SAFE

MOTHERHOOD IN EMERGENCIES?
© UNICEF Pakistan
During an emergency it is easy for

pregnant women to become
exhausted, malnourished and anaemic
because of stress, lack of food and
water, a hurried evacuation, or the
PROMOTING SAFE
MOTHERHOOD
need to travel long distances to reach
safety or humanitarian assistance.
Transportation routes may be cut off,
PAKISTAN: A healthworker checks a woman’s blood pressure in a
health center tent in one of the camps for families affected by the South distribution networks dissolved and
Asia earthquake.
health facilities destroyed. Maternal
support services that are normally Identify key audiences for each of the
available to the affected community prioritised behaviours:
may have been destroyed or § Pregnant and post-partum women.
operating at reduced capacity; and § Family decision makers (this may

vary depending on culture, situation,
existing supplies may fall far short of and household composition).
§ Community opinion leaders
demand when large numbers of
(religious, women group leaders,
people move into a new location.2 locally elected leaders, others).
§ Birth attendants (professional or
These circumstances put women at a higher traditional).
risk of death or disability from complications § Community health providers
during pregnancy and/or delivery. In close involved in maternity care.
partnership with health providers, you can § Health facility based health
support the protection of infants and pregnant professionals (private and
women in emergency situations through safe government).
motherhood promotion, social mobilisation, Source: Saving Mother’s Lives1
and advocacy with local governments,

The “four pillars” of
health providers and humanitarian
safe motherhood4
agencies.3
Safe
Motherhocd
The pillars of safe motherhood, as
Family Planning
illustrated below, highlight the strategic
Cleansafe
Antenatal
Obstetriccare
Delnery
Essentialy
Care
safe motherhood interventions that you can
promote in your communication initiative.
During the initial emergency response it Basic Maternity Care
would be wise to focus on a few risk- Primary Health Care

reducing behaviours that are discussed in Equity For Women
the Getting the message right section.
PRINCIPLES OF SAFE
MOTHERHOOD PROMOTION
Safe motherhood promotion in emergencies should focus on a limited
number of practices that are proven to decrease infant and mother
deaths. Your communication effort should result in women having the
power to have healthy pregnancies, safe deliveries and positive birth
outcomes. Consider the following principles when planning your
communication initiative to support safe motherhood goals:
1. Prioritise behaviours, emphasising the ones with the most potential to

reduce death and disability.
To reduce death and disability in mothers and infants the priority safe
motherhood practices are seeking antenatal care within the first three months;
a safe and clean delivery; and receiving immediate post-natal support.
2. Involve the decision makers in a mother’s life.

In many South Asian cultures, a mother-in-law, husband or other family
decision maker influences the antenatal and postnatal practices of new and
expectant mothers. Identify and involve the family decision makers and include
them as key participants in participatory assessment, community mobilisation
and support efforts as well as in monitoring activities. However, be aware that
the household composition may

have changed as a consequence of
the disaster. Some expectant
Continued access to family
women and mothers may be alone, planning in emergencies
or new heads of the household. You
will need to know this too!
F amily planning is especially
important when health services
have been damaged or destroyed by
3. Disseminate positive safe
war or natural disaster. Experience
motherhood messages. has shown that in emergencies
Messages should show how safe women, girls and adolescents are
motherhood practices benefits sometimes raped; forced into having
PROMOTING SAFE
mother, baby and family. sex in exchange for food and other
MOTHERHOOD
needed items; and otherwise sexually
4. Your communication support abused.
should be aligned with and in
support of the national maternal We should be mindful of the
health plan/policy. weakened/absent law enforcement in
emergency situations and ensure that
Don’t reinvent the wheel; build on the
emergency contraceptives are
country’s existing health policies
available; and that women who have
and find ways to fill in the gaps.
been using family planning services
pre-disaster continue to have access
to these services.
DOING THE
GROUNDWORK Communication actions should
ensure that women, men, and
adolescents know when, where and
Before any emergency strikes, how-to access family planning
services and supplies; know the
communicators should form
importance of seeking medical care
alliances and work in and counselling if raped or sexually
abused; and know where to go for
coordination with key partners in these services.
safe motherhood promotion.
Be sure that your family planning/safe
These allies could be the motherhood actions are in line with
the affected community’s national
community health workers, birth reproductive plan, and that your
messages are in sync with other
attendants (professional and
concerned agencies.
traditional), nurses, doctors
Source: Adapted from Family Planning2
(private and government), district
health officers, faith-based leaders and others. If you establish these

partnerships your groundwork will become a process of filling in the
gaps - combining pre-existing knowledge about the affected
community with new information received from rapid assessments. By
information and feedback gathering - both pre-and-post emergency -
you will be able to influence relevant behavioural results, safe
motherhood communication actions, messages and materials.
Keep in mind that during emergencies it may be harder for an affected community
to part from social and cultural beliefs, practices and traditions that vary from the
positive behaviours you are presenting. Understanding such barriers will be critical
in planning your communication initiative.
Some tools to do the groundwork

Key informant interviews
There is sufficient evidence that in many countries in South Asia, a woman’s
beliefs, practices and attitudes toward pregnancy are influenced by family decision
makers such as husbands, mothers-in-law, and community and family elders.
These decision makers are often the ones who decide whether a woman needs
antenatal or post-natal care, should breastfeed, or go to a health facility for an
obstetric emergency. In emergency situations, this tradition will depend on factors
such as the extent of community disruption, displacement, mortality and morbidity
rates. You can use key informants – affected pregnant women, adolescent girls,
health workers, men and family decision makers – to provide insight on the
decision making processes that form the beliefs, attitudes and practices on
pregnancy, delivery and other safe motherhood-related issues. Please see Tool 5
in Part III of the toolkit.

In stabilised situations mothers have many obstacles to making sure that they
have a safe pregnancy and delivery. In an emergency, ensuring safe motherhood
becomes even more difficult. Some women may not know how to have a healthy
pregnancy; rumours can spread about health services or providers; or the affected
community does not support a woman’s choice to adopt safe motherhood
practices. Through focus group discussions identify the cultural traditions,
practices and beliefs that are disincentives to positive change in the cultural
129
129
context of the country and the Pointers on using counsellors in a safe

emergency. The added value of focus motherhood BCC programme5,6
groups is that participants not only
provide information for your A component of safe motherhood promo-
tion can include training health workers
communication initiative but can also
and peer educators to counsel and
carry lessons learned back to the
communicate the benefits and importance
affected community. Please see also
of safe motherhood practices to the
Tool 9 in Part III of the toolkit. affected women, their families and
community.
By using these tools in different stages
of an emergency, you can determine Counselling is beneficial in that it can be
PROMOTING SAFE
whether the priorities that centre on used to reinforce safe motherhood
MOTHERHOOD
safe motherhood issues change at messages disseminated via IEC materi-
different phases of an emergency. als and the mass media. It can also help
bridge cultural, ethnic, and social gaps
between healthcare providers, TBAs and
GETTING THE affected women.
MESSAGE RIGHT Counselling should only be used if you
In emergencies, new mothers have the resources and capacity to do so.
This can be challenging in an emergency
and pregnant women will receive situation, because there is often a poor
messages on hygiene, client-counsellor ratio. However, if you have
the resources and capacity, consider that
breastfeeding, child protection the affected women and families should
receive:
and measles vaccination.
Prevent message clutter and Information - To learn about the benefits
and availability of the services and access
focus on messages on the two to services regardless of gender, creed,
colour, marital status or location.
main risk-decreasing strategies.
These strategies are:

1. Creating demand and support for antenatal and post natal care.
2. Knowing how to have a clean and safe delivery.
Promote the above strategies with clear, concise and easily understood messages.
Choosing the right mix will depend on which key behaviours you have prioritised as
the most critical ones to save the lives of infants and new and expectant mothers in
the emergency. Your choice of messages will also depend on who your main
audiences are – for example, pre-and-post partum women, community health
workers, village elders and/or relief

workers. Involve women and other
key audience members in Choice To understand and be able to apply
developing the messages. This will all pertinent information and make an
go a long way in ensuring that the informed choice, freely ask questions, and
messages are effective, clear and receive answers in an honest, clear and
understood by all of the intended comprehensive manner.
target audiences. Safe motherhood
messages might include:7 Safety A safe and effective service.
1. It is important for all family
members to be informed about Privacy To have a private environment
during counselling or services.
and able to recognise the
warning signs of problems during
Confidentiality To be assured that any
pregnancy and childbirth. personal information will remain
2. Make a birth plan and know confidential.
where to get immediate skilled
help if problems during Dignity To be treated with courtesy,
pregnancy or delivery arise. consideration and attentiveness.
3. A skilled birth attendant, such as
a doctor, nurse, or trained Comfort To feel comfortable when
midwife, should check the receiving services.
woman at least four times during
every pregnancy and assist at Continuity To receive services and
supplies for as long as needed.
birth.
4. All pregnant women need
Opinion To express views on the services
particularly nutritious meals and offered.
more rest than usual throughout
the pregnancy.
5. Smoking, alcohol, drugs,
poisons and pollutants are
especially harmful to pregnant women and young children.
6. Physical abuse of women and children is a serious public health problem. Abuse
during pregnancy is dangerous both to the woman and the foetus.
7. Every woman has the right to health care, especially during pregnancy and
childbirth. Health care providers should be technically competent and treat
women with respect.
FOR SAFE MOTHERHOOD
organisational framework in a humanitarian response (see Chapter
3). The table below outlines the CCC in the areas of Health and
Nutrition related to safe motherhood. Included are suggested
PROMOTING SAFE
MOTHERHOOD
behaviour change communication (BCC) and social mobilisation
activities that have been effective in improving women's health during
pregnancy and delivery in an emergency situation. Remember to
involve relevant members of the affected community and your partners
in planning your communication and social mobilisation actions, as
well as to carefully monitor and evaluate the programme.
TABLE: Extract from UNICEF's CCC in health and nutrition and

corresponding suggested BCC and social mobilisation support.

1. Support the establishment of n Ensure that affected women, family
essential health-care decision makers, birth attendants, and
services, by providing traditional healers know the warning
outreach services and home- signs during pregnancy and danger
based management of signs in a delivery that mean that they
childhood illnesses and must get help immediately. They must
emergency obstetric care receive information on when and where
services, and treatment for to seek antenatal care and emergency
malaria, diarrhoea and obstetric care – i.e. through group
pneumonia. discussions, women’s shelters,
maternity caregivers, health workers,
counselling and IEC materials.

n Ensure that health workers and other
service providers know and understand
the importance of seeking professional
emergency obstetric care and are able
to communicate this to women.
n Involve government agencies and
professional health associations in
training support service providers, in
giving advice and support to women on
preparing a birth plan and planning for
potential obstetric emergencies.
n Mobilise the community to support
pregnant women in obstetric emergencies
by designing a community-based birthing
plan and increasing knowledge on danger
signs during delivery through talks with
women’s groups, mass media, IEC
materials, audiovisual presentations, flip
charts, etc.
n Advocate and mobilise support with the
local government, camp management,
private sector and humanitarian
agencies to increase knowledge on the
need for reliable emergency obstetric
care for all affected women, providing
reliable transportation systems, and
training of birth attendants.
2. Provide tetanus toxoid with n Ensure that all affected women and
auto-disable syringes and other family decision makers know the
critical inputs such as cold- benefits of tetanus toxoid shots to both
chain equipment, training and mother and baby; when, and where to
behavioural change expertise, get the vaccination – i.e. one-one-
and financial support for counselling/talks, health worker visits,
advocacy and operational women’s representatives, midwives, and
costs for immunization of IEC materials.
pregnant women and women of
childbearing age.

n Train birth attendants, health workers,
counsellors and service providers on
how to communicate the importance of
tetanus toxoid vaccinations to affected
mothers and family decision makers.
n Advocate and mobilise support with
local authorities, camp management
PROMOTING SAFE
provide tetanus toxoid vaccinations to
MOTHERHOOD
all affected women (especially those of
reproductive age).
n Involve public figures in advocating the
benefits of tetanus toxoid vaccination to
affected women and communities.
Communication to support safe motherhood initiatives in emergencies has to be

timely, appropriate and based on the nationally identified priorities and national
maternal health policies. Remember to build on existing activities and partnerships!

3. Support the establishment of n Ensure that affected women, family
essential health-care decision makers, birth attendants, and
services, by providing traditional healers know the warning
outreach services and home- signs during pregnancy, and danger
based management of signs in a delivery that mean get help
childhood illnesses and immediately; and that they know when
emergency obstetric care and where to seek antenatal care and
services, and treatment for emergency obstetric care – i.e. group
malaria, diarrhoea and discussions, community based radio,
pneumonia. women’s shelters, maternity caregivers,
health workers, counselling and IEC
materials.

n Ensure that health workers and other
service providers know and understand
the importance of seeking professional
emergency obstetric care and are able
to communicate this to women.
n Involve government agencies and
professional health associations to train
and support service providers in giving
advice and support to women on
preparing a birth plan and planning for
potential obstetric emergencies.
pregnant women in obstetric emergencies
by designing a community-based birthing
plan and increasing knowledge on danger
signs during delivery through talks with
women’s groups, mass media, IEC
materials, audiovisual presentations, flip
charts, etc.
private sector and humanitarian
agencies to increase knowledge on the
need for reliable emergency obstetric
care for all affected women, reliable
transportation systems, and training of
birth attendants.
4. Provide health and nutrition n Ensure that affected women and family
education, including decision makers know the components
messages on the importance of maternal nutrition – a pregnant
of breastfeeding and safe woman needs the best foods available
motherhood practices. to the family; should avoid food
restrictions; needs iodised salt, vitamin
A and iron supplements. Understands
that a woman should exclusively
breastfeed for the first 6 months (unless
in exceptional cases in which the infant

should be cup fed an adequate amount
of appropriate BMS); receive antenatal/
postnatal care; seek and use clean
delivery kits (where available); have an
attended birth; and get immediate care
for warning signs during pregnancy or
delivery – i.e. counselling, health
workers, audiovisual presentations,
PROMOTING SAFE
women’s representatives, birth
MOTHERHOOD
attendants/midwives, and IEC
materials.
n Ensure that health workers, birth

attendants and maternity caregivers,
women’s representatives, counsellors
and other relevant stakeholders know
and can communicate to affected
mothers and family decision makers the
factors of maternal nutrition; exclusively
breastfeeding for the first 6 months
(unless in exceptional cases); receiving
antenatal/postnatal care (including
tetanus injections); and immediately
seeking help for emergency obstetric
situations.
pregnant women and new mothers by
facilitating mother-to-mother support
networks, women’s group, community-
based birthing plans, referral systems,
etc.
© UNICEF/ Afghanistan 004335/Nich Danzinga
AFGHANISTAN: Woman receives vaccination in a clinic.

© UNICEF/ HQ05-0217/Tom Pietrasik

The result of a safe motherhood
programme in an emergency
situation is to reduce maternal and
neonatal mortality and morbidity
through timely and appropriate
safe motherhood interventions.8
PROMOTING SAFE
MOTHERHOOD
SRI LANKA: Deputy Principal Mohammad Hanifa Abdul Rahman
This is usually the overall objective teaches social studies to Grade 8 boys in a temporary classroom at
Al-Arham Vidyalaya School in the Addalaichenai area in the eastern
your communication initiative district of Ampara. The school, whose students are from a Muslim
fishing community, has been relocated to a temporary structure on
rented land. The original school, located less than 40 metres from
should seek to support. It is critical the sea, was completely destroyed by the tsunami. Two of its 350
students were killed during the disaster and 80 percent of the
children's homes were damaged or destroyed. Many of the students
to monitor whether your have been traumatized and are afraid to return to the original school
site. UNICEF has provided the materials for a temporary school
building as well as 12 school-in-a-box kits.
communication support to the safe
motherhood programme is on
track. On which indicators you need to monitor your communication
efforts depends on which specific behavioural results you seek to
achieve from the affected groups. The following are, however, some
common core indicators listed to give you an idea. Tools 12 and 13
in Part III lists possible sources of information to help you
measure the indicators.
n Health workers, midwives, women’s representatives, counsellors and other
relevant stakeholders are trained on maternal nutrition and breastfeeding facts
and communicate the importance of antenatal and postnatal care visits, clean
and attended delivery, the warning signs during pregnancy and danger signs
during pregnancy.
n Affected women and their families know the benefits of and practice healthy
eating, taking vitamin A supplements and iron; receiving tetanus shots; having
a clean and attended delivery; seeking antenatal and postnatal care.
n Affected women and their families know the warning signs during pregnancy;
when and where to get immediate help, and seek medical help when
complications occur.
n The affected community demonstrates support to pregnant women via mother-

to-mother support networks, women’s group, community-based birthing plans
and referral systems, etc.
n Local governments and humanitarian agencies have allocated the resources

needed for adequate care and affordable quality services; have established the
necessary transportation systems, supplied essential drugs, clean delivery kits
– and have formed necessary partnerships to supply these.
SPECIAL CONSIDERATIONS:
SAFE MOTHERHOOD AND HIV
In an emergency situation, the effects of poverty, powerlessness and
social instability are intensified and the social norms regulating
behaviour are often weakened. Women – including those who are
pregnant – and children are at an increased risk of violence, and can
be forced to have sex for them to gain access to basic needs such as
food, water or security. These are all factors which make affected
women and children more vulnerable to HIV infection.9
In South Asia, where HIV prevalence is still considered to be generally low,

communication initiatives must take into account whether HIV and AIDS
prevention, treatment and support should be part of the communication strategy to
support the larger goals of safe motherhood. When you plan and prepare a
behaviour and social change component for a safe motherhood response in an
emergency situation, which includes an HIV/AIDS communication component,
consider the following factors:
n What were pre-emergency HIV incidence and prevalence figures?
n What is the general knowledge level among the affected population regarding
HIV and AIDS?
n Were comprehensive PMTCT services available prior to the emergency? Are
they available post emergency in the affected area (this includes determining if
anti-retroviral prophylaxis and treatment are available for mothers and their
newborns prior to the emergency)? If yes, the rapid assessment which is
conducted in the initial phase of an emergency will have to establish if there
was an interruption of anti-retroviral therapy caused by the emergency.
n Are voluntary and confidential HIV counselling services available in ANC

services?
n Are trained HIV counsellors available?
n Does the country have a national HIV and infant feeding policy? If not, we
should seek guidance from global policies.10
RESOURCE BANK
Further reading
PROMOTING SAFE
MOTHERHOOD
1. Advances in Maternal and Child Health, Vol.3, Oxford University Press, Oxford,
1983.
2. Berer, M. and Sandari Ravindran, T.K., Safe Motherhood Initiatives: Critical
issues, London, Blackwell Science, 2000.
3. De Brouwere, V., et al., ‘Safe Motherhood Strategies: A review of the evidence’,
Studies in Health Services Organizations and Policy, Vol. 17, 2001.
4. United Nations Children’s Fund, A Human Rights-based Approach to
Programming for Maternal Mortality Reduction in a South Asian Context, A
review of the literature, UNICEF, ROSA, Kathmandu, 2003.
5. United Nations Children’s Fund, Surviving Childbirth and Pregnancy in South
Asia, UNICEF, ROSA, Kathmandu, 2005.
6. United Nations High Commissioner for Refugees, Guidelines on Refugee
Women, UNHCR, Geneva.
7. World Health Organization, Reproductive Health at a Glance, WHO, Geneva,
2002.
8. World Health Organization, Managing Complications in Pregnancy and
Childbirth: A guide for midwives and doctors, WHO, Geneva, 2003.
9. World Health Organization and Reproductive Health Outlook, Developing Health
Promotion and Education Initiatives in Reproductive Health: A framework for
action planning, WHO/RHR, Geneva, 1998.
Web sites
1. Global Reproductive Health Forum
http://www.hsph.harvard.edu/Organizations/healthnet/
2. Reproductive Health Outlook
http://www.rho.org/index.html
http://www.rho.org/html/menrh.htm
3. Saving Women’s Lives Initiative
http://www.savingwomenslives.org
4. The Safe Motherhood Initiative

http://www.safemotherhood.org
http://www.unicef.org/health/index.html
6. United Nations High Commissioner for Refugees
http://www.unhcr.ch
7. United Nations Population Fund
http://www.unfpa.org/emergencies/index.htm
http://www.unfpa.org/icpd
8. US Center for Disease Control and Prevention (CDC)
http://www.cdc.gov/nccdphp/drh/
http://www.cdc.gov/nccdphp/drh/mrh_mens.htm
9. White Ribbon Alliance for Safe Motherhood
http://www.whiteribbonalliance.org
http://www.who.int/topics/reproductive_health/en/
Footnotes
1
White Ribbon Alliance, Saving Mother’s Lives, What Works: A field guide for
implementing best practices in safe motherhood, India, 2002.
2
Adapted from ‘Family Planning’, retrieved from http://www.unfpa.org/emergencies/
planning.htm on 9 October 2005.
3
World Health Organization, Health in Emergencies, WHO, Geneva, 2001, p. 6.
4
World Health Organization, Mother-baby Package: Implementing safe motherhood
in countries, Maternal Health and Safe Motherhood Programme Division of Family
and Health, WHO, Geneva, 1996, p. 11.
5
JHPIEGO, Behavior Change Interventions for Safe Motherhood: Common problems,
unique solutions, JHPIEGO, Baltimore, 2004, p. 3.
6
United Nations High Commissioner for Refugees, Reproductive Health in Refugee
Situations: An inter-agency field manual, UNHCR, Geneva, 1999, p. 105.
7
Messages taken from United Nations Children’s Fund, Facts for Life, UNICEF, New
York, 2002, pp. 10 -11.
8
United Nations Children’s Fund, Technical Notes: Special considerations for
programming in unstable situations, UNICEF, New York, 2003, p.91.
9
Inter-Agency Standing Committee, Guidelines for HIV/AIDS Interventions in
Emergency Settings, IASC, Geneva, p.7.
10
UNICEF, UNAIDS, UNFPA, WHO, HIV and Infant Feeding, Guidelines for decision
makers, Geneva, 2003.
© UNICEF Maldives /Jeremy Horner
CHAPTER- 8
SUPPORTING CHILD
PROTECTION AND
PSYCHOSOCIAL RECOVERY
CHAPTER- 8
SUPPORTING CHILD PROTECTION

AND PSYCHOSOCIAL RECOVERY
WHY PROMOTE CHILD PROTECTION IN EMERGENCIES?
PRINCIPLES OF CHILD PROTECTION PROMOTION
COMMUNICATION ACTIONS FOR CHILD PROTECTION
MONITORING MILESTONES: TRACKING BEHAVIOUR RESULTS
RESOURCE BANK
WHY PROMOTE CHILD

PROTECTION IN EMERGENCIES?
Child protection is a special
© UNICEF/ Nepal 00661/Martin Chamberlain

concern in emergencies as many of
the defining features of a disaster -
displacement, breakdown in family
and social structures, erosion of
traditional value systems, potential
violence, weak governance,
absence of accountability, and

AND PSYCHOSOCIAL RECOVER
inaccessibility to basic social
services - put children at risk of
NEPAL: A child club meeting at Khairenistar High School, 2004
being injured, disabled or separated
from their primary caregivers or being orphaned; for trafficking,
physical and sexual abuse, and other forms of exploitation. In the
South Asian context, where girls are often marginalised even in
stabilised situations, the environment in a camp or emergency site
can make them even more vulnerable to abuse and exploitation.
The threat of physical harm to children is compounded by the stress and trauma
created by the emergency. Nearly all children and adolescents who have
experienced catastrophic situations will initially display various symptoms of
psychological distress, including intrusive flashbacks of the stress event,
nightmares, withdrawal and an inability to concentrate. Child development
professionals consider that the key element in promoting a child’s recovery is
building resilience as well as meeting basic needs.2
In emergency situations where people are displaced, parents/primary caregivers

are faced with situations where:
n Boys and girls are in unfamiliar surroundings with people they do not know (i.e.
in camps or in temporary shelters).
Child protection in emergencies

Remember: Children in the midst of armed conflict and
n Increased alcohol consumption may natural disasters, such as droughts, floods and
be prevalent – because of the general earthquakes, have the same needs and rights as
destabilisation and higher availability children in stable environments.1
of cash among men from relief efforts.
n Adolescents may also be Communication initiative key to protecting children in
psychosocially affected, which can Sri Lanka tsunami camps In Sri Lanka, an estimated
increase the risk of sexual and 5,000 children lost one or both parents, and countless
physical abuse of children, more lost relatives, friends and teachers. UNICEF’s
response to protect these children in the camps
especially among girls.
focused on the issues of injury, being orphaned or
n Crowded living conditions, where
separated from their primary caregivers, child abuse,
families share sleeping quarters, trafficking, exploitation and other vulnerabilities.
can lead to adults having sex in UNICEF put emphasis on advocacy and awareness
front of children. raising campaigns on these issues. Actions were taken
to identify the relevant protection messages using
Moreover, parents/primary caregivers available means to mobilize the affected community
might feel helpless in the aftermath of and to ensure that the messages reached the intended
disasters because of destroyed support audience.
systems. They may attempt to lessen
their responsibilities by forcing girls to UNICEF partnered with the National Child Protection
marry early or live with distant relatives; Authority on a set of key messages on the protection of
women and children against sexual abuse and
sending children to work with
exploitation. The messages were sent out as part of
“employers” who are traffickers; and
instructions to all police officers in the camps from the
engage in other actions that put Police Headquarters. Posters on child abuse were also
children, especially girls, in harm’s path. developed and posted in strategic places within the
camps. The same messages were distributed by
UNICEF recommends the following Sarvodya, the largest Sri Lankan NGO, in the camps.
child protection strategies in an
emergency situation:3 These messages covered the following four issues:
n Advocacy and increasing knowledge. n Giving extra love and attention to children during
n Ensuring written commitments. this difficult time.
n Monitoring and reporting violations. n The importance of family unity and protecting
n Creating safe environments. children from being separated from their families,
n Strengthening local institutions injuries, sexual abuse and exploitation.
n Procedures for reporting unaccompanied and
Depending on the detailed priorities of separated children; the need to avoid
institutionalization of unaccompanied children; the
the child protection and psychosocial
importance of following national laws and
development response efforts, your
procedures when handing over children to
communication initiative should support caregivers.
the above priorities in partnership with n Mine-awareness (education messages were
the government, affected community, produced and included in the school-in-the-box),
camp management, sister UN agencies because landmines may have been carried by the
and other relevant stakeholders. tsunami.
PRINCIPLES OF CHILD
PROTECTION PROMOTION
Communication efforts to support child
© UNICEF Pakistan
protection in emergencies require a multi-
pronged approach - advocacy, social
mobilisation and behaviour change
communication. These efforts should seek
to improve the prevailing knowledge,
attitudes and practices of the various
stakeholders (at all levels) toward child

protection, wellness and survival. The

following principles provide some
guidance for your emergency child
protection communication programme.
1. Emphasise behaviours that decrease risks of child trafficking, abuse,
exploitation and separation
To protect children, some of the practices emphasised are the ones that prevent
abuse and violence from happening in the first place – i.e. not leaving children
unattended; knowing the normal/abnormal reactions to stress and how to manage
them; parents and primary caregivers using camp-or-shelter provided education/
recreation activities; and reporting abuse to authorities. Special attention should be
paid to protecting girls from different forms of exploitation and abuse.
2. Strengthen local capacity through communication activities
Communication initiatives should equip the affected parents/primary caregivers,
health workers, teachers, police officers, social workers, children and youth
groups and other relevant partners with the knowledge, authority and motivation
to identify and respond to child protection issues.
3. Develop communication activities that give children life skills,
knowledge of their rights, and the ability to protect themselves
Children need information and knowledge to help protect themselves. If children are
unaware of their rights, or of the signs and dangers of abuse, they become more
vulnerable in emergencies. Children also need to be provided with safe and
protective channels for participation and self-expression. Communication initiatives
that support life skills should be Communication channels

gender sensitive, and encourage the UNICEF mobilized several
communication channels to get the
development of non-traditional life
message out to the affected community:
skills for both, boys and girls.
mass media, small media and capacity
4. Advocate with affected
building via the training of local NGO
communities, local workers and community volunteers.
governments, police and law
enforcement agencies to Mass media
strengthen child protection Child protection messages were
mechanisms and systems in an broadcast over local radio stations both
emergency in government and Liberation Tigers of
Communication interventions must Tamil Eelam (LTTE)-controlled areas.
recognise and build upon the local The same messages were also printed
community’s coping mechanisms in both Singhalese and Tamil and
to protect affected children within distributed to the affected communities.
the community. Our efforts should
focus on increasing the affected Small media
community’s knowledge and ability Previously developed leaflets were
distributed in all camps on the prevention
to practice behaviours that protect
of under-age recruitment into the army.
their children. Moreover, we should
Given the large number of new agencies
support legal mechanisms and
operating in the North and East who are
systems that allow communities to not familiar with these policies relevant to
quickly report cases of child abuse, child recruitment, UNICEF briefed INGOs
trafficking or violence. on procedures for registering cases of
under-age recruitment.
I n the India tsunami shelters,

UNICEF supported the printing and
distribution of more than 5,000
Capacity building
Capacity building took place on several
booklets and posters, along with levels: UNICEF provided training to all
1,000 banners on trafficking staff members of Sarvodya, a Sri Lankan
awareness. The materials had NGO, on psychosocial activities and on
phone numbers of a helpline and the use of UNICEF psychosocial kits.
helped to report child trafficking The Department of Social Services, Tamil
cases quickly. These communication Relief Organization (TRO) and SCISL
actions took place in early 2005. coordinated the training of community
volunteers and SCISL volunteers on
protection issues and activities. They
In planning for disasters and seeking to were trained on conducting awareness
mitigate its’ potential impact on the campaigns on the Rights of the Child so
emotional and physical well-being of that volunteers could sensitize
children, we have to prepare communities on child rights, child abuse
communication efforts in advance. and reporting of abuse.
© UNICEF Pakistan
The details for your groundwork will largely
depend on how well you were prepared, what
kind of capacities and resources you have at
your disposal, and which partnerships are
already in place. For instance, do you have any
partnerships with the police, military, journalists,
lawyers, humanitarian organisations, UN sister
agencies, local governments, religious leaders,
academic institutions and others? These types

of alliances can provide valuable assistance in an emergency in your

communication initiative towards building a protective environment for
children. Also, explore if any qualitative and quantitative data exists
from which you could draw from to plan your communication initiative.
Some tools to do the

groundwork What is psychosocial development (PSD)?
“Psychosocial” refers to the dynamic
Group discussions/observations relationship that exists between
If the affected community is one where psychological and social effects, each
attitudes or traditions facilitate abuse – continually interacting with and influencing
for example, sex with minors, the the other. “Psychological effects” are
appropriateness of severe corporal those that affect different levels of
punishment, the application of harmful functioning including cognitive
traditional practices or differences in (perceptions and memory as a basis for
thoughts and learning), affective
the value of boys and girls, or ethnic
(emotions), and behavioural. “Social
and disabled children – it is likely that
effects” pertain to altered relationships,
the environment will not be protective.
family and community networks, and
In societies where all forms of violence economic status.1
against children are taboo, and where
the rights of children are broadly The psychosocial effects of a disaster
respected by custom and tradition, can be long-lasting if appropriate and
children are more likely to be
© UNICEF/ HQ05-0160/Shehzad Noorani
protected.4 You can find out the

practices and attitudes toward
child protection via group
discussions, key informant
interviews, observing the
treatment of children in the camp
or household, etc. See Tool 5 in
Part III of the toolkit.
Observations and group

discussions can also help
determine the need for
SRI LANKA: Children gather around as sports and other games from psychosocial counselling of
a UNICEF Recreation Kit are distributed at a relief camp for people
displaced by the tsunami, in Rahula College in the southern city of children and adults.
Matara. Each kit contains recreational items for 80 to 90 children.
Other tools
Participatory activities that are geared toward children such as role play, drama and other
play activities can be used as means to provide information on child protection issues.
A note on police records as information sources:

Police records may provide useful information about the extent and type of abuse
and violence against children, both pre-and-post emergency. Be aware that there
may be gross under reporting.
Observations from India
I n some districts in India, adults left the tsunami camps during the day either to work
or to go back to their original residences leaving children considered to be “old
enough to take care of themselves” alone in the camps. These children were not
technically considered “unaccompanied” or “separated” but their situation posed a
risk to their safety and protection. Girls were put in a rather risky situation considering
the observed increase of alcohol consumption among the men folks in shelter
camps. Many feared that this could lead to both sexual and physical abuse.

Child protection messages will most likely focus on preventing and
reporting child abuse, trafficking, exploitation and on monitoring
children’s psychosocial development.
Initially you may have to focus on three immediate risk-reducing strategies.

1. Don’t leave children unattended in the camps/temporary shelters.
2. Send children to education or camp activities to restore a sense of normalcy.
3. Give extra love and attention to children in emergencies.
Fight child trafficking

n Inform authorities in the camp or community if you know of suspected
traffickers that enter the camp or the affected community.
n Take note of strangers entering the camp.
n Talk to your children about traffickers and ensure that they know the danger
signs for trafficking.
n Do not leave children alone in camps or in the affected community.
R eporting cases of child abuse and trafficking took on different forms in the three
South Asian countries which were hit by the tsunami in December 2004. In the
Maldives and India, they used telephone hotlines. In Sri Lanka, confidential boxes

were strategically installed in various camps so that child abuse cases could be
anonymously reported. In India, community-based networks were established to
prevent child abuse and trafficking. These experiences show that in future
emergencies it would be worthwhile to combine the different strategies.
Prevent child separation

n In case of migration, have children walk in front to prevent separation.
n Insist on the importance of registering children at birth to aid in tracing efforts in
case of separation.
Prevent and monitor abuse

n Report child abuse to camp authorities.
n Children should report abuse to themselves (or their friends) to a trusted adult.
Encourage mothers primary caregivers to aid in the

recovery of children
n Know the signs of ab/normal reactions to stress.
n Help children get back to daily routines.
n Don’t discourage children when they verbalise their feelings or use other forms
of communication such as drawing, playing, etc.
n Seek help if children continue to show abnormal signs of stress even after one
month.
n Allow children to attend recreation/education activities.

n Don’t minimise children’s fears, and ensure that you respond with correct
information.
n Don’t send children away from you, to get them away from the scene of
disaster; separation from parents/loved ones will traumatise them even more.
Observations from the Maldives

After the tsunami hit the Maldives in December 2004, mothers in Ishdhoo Island
agreed that there was much fear among children. “They wake up during the night,
cannot sleep, and easily cry”, the mothers reported. Children refused to stay alone in
the house, not even with elder family members. Often, they could not go to the toilet
alone, and needed someone to be near when they studied for school. A child
protection communication initiative used a mix of communication channels:
counsellors and TV programmes disseminated psychosocial development
messages about child stress management, the importance of being honest about
the tsunami, and organising play groups so that the children didn’t have to play
alone. Afterwards, mothers said that they could more easily talk to their children
about the aftermath of the disaster, answer their questions, and be honest about the
possibility of another tsunami.
What camp authorities and service providers

should know
Create a protective environment
n Regulate alcohol selling and consumption.
n Make sure camp is well lit.
n Build separate latrines for men and women.
n Build latrines that give women privacy.
n Immediately register unaccompanied, separated children.
n Provide proper security guards for camps and settlements.
n Provide a play/recreation area for children within the camp or temporary shelter,
close enough to be observed by adults.
n Encourage older children to look out for the younger ones.
In the Maldivian tsunami shelters, there were situations where three or more
families were living together in one room. This increased the risk of sexual abuse
to women and children. Night posed special dangers because the latrines were
not well lit and were far from the sleeping quarters. While some might argue that
this is a camp management issue, communicators can disseminate child
protection messages to camp managers, and advocate for appropriate living
quarters, well-lit latrines that are close to the sleeping quarters, and the
designation of safe play areas for children.
Protect separated/orphaned children

n Separated/orphaned children have the right to participate in and be informed of
plans being made for them.
n Place unaccompanied, separated and orphaned children in the care of
reputable affected community members.
n Adoption should not be the first option for orphaned children.
n Register all unaccompanied, separated and orphaned children and make sure
that they receive the essential basic needs.
n Avoid institutionalisation of children until all other alternatives have failed.
Sample media release: Unaccompanied and separated children

The below media release was issued by UNICEF Sri Lanka, National Child Protection
Authority, Department of Probation and Child Care, and Save the Children a few days after the
tsunami had devastated parts of the country in December 2005.
“Many of the children who survived last week’s (26 December 2005) lethal earthquake and

tsunami were separated from their families and caregivers. The Government of Sri Lanka,

UNICEF and Save the Children Sri Lanka (SCiSL) are working together closely to ensure that
these children remain in safe environments, protected from violence, exploitation and abuse.
The National Child Protection Authority (NCPA), Dept of Probation and Childcare, UNICEF and
SCiSL have mobilised teams to identify and register all unaccompanied and separated
children. Joint teams are identifying children living in temporary camps for the displaced as a
priority. They will then be working with communities to identify and register all children who
have been separated from their immediate families.
The agencies are asking communities to contact any of the above agencies at their local
offices, with information on separated children within their communities.
The teams will be tracing the children’s closest relatives, in order to reunite them as quickly as
possible. If relatives cannot be found, Probation Officers will make comprehensive assessments
to plan for the best possible care. Options include fostering, adoption or, as a last resort, a home
for children. The agencies stress that children will not be considered for adoption during the
emergency phase, and until every opportunity to locate family members is exhausted. Adoption is
a lengthy process and takes many months. The relevant authority for this is the DPCC.
Family members or others who are caring for children who have lost their parents should
register with the Divisional Secretary or the Department of Probation and Child Care (DPCC).
Even if children are being cared for they should register the children so that tracing of their
family can be activated for the child – in the case of children whose parents have died other
family members will be traced.
Parents and other family members who have lost children should go to any of the following
agencies to register details of their child: District Child Protection Committees, Department of
Probation and Child Care, Save the Children Sri Lanka or UNICEF”.
Prevent recruitment of children

n Increase knowledge among camp officials on the international laws on child
rights and recruitment.
n Advocate with military groups and local authorities for the demobilisation of
child soldiers.
n Be on alert for “creeping recruitment”.
Some child protection issues in Sri Lanka after the Tsunami devastated the country
in December 2004:
Within the first 10 days of 2005, there were 14 verified reports of underage
recruitment by the Liberation Tigers of Tamil Eelam (LTTE) in Sri Lanka. Because of
the presence of the militia groups, and reported cases of forced recruitment, UNICEF
widely distributed previously developed leaflets on the prevention of underage
recruitment. Efforts such as this can be strengthened by encouraging parents/
primary caregivers not to leave their children alone, promoting the provision of
supervised child activities and play, and advocating with camp officials to design
camps that are safe for children.
FOR CHILD PROTECTION
Child protection communication actions will depend on the priorities of the emergency,
capacity, established partnerships and the knowledge, attitudes and practices of the
affected community in regards to child protection and survival. UNICEF commits to the
protection of children and women from violence, exploitation, abuse and neglect.
The table below outlines UNICEF’s Core

© UNICEF/ HQ05-1492/Asad Zaidi
Commitments for Children in Emergencies in

the area of Child Protection. Included are
suggested behaviour change communication
(BCC) and social mobilisation activities that
have proven to be effective in improving child
protection and psychosocial development in
emergency situations. Remember to plan your
communication and social mobilisation actions
with the involvement of the affected community
and your partners. And to carefully monitor and
evaluate the programme.
PAKISTAN: Children gather outside a tent in the Jalalabad camp for people
displaced by the earthquake, in Muzaffarabad, capital of Azad Jammu and
Kashmir (AJK), in Pakistan-administered Kashmir. About 1,500 people are
sharing cramped quarters in 170 tents in the camp. In some cases, 30 people
in 3 families, more than half of whom are children, are living in one tent.
TABLE: Extract from UNICEF's CCC in child protection and

corresponding suggested BCC and social mobilisation support.
FIRST SIX TO EIGHT WEEKS BCC AND SOCIAL MOBILISATION

ACTIONS TO SUPPORT
1. Conduct a rapid assessment n Ensure that the affected community
of the situation of children and receives information on severe,
women. Within the systematic abuse, violence and
appropriate mechanisms, exploitation of women and children and
monitor, advocate against, knows how to monitor and report it to
report and communicate camp management, local authorities
on severe, systematic and relevant humanitarian agencies –
abuse, violence and i.e. hotlines, IEC materials,
exploitation. establishment of camp watch groups,
peer educators, etc.
n Train social workers, healthcare

professionals and other service providers
on the signs of abuse, violence and
exploitation, and how to monitor and report
it to the proper agencies/authorities.
n Advocate and mobilise support with
camp management, social welfare
departments and local authorities to
establish simple monitoring and
reporting systems on abuse, violence
and exploitation, – i.e. boxes for
anonymous reporting, etc.
n Work with camp management to design
camps that provide well-lit latrines that
are close to sleeping quarters and safe
spaces for children to play to decrease
the likelihood of abuse, exploitation,
trafficking, etc.
n Increase knowledge among
humanitarian workers and all UN staff
members and partners about the code
of conduct and zero tolerance policy
on abuse and exploitation.
n Provide all humanitarian workers the six core
principles to prevent sexual exploitation.

ACTIONS TO SUPPORT
2 Assist in preventing the n Ensure that the affected parents/primary
separation of children from caregivers know how to prevent child
their caregivers, and separation in camp situations migration/
facilitate the identification, evacuation; that separated children
registration and medical should be registered; where and how to
screening of separated register separated children, and the
children, particularly those policies regarding separated children. In
under 5 years of age and addition, ensure that separated children
adolescent girls. know their rights to be informed of-and-
participate in the plans being made for
them, and know where to go to receive
essential services.
n Train social workers, police, and camp
managers to communicate with affected
parents/primary caregivers on how to
prevent child separation, how to register
separated children, and how to reach
communities with the child protection
messages, particularly those on
keeping girls safe.
social welfare departments and
humanitarian agencies to provide
families’ basic needs to prevent
intentional separation; immediately
implement systems to register
separated children straight away, and to
increase knowledge on the rights of
separated children to receive medical
screening, and other essential services.
3. Ensure that family-tracing n Ensure that the affected parents/primary

systems are implemented caregivers and separated children know
with appropriate care and where to go for family-tracing services
protection facilities and the process – i.e. social workers,
healthcare professionals, mass media
and IEC materials.

ACTIONS TO SUPPORT
n Advocate with camp officials, local
authorities, social welfare departments,
religious institutions and other relevant
stakeholders to establish family-tracing
services that use community monitoring;
and provide appropriate follow-up services.
BEYOND THE INITIAL BCC ACTIONS OR SOCIAL MOBILISATION

RESPONSE TO SUPPORT
4 Within established n Establish and build upon the initial
mechanisms, support the response to ensure that the affected

establishment of initial community continues to receive

monitoring systems, including information on severe, systematic abuse,
on severe or systematic violence and exploitation of women and
abuse, violence and children and knows how to monitor and
exploitation. report it to camp management, local
authorities and relevant humanitarian
agencies – i.e. hotlines, IEC materials,
establishment of camp watch groups,
peer educators, etc.
n Provide refresher training to social
workers, healthcare professionals and
other service providers on the signs of
abuse, violence and exploitation; and
how to monitor and report it to the
proper agencies/authorities.
n Continue to advocate and mobilise
support with camp management, social
welfare departments and local authorities
to maintain systems to monitor and
report abuse, violence and exploitation.
n Increase knowledge and provide
refresher training among humanitarian
workers and all UN staff members and
partners about the code of conduct and

RESPONSE TO SUPPORT
zero tolerance policy on abuse and
exploitation. Provide all humanitarian
workers the six core principles to
prevent sexual exploitation, and ensure
that they are able to adhere to the
principles.
5 In cases where children are separated, or at risk of being separated from

caregivers, work directly or through partners to:
(i) assist in preventing the n Ensure that affected parents/primary
separation of children from caregivers know where/how to register
their caregivers; their children at birth to facilitate tracing
in the event of a separation, know how
to prevent separation in the camp or in
case of migration/evacuation, etc. – i.e.
counselling, social workers, IEC
materials, mass media, etc.
n Enable social workers, healthcare
professionals, humanitarian agencies
communicate with parents/primary
caregivers on how to prevent the
separation of children.
and humanitarian agencies to provide
the basic needs of families to prevent
intentional separation, particularly for
those under five and adolescent girls,
and to implement evacuation plans.
n Enable social workers, camp leaders,
humanitarian workers to facilitate
emotional and social support to single
parents/primary caregivers, to ensure
that they take on/continue their
parenting responsibilities.

RESPONSE TO SUPPORT
(ii) facilitate the identification, n Build upon communication initiatives
registration and medical implemented in the initial response to
screening of separated ensure that the affected community
children, particularly those knows and can help separated children
under five and adolescent register and be medically screened,
girls; knows where to register separated
children, and is aware of the policies
regarding separated children. In
addition, ensure that separated children
know their rights to participate in and be
informed of the plans being made for
them, and know where to go to receive
essential services.

n Provide refresher training to social

workers, police, camp managers and
service providers on the policies
regarding separated children, the
importance of working with the
community to immediately identify,
medically screen and register separated
children – and how to communicate this
to the affected community.
n Continue to advocate and mobilise
support with the local government,
camp management, social welfare
departments and humanitarian agencies
to provide the basic needs of families to
prevent intentional separation; to
immediately implement systems to
register separated children straight
away, and to increase knowledge on the
rights of separated children to receive
medical screening, and other essential
services.

RESPONSE TO SUPPORT
(iii) facilitate the registration of all n Ensure that affected parents/primary
parents and caregivers who caregivers and separated children know
have lost their children; where to go to register for tracing
services and the procedures – i.e.
social workers, service providers, IEC
materials, mass media.
n Ensure that social workers, camp
officials, and service providers know
how to communicate the tracing
process to parents/primary caregivers
who have lost their children.
n Advocate with camp officials, local
authorities, social welfare departments
on the relevant laws, standards and
good practices in the protection for and
care of separated children.6
6. Support the establishment of n Ensure that the affected community

safe environments for children knows where to take their children for
and women, including child- recreation/education activities and the
friendly spaces, and integrate importance of doing so – i.e. IEC
psychosocial support in materials, loudspeaker announcements,
education and protection social workers, etc.
responses. n Promote child protection and
psychosocial development through the
establishment and facilitation of child-
friendly spaces, life skills promotion,
art, drama, theatre and class activities.
n Ensure that camp officials, police, local
authorities know how to make camps
safe for women and children and
participate in doing so.
n Provide training for community workers,
camp volunteers and teachers to
organise recreation groups and
activities for children.
The objective of an emergency child protection programme is to protect
children and women from violence, exploitation, abuse and neglect. Be
sure to monitor whether your communication strategy is supporting this
objective. Identify the indicators you will need to monitor your
communication efforts based on the behavioural results and actions you
have defined from the outset. The following are some common core
behaviour result indicators. Tool 13 in Part III lists possible sources
of information to help you measure the indicators.
1. Parents/primary caregivers know the importance of children’s participation in

recreational activities in hastening healing from trauma and psychological
recovery. They also know where these activities are provided in the camp and
are sending their children there.
2. Parents/primary caregivers know the dangers of leaving their children
unattended, and are aware of the unsafe areas for children in the camps.
3. Parents/primary caregivers know how to prevent child separation in the camp,
during migration or evacuation and are doing it.
4. Parents/primary caregivers understand the risks of sending their children away
for employment and marriage and refrain from doing so.
5. Camp officials know the importance of lighting latrines, providing adequate
camp security and designating safe spaces for women and children and are
making the necessary adjustments.
6. The affected community knows to report strangers, (suspected) traffickers that
enter the camp and are doing it.
7. Parents/primary caregivers who have lost children know how to register and
where to go to facilitate tracing.
8. Separated children know their rights to be involved in the decisions being made
for them; know where to go to register, facilitate tracing and receive essential
services.
9. Social workers, camp managers, service providers know the rights of separated
children and how to communicate these rights to them.
10. Community members know the signs of abuse, trafficking, molestation; and
know where to report it.
11. Affected children know where to report abuse to them or friends.
Participatory drama helps children move on after tsunami
I t is 3 p.m. at the IDH Watte camp in Galle, Sri Lanka. The community centre is
crowded. More than 50 children are anxiously waiting for the play to start. Eight-year
old Rajan and his friends are beaming with delight. As the animators enter the room
and address the young audience, it springs to mind that this is not a regular
performance: this is an awareness programme on the tsunami using high drama.
“Is this the sea?” asks one animator.

“Those days we loved the sea”, answers the other.
“What did you do at the sea?”
“Playing, fishing, bathing...”
“What do you know about the tsunami?”
“We are the people who got caught by the big waves. Our homes were damaged and
washed away”.
“We used to fly kites on the beach”.
Rajan and his friends mime flying kites. They laugh and eagerly answer questions from
the audience. Most of the children belong to fishing communities in Galle that were
terribly affected by the tsunami. Most are still living in camps or transitional shelters. As
the two actors move on with the show, personal memories amongst the audience are
triggered and they begin to think about their own experience on 26 December 2004.
Rajan becomes more involved in the stories they tell and he too remembers. The big
wave that the actors are pointing at in the picture destroyed his house. He had to run
away, but the water caught him and his mother. They had to cling to a tree and wait for
the wave to withdraw. His little sister didn’t survive. “But now I am happy I can play with
my friends”, he says. “I still have my mother and my father, and I can go to school”.
“What is a tsunami? Have countries other than Sri Lanka suffered from the waves? Will
another tsunami come again? How can we protect ourselves from another tsunami?”
These are the questions raised during the one-hour long programme.
“After the tsunami, UNICEF quickly identified the need for an Awareness Programme.
Nobody was prepared for the tsunami. Nobody expected it and it was a great shock to
the country”, explains UNICEF Child Protection Officer Sarah Graham. “There were many
rumours and unanswered questions: Will another tsunami come? Why did it hit Sri
Lanka? Is the water poisoned? Can we eat fish again? People wanted and needed to
learn more about the tsunami and tsunamis in general so UNICEF decided to work on a
programme to answer their questions”.
161
161
UNICEF’s Tsunami Awareness Programme gives children and adults the opportunity to
learn, participate, and reflect on their own experiences. The tsunami awareness
materials come with a guide that is used by community support workers, youth leaders
and teachers to facilitate the programme. It is designed so that each child or adult can
participate in their own way. Some will sit and listen, others will share their ideas and
some will stand up and interact with the facilitators.
“Each material was carefully planned to initiate a discussion based on children’s

personal experience and perceived notions, the facts and what they can do to insure
their safety and to rebuild their lives”, Graham said.
UNICEF has tested the Tsunami Awareness materials in affected areas across Sri
Lanka. In the South, this was carried out with support from Multi Diverse Community
(MDC), a local organisation that is implementing child well-being programmes in
camps around Galle. “The reactions were very positive, Graham said. “We tested the
materials in Hambantota the day after the last scare on 28 March 2005. It was amazing

to hear people’s personal experiences from the night before. They realised that they, as
a community, were able to protect themselves and that was very empowering”.
Thousands of young Sri Lankans are still haunted by the specter of the tsunami.
Although very sensitive issues are tackled through the programme, the children are
given the opportunity to interact and reflect on their own experiences. Lack of information
about tsunamis had created fear among the Sri Lankan people. But the Tsunami
Awareness Programme stimulated discussions amongst children and communities.
The programme also provided accurate information on what happened that tragic day
late last year, along with the role each person has in rebuilding their own lives and
community.
RESOURCE BANK
Further reading
1. Ariyabandu, M., and Wickramasinghe, M., Gender Dimensions in Disaster
Management: A guide for South Asia, ITDG South Asia Publication, Colombo,
2003.
2. Burnham, A., Public Health Guide for Emergencies, Johns Hopkins School of
Hygiene and Public Health, Baltimore, IFRC, 2000.
3. Ehrenreich, J., Coping With Disaster: A guidebook to psychosocial

intervention, Center for Psychology and Society, State University of New York,
New York, 2001.
4. Hanbury, C., Child-to-Child and Children Living in Camps, Child-to-Child Trust,
London, 1993.
5. Jabry, A. (editor), After the Cameras Have Gone: Children in disasters, Second
Edition, Plan, England, 2005.
6. Oxfam, ‘Gender and the Tsunami’, Oxfam Briefing Paper, Oxfam, London,
2005.
7. Save the Children, ‘Protecting Children in Emergencies,’ Policy Brief, 1(1),
Spring 2005, SAVE, London.
8. Save the Children, Psychosocial Care and Protection of Tsunami Affected
Children: Guiding principles, SAVE, London, 2005.
9. Segerstrom, E., Focus on Refugee Children: A handbook for training field
refugee workers in social and community work, Stockholm, 1995.
10. Uppard, S and Petty, C. Working with Separated Children: A field guide, SAVE,
London, 1998.
11. United Nations High Commissioner for Refugees, Sexual Violence Against
Refugees, Guidelines for Prevention and Response, UNHCR, Geneva, 1995.
12. United Nations High Commissioner for Refugees, Guidelines on Protection of
Refugee Children, Geneva, 1994.
13. United Nations Children’s Fund, Helping Children Cope with the Stresses of
War, A manual for parents and teachers, UNICEF, New York, 2000.
14. United Nations Children’s Fund, Convention on the Rights of the Child,
UNICEF, 1989.
15. United Nations Children’s Fund, Working with Children in Unstable Situations,
UNICEF, New York, 2002.
16. World Health Organization, Mental Health in Emergencies: Mental and social
aspects of health of population exposed to extreme stressors, WHO, Geneva,
2003.
17. World Health Organization, Psychosocial Care of Tsunami affected
Populations: Manual for trainers of community level workers, WHO Regional
Office for South East Asia, SEA-EHA-8, New Delhi, 2005.
Web sites
1. Child’s Rights Information Network
http://www.crin.org
2. Childtrafficking.com
http://www.childtrafficking.com
3. Save the Children

http://www.savethechildren.org/uk
http://www.unicef.org/protection/index_3717.html
6. Academy of American Paediatrics
http:/www.aap.org/new/disasterresources.htm
Glossary
Child means any person under the age of 18, unless under the (national) law
applicable to the child, majority is attained earlier (Convention on the Rights of the
Child, or CRC, Article1).
Child protection refers to protection from violence, exploitation, abuse and

deprivation from primary givers. Violation of the child right to protection, in addition
to being human rights violation, is also massive, unrecognized and underreported
barriers to child survival and development. Children subjected to violence,

exploitation, abuse and neglect are at risk of shortened lives, poor physical and

mental health, education problems, poor parenting skills later in life and
homelessness, vagrancy and displacement.
Child-friendly space consists of a safe space where children can go a few hours
a day, attending pre-school, taking part in youth activities, playing sports, having
access to trained social workers, etc. These hours help children socialize and give
relief to overwhelmed caregivers. They can also make it easier to detect children
with particular problems and provide assistance to them and their families. Having
designated child friendly spaces and engaging in these activities facilitate a return
to normalcy.
Fostering refers to situations where children are cared for in a household outside
their family. Fostering is usually understood to be a temporary arrangement and in
most cases, the birth parents retain their parental rights and responsibilities. The
term fostering is used to cover a variety of arrangements as follows:
§ traditional or informal fostering, where the child is taken into the care of a
family or other household that may or may not be related to the child’s family –
no third party is involved in these arrangements, though they may be endorsed
or supported by the local community and may involve well-understood
obligations and entitlements;
§ spontaneous fostering, where a family takes in a child without any prior

arrangement – this is a frequent occurrence during emergencies and may
involve families from a different community in the case of refugee children;
§ arranged fostering, where a child is taken into the care of a family as part of
an arrangement made by a third party, usually an agency involved in social
welfare such as a government department, a religious organization, or a
national or international NGO – this arrangement may or may not be covered by
formal legislation.
Orphans are children, both of whose parents are known to be dead. In some
countries, however, a child who has lost one parent is called an orphan.
Separated children are those separated from both parents, or from their previous
legal or customary primary caregiver, but not necessarily from other relatives.
These may, therefore, include children accompanied by other adult family
members.
Traffic in persons has been defined as: the recruitment, transportation, transfer,
harbouring or receipt of persons, by means of the threat or use of force or other
forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a
position of vulnerability or of the giving or receiving of payments or benefits to
achieve the consent of a person having control over another person, for the purpose
of exploitation.
Unaccompanied children are children who have been separated from both
parents and other relatives and are not being cared for by an adult, who, by law or
custom, is responsible for doing so.
Footnotes
1 United Nations Children’s Fund, Core Commitments for Children in Emergencies, UNICEF, New
York, 2005.
2 United Nations Children’s Fund, Emergency Field Handbook, UNICEF, New York, 2005.
3 United Nations Children’s Fund, Technical Notes: Special considerations for programming in
unstable situations, UNICEF, New York, 2003, p. 419.
4 O’Donnell, D., Child Protection, a Handbook for Parliamentarians, UNICEF Geneva, 2004, pp. 18-20.
5 Save the Children, Psychosocial Care and Protection of Tsunami Affected Children: Guiding
principles, SAVE, London, 2005, p. 1.
6 ICRC, Inter-agency Guiding Principles on Unaccompanied and Separated Children, 2004, p.66.
PART THREE
TOOLS
TOOL 1
HOW TO DEVELOP SMART
BEHAVIOURAL OBJECTIVES / RESULTS
Be smart. Always define SMART behavioural objectives or, in the
context of the results-based management approach - SMART
behavioural results - that are specific to a problem (like reducing
diarrhoea outbreaks in a community). Avoid citing generic behaviour
results like "to raise awareness" or "to improve knowledge". These
are useful only if they lead to behavioural results. The rapid changes
that are characteristic in emergencies make your planning and
results-setting imperative. It is therefore a MUST for you to define
behavioural results in specific terms before you develop your strategy
and begin to implement.3
Avoid the tendency to proceed with your communication strategy without the
benefit of evidence-based planning. The inexperienced would go ahead and say
"Let's print a poster to address people's lack of knowledge". Also avoid this mode
of thinking: "Let's use the same strategy for polio eradication for our hand-washing
campaign". Both approaches are doomed to failure and are not sustainable.
Achieving behavioural impact, maintaining the intended behaviour and influencing
others to follow suit in a sustained manner - require research and consultation with
the participant actors within their own environment. This entails far more than
simply printing a poster.4
How to do it
1. Answer the following questions to help you develop behaviour
objectives/results. To do so, you and your team need to work with the affected
community.
n Whose behaviour needs to change to bring about a given desired health or social
outcome in the emergency (mothers'; primary caregivers'; fathers'; neighbours';
volunteers'; health workers'; religious leaders', teachers'; politicians')?
n What are the current behaviours? Why are people currently doing it all the time;
doing it sometimes, or not doing it at all? What factors account for the
difference?
n If they are not doing it now, why not? Are they practising a similar desired
behaviour? How can you best influence and support that behaviour? What are
the barriers to change?
n What factors - social, cultural, economic, environmental, psychological,
physiological, etc. - and who, what, where are the most influential channels that
can motivate changing or maintaining the behaviour?
n What skills and resources are needed for the affected groups to practice the
desired behaviours?
2. Conduct a rapid communication assessment using a combination

(triangulation) of techniques. The rapid assessment will give you the answers to
the above questions and will help you define your SMART behavioural results. To
do this, you can conduct exploratory or transect walks and participant or non-
participant observations. You can also engage in discussions with key informants
and opinion leaders such as religious and secular heads, community opinion
leaders – usually the elders and local leaders - service providers, relief workers and
others. You can further gain insights into people’s social habits, attitudes, risk
behaviours and underlying vulnerabilities of families and communities through
community mapping, network analysis, focus group discussions (men, women and
children) and other participatory learning approaches or PLA tools. While they
participate in these activities, they too gain collective insights about themselves
and their own communities. You can perform these rapid assessment techniques
easily and quickly in an emergency setting.
3. Analyse, prioritise, and finalise the statement of behavioural results after

you have collected the information you need. Do so with representatives from the
affected groups. Remember to keep the list short – too many behavioural
expectations are as bad as none at all. Target a few behaviours, if possible not
more than three behaviours that are feasible for the intended participant actors to
practice.
What is a SMART behaviour objective/result?

Behavioural results are best stated in terms of the intended behaviour change
or the maintenance of an existing desired behaviour. A behavioural result
usually has at least three features, which makes it a SMART result:
TOOL 1
n Clear identification of the participant group.
n Detailed description of the promoted behaviour (appropriate and realistic); and
how many times the behaviour should take place.
n The measurable result you hope to observe over a specific time period.
Examples of SMART behavioural objectives and results:
Behaviour Objective:
Within two weeks from the start of the emergency, to increase from 30 percent
to 60 percent the number of caregivers who wash hands with soap or ash and
water before preparing food, after going to the toilet and after washing the baby.
Behaviour Result:
Within six weeks from the start of an emergency, the number of Community
Nutrition Promoters who provide friendly and accurate answers to questions at
every nutrition education session would have increased from 30 percent to 60
percent.
Footnotes
1
SMART is an abbreviation for Specific, Measurable, Achievable, Relevant, Time-bound. See
Chapter 2 for more information.
2
Adapted from Parks, W., et al., Planning Social Mobilization and Communication for Dengue
Fever Prevention and Control, WHO, Geneva, 2004, p. 35.
3
Adapted from Oxfam UK, Guidelines for Public Health Promotion in Emergencies, Oxfam,
London, 2001, p. 34.
4
Adapted from Parks, et al., op.cit., pp. 35-36.
5
Graeff, J., Programme Communication Advisor, UNICEF, Bangladesh Final Report on
Behavioural Monitoring Workshop, UNICEF, Dhaka, 2005.
TOOL 2
HOW TO DEVELOP INDICATORS BASED
1
ON BEHAVIOURAL RESULTS
How do you know if your efforts in communicating to

change behaviour and social mobilisation are actually
making a difference in emergency situations?
This is an important question that highlights the value of well-planned monitoring

and evaluation (M&E). Unfortunately, M&E is often an afterthought in emergency
management planning. This trend tends to reduce the quality and cost-
effectiveness of actual and future responses. Likewise, tracking and assessing
communication activities during an emergency are often weak, which makes it
difficult to report on results.
This tool shows you how to plan the monitoring and evaluation of behaviour change
communication and social mobilisation in emergency situations. We look at
participatory methods on how to develop indicators based on behavioural results in
a participatory way. We consider some simple data collection methods that can
be used to monitor and evaluate communication and mobilisation activities.
Let's begin by clarifying the basic terms:
What is an M&E system?

Monitoring provides insight into how well a response or planned set of activities is
being implemented. It is part of the evaluation process. Evaluation is a continuous
process, done periodically, i.e., at each stage of the programming cycle. It offers
a comprehensive review of whether an emergency response is achieving its short-
term results and longer-term goals. Continual and careful monitoring of relevant
indicators and processes generates information for evaluation and, more
importantly, for corrections that may be needed as an emergency response
unfolds.
An M&E system refers to a textual, graphical and/or numerical data system used
to measure, manage and communicate desired performance levels and emergency
response achievements. M&E systems are often based on a combination of
evaluation types (see Table 1 below).
Type of evaluation Broad purpose Main questions answered
Baseline Analysis/ Determines concept and Where are we now?

Formative Evaluation design Is an intervention needed?
Research Who needs the intervention?
How should the intervention be
carried out?
Monitoring/Process Monitors inputs and How are we doing?

Evaluation outputs; assesses To what extent are planned
service quality activities actually realised?
How well are the services
provided?
Outcome/Effectiveness Assesses outcome and How did we do?

Evaluation impact What outcomes are observed?
What do the outcomes mean?
Did the response make a
difference?
Future Plans/Cost- Value-for-resources What are our next steps and

Effectiveness Analysis committed including needed resources?
sustainability issues Should response priorities be
changed or expanded?
To what extent should resources
be reallocated?
What is an indicator?
An indicator is information on a particular circumstance that is measurable in some
form. Indicators are approximations of complex processes, events and trends. They
can measure the tangible (e.g., service uptake), the intangible (e.g., community
empowerment), and the unanticipated (e.g., results that were not planned). An
indicator gives an idea of the magnitude and direction of change over time. But it
cannot tell us everything we might want to know.
Indicators need not be perfect - only sufficiently relevant and accurate enough so
that those interpreting the information can do so.
Indicators should be easily interpreted. It is very important, therefore, to carefully

define any indicators and ensure that the way they are defined "travels accurately"
TOOL 2
back and forth between languages and cultures (including organisational cultures).
Indicators can also be "progress markers". It is clear that behaviour change

communication and social mobilisation in emergency responses must demonstrate
impact. Stakeholders - whether members of affected communities, programme
managers, donors or policy makers - need immediate data that show the
contribution your communication initiative has made. Because behaviour and social
change often take time to happen, we sometimes need signpost indicators or
progress markers - measures that do not necessarily tell us that the ultimate
outcome or impact has been reached, but signals that we are on the right track. In
communication programmes, for example, "intent to change" has been used as
predictor of actual change.
Types of indicators
Indicators may be pictorial. For example, drawings and photographs that show the
situation immediately after an emergency that are then compared with drawings
and photographs produced some time after the emergency (e.g., 6 weeks, 3
months, etc.) can promote greater discussion and lead to a better understanding
amongst both literate and non-literate stakeholders. We will look at examples of
pictorial methods that can generate information for indicators in Table ** below.
Indicators may be in the form of stories. Qualitative approaches to monitoring and

evaluation usually include the collection of "stories from the field". These stories
often provide meaning to quantitative information or capture real "voices". A
monitoring technique known as the Most Significant Change (MSC) has been
developed that allows for the systematic collection and interpretation of stories.
Please refer to Tool 3 for the MSC Technique.
How many indicators do we need?

In choosing indicators, it is important for you to limit the number to a set of critical
indicators. A multitude of indicators will create problems when you attempt to
interpret results. The challenge then lies in defining what is a critical indicator, while
at the same time making each indicator comprehensible, measurable, comparable
(to ascertain trends) and affordable.
Spending the time working out (and trialing) the few, critical measurements needed
to tell your programme’s essential story will undoubtedly save you the time (and
frustration) later. Applying the Rapid Appraisal principle of optimal ignorance
helps here. “Optimal ignorance” refers to the importance of knowing what facts are
not worth knowing, thus enabling the cost-effective, timely collection and analysis
TOOL 2
of information.1 Applying this principle avoids collection of irrelevant data but its
application requires courage!
How todevelop indicators

Each chapter in this Toolkit offers examples of possible indicators. Remember,
these examples are intended to foster debate and negotiation about what should be
measured amongst those planning and implementing emergency responses. You
may end up with a range of locally created indicators that are supplemented by
these examples.
Here we consider how todevelop indicators based on your programme's intended

behavioural results. The emphasis is on completing the bulk of this work before a
disaster occurs - in other words, these steps should ideally be taken during
disaster preparedness planning. We recognise, however, that much depends on the
nature, scale and extent of a particular emergency. For this reason, we offer simple
monitoring tools and indicators in the main chapters of this Toolkit that can be used
to get a basic M&E system up and running during an emergency. The indicators
and data collection methods presented below are likely to be more useful when
time allows or when preparedness planning is conducted in a comprehensive
manner.
Indicator development is best viewed as part of an M&E process. We can

summarise the core steps or stages for this process as follows:
1. Assemble an M&E core team.

2. Clarify the question: who wants to know what and why?
3. Identify indicators that will provide the information needed.
4. Choose and adapt data collection methods.
5. Synthesise, verify data, and analyse contribution.
6. Use M&E results to re-develop future communication/social mobilisation
activities.
With each step, we offer questions that you can discuss with relevant
stakeholders. Between selected steps, we offer a checklist for you to complete
before proceeding to the next step.
Step 1. Assemble an M&E core team

Who should, and wants to be involved in the monitoring and evaluation of a
behaviour change communication effort in emergency responses? How should
participants be identified and selected? What should participants' backgrounds and
interests be? What constraints will they bring to the task (workload considerations,
TOOL 2
educational limitations, motivation)? What type of skills, knowledge, changes in
behaviour and attitudes are required to effectively conduct M&E?
Minimal requirements for core team members are:

n Personal commitment to an interactive process and the principles of
participatory monitoring and evaluation.
n Ability to work as a team.
n Competency in a wide variety of research techniques and methodologies, with
emphasis on participatory methodologies.
n Group facilitation skills, understanding of group process, dealing with tensions
and conflict, equalising participation, running participatory activities,
summarising, and being an active listener.
n Ability to communicate with different stakeholders, such as members of
affected communities, government representatives, and representatives of
international donor and UN agencies.
Additional questions to ask at this step include: How is the training of participants
in M&E to be accomplished? To what extent do cultural and linguistic differences
impact training effectiveness? Can evaluators and other professionals assume the
role of trainer or facilitator with relative ease? How does one listen for the voices
that have not been heard yet? How can cultural, language, or racial barriers be
addressed?
Step 2: Clarify the question: who wants to know what and why
Gather stakeholders together and pose the question: "Who wants to know what
and why?" Responses to this question will help develop the behavioural results -
statements of intent that begin with words such as: "To assess…" or "To
measure…" or "To monitor…" or "To evaluate…"
Ensure that many stakeholders are involved in this planning step as possible.
Different groups of stakeholders will have different interests, values, and information
requirements. Excluding stakeholder groups from planning how the communication
and social mobilisation will be monitored and evaluated may disenfranchise these
groups.
Behavioural results should be derived and linked to what your team is aiming to
achieve in relation to the promotion of hygiene, breastfeeding, immunization and
vitamin A, safe motherhood, and child protection in emergency situations.
To help you discuss what people need to know and why, you could ask stakeholder
groups the following questions:
n From your point of view, what difference will the communication strategy make?
In what way will communication influence individual and group behaviour? How
will we know?
n Will the communication strategy strengthen individual and affected community
communication capacity, decision-making and action? If so, how will we know?
n Do you think the strategy takes into account obstacles to behaviour and social
change? If so, how? If not, what could be done to consider these obstacles?
How will we know when these obstacles have been overcome?
n In your opinion, will the proposed communication strategy enable previously
powerless individuals and communities to take control of the means and
content of communication, to achieve their own behaviour and social change
goals? If so, how will we know?
*Quick checklist before you proceed to Step 3

Have you assessed the link between project overall
¨ Yes ¨ No
results, behavioural results and strategies?
Have you included individuals and organisations that
¨ Yes ¨ No
will be affected by the emergency response in your
monitoring activities?
Are participants involved in the monitoring trustworthy
¨ Yes ¨ No
and competent?
Have they made an informed decision about where,
¨ Yes ¨ No
when and how they want to be involved?
Have steps been taken to assure that all stakeholders
¨ Yes ¨ No
and the population served will be respected, and their
values honoured during the monitoring and evalua-
tion?
Have conflicts of interest been discussed to ensure
¨ Yes ¨ No
that the results or findings will not be compromised?
Have you described the purpose of your monitoring
¨ Yes ¨ No
and evaluation in detail?
Is there a written or at least verbal understanding
¨ Yes ¨ No
among stakeholders about the purpose of the moni-
toring and evaluation activities?
Step 3: Identify indicators that will provide the information needed

Identifying indicators is one of the most challenging tasks when setting up an M&E
system. More so than any other step, identifying and agreeing on what indicators
to use highlights the different information needs and expectations that the different
stakeholders have of the monitoring work.
TOOL 2
Identification of indicators is best started after a dialogue on the affected
community's concerns, goals, issues and obstacles, and the vision of the change
they seek. The indicator-specific discussion begins by asking stakeholders to
reflect on their M&E results (what they want to know and why) and consider the
information they are already collecting; and what methods of information exchange
or reporting they are using that may be appropriate. One question you should ask
stakeholders is: what behavioural information is needed early on, continuously or
frequently to make sure this communication initiative is on track and achieving its
results?
Several M&E processes and indicators set for measuring communication and
social mobilisation have been created and offered in Tool 3 as useful guides
Step 4: Choose and adapt data collection methods.

M&E systems may use visual (maps, calendars, problem ranking, wealth-ranking,
photonovella, pocket charts, story with a gap) and dramatic forms (story telling,
songs, dances, sculptures, role plays) of data collection together with more
standard methods such as interviewing, observation, focus group discussions,
workshops, community meetings, questionnaires, and document analysis. A few of
these methods are described in Table 2.
Table 2: Examples of M&E data collection methods
TECHNIQUE BRIEF DESCRIPTION

Mapping Establishes connections and local insights into what
is "useful" and "significant" in order to understand
community perceptions of the local environment,
natural and human resources, problems and
resources for dealing with them. There are several
different types of maps including: spatial maps; social
maps (depicting social relationships); temporal maps
(showing changes over time); aerial maps (aerial
photographs or standard geographic maps); and
organisational maps (venn diagrams depicting
institutional arrangements or networks).
Seasonal calendars Ways of illustrating seasonal changes in subjects of

interest - i.e. harvests, labour availability, fever,
seasonal transmission of HIV and communication
resources. Months, religious events, seasons and
other local climatic events, for example, are used to
illustrate time periods. Issues of interest are then
discussed (sometimes using stones, sticks, or
marks on paper in relation to these periods).
Discussions usually highlight periods of maximum
stress, constraints (no time or resources available),
or the best time when new initiatives could be
undertaken.
Problem ranking/ sorting Cards with words or pictures are sorted into piles or
ranked according to local criteria in order to
understand how participants rank problems (e.g.,
communication obstacles) in terms of frequency,
severity, and so on. Ranking provides a systematic
analysis of local terms, perceptions or evaluations
of local issues. Disadvantage is that ranking can
force participants to structure their knowledge in
artificial ways unless the ranking criteria are
themselves developed through a participatory
process. This exercise can be used in pre- and
post-intervention evaluations to measure change in
particular rankings.
Well-being and Uses perceptions of local inhabitants to rank

wealth-ranking households, families or agencies within a social
network or village/neighbourhood according to
wealth, well-being or social contacts. For example,
names of household heads are written on cards.
These cards are then sorted into piles by at least
three M&E participants (ideally interviewed
separately) according to criteria that they describe to
the M&E team member. The resulting classifications
are often at odds to conventional socio-economic
surveys, revealing locally important well-being or
wealth criteria that can be used to measure more
subtle and usually important social changes than
can be measured in quantitative methods.
Local people themselves produce visual images

through the use of video or instamatic camera. The
Photo-novella images then serve as a catalyst to depict, reflect on
and discuss social conditions affecting their lives
and future possibilities.
TOOL 2
Helps people to assess and analyse their situation
in a new way using pictures and a "voting" process
Pocket charts based on a simple grid-sheet with rows of pockets,
pictures, and markers (clothes pegs, pebbles, etc.).
Can be used in group or individual (confidential)
situations. Dialogue members place their "vote"
(pebble) in a pocket underneath or corresponding to
picture they agree with or prefer.
Engages people to define and classify goals, and to

make sustainable plans by working on "before and
Story with a gap after" scenarios. A variety of pictures depicting
present problems and future possibilities are
presented. Dialogue members consider possible
reasons for differences in the contrasting pictures,
create stories to explain the "gap" between pictures,
and identify community solutions to local problems.
Can be used in one-to-one interviews but best in
group situations.
A semi-structured interview using a flexible interview

guide consisting mainly of open-ended questions
In-depth individual (questions that cannot be answered with a "yes" or
interview "no" or any other single word or number). The aim is
to collect detailed information on the individual's
beliefs and attitudes related to a particular topic.
A "key informant" is someone who has extensive

experience and knowledge on a topic of interest to
Key informant interview the evaluation. Often key informants are community
or organisation leaders. The interviewer must
develop a relationship of confidence with the
individual so that his/her experience and insights
will be shared.
There are several different types of group interview

such as consensus panels (local experts debate to
Group interview reach a consensus on a series of issues), structured
group interview (participants are asked the same
questions as individuals), focus group discussions (a
facilitator guides 10-15 participants through a series of
issues, with the group interacting with each other
rather than just with the facilitator - reaching
consensus is not the main aim), community meetings
(formal discussions organised by the local group or
agency at which the M&E team or facilitator ask
questions and/or make observations), spontaneous
group discussions (everyday meetings e.g., a sports
event, at which groups of people gather around to chat
and in which the M&E team or facilitator participates).
While an activity is ongoing, an observer records what

he/she sees either using a checklist or by taking
Observation descriptive notes. The observation can include
information on: the setting (the actors, context, and
surroundings); the actions and behaviour of the actors;
and what people say - including direct quotations.
Analysis of secondary Reports and other written documents that provide

data information on the activities planned and carried out.
When choosing the methods needed to collect information for each indicator, core
M&E team members should facilitate discussion with stakeholders on:
n The indicator and the kind of data required.

n The technical difficulty and adaptability of the method to a particular level of
expertise.
n Cultural appropriateness of the method - will it make people feel comfortable
learning, communicating, and interacting?
n Facilitation of learning - does the method facilitate learning?
n Barriers to participation - e.g., levels of literacy, command of language used,
social class, physical challenge, age, and time constraints.
YYou will also have to make decisions on the number and location of data
collection sites, the sampling processes involved (random or deliberate), the
characteristics and sample size of people to be interviewed or invited to meetings,

the selection of people or events to be observed, and the scheduling of data
collection (e.g., the date and time for site visits, meetings, interviews).
Now in the following table (make a copy for each behavioural result):
TOOL 2
n List the indicators you have decided to develop or use to monitor progress
against each result.
n For each indicator, determine what method or methods will be used to collect
information to inform the indicator/s.
n Work out what samples your behavioural indicators will require.
n Then give thought to who will collect the information (e.g., who will conduct the
interviews, observations, focus groups, participatory methods, questionnaires).
Quick checklist before you proceed to Step 5
Have you assessed the link between the behavioural results, indicators, ¨ Yes ¨ No
methods, and samples?
Have you checked whether measuring the indicators is feasible in terms of ¨ Yes ¨ No
how much information is required, how many methods, how much time, how
many data collectors are needed, and their skill levels?
Will the methods and tools you have chosen require development, pre- ¨ Yes ¨ No
testing and training of data collectors? If “Yes”, make a note in the space
below.
Have you made sure that information will be collected using more than one ¨ Yes ¨ No
method (triangulation)?
Have you determined the samples that you will require? ¨ Yes ¨ No
Have you identified who will be needed to collect the information? ¨ Yes ¨ No
Note here if any tool development, pre-testing or data collector training will be
required for one or several of your measurement methods:
182
BEHAVIOURAL RESULT 1 BEHAVIOURAL MEASUREMENT SAMPLES WHO WILL
INDICATOR/S METHOD/S COLLECT INFORMATION
AND WHEN
Step 5: Collect, synthesise, verify data, and analyse contribution

Data collection to monitor and evaluate communication in emergency responses is
usually drawn out over a number of weeks or months. It is highly desirable that
data synthesis and analysis occur as the data are collected. In other words, there
should not be a distinct period of “data collection” followed by a distinct period of
TOOL 2
“data analysis” – analysis usually leads to new questions requiring further data
collection, and so on.
“Data saturation” is often used as a sign that data collection can be reduced in
intensity. Data saturation can be defined as the point at which no new answers to
questions are being recorded and no new insights are being generated from the
data analysis, which suggest the need for further periods of data collection for the
time-being. It is important also to have regular reviews or reflections on the
methods. Methods and questions may need to be adapted or modified on
occasions.
Step 5 also involves processing and analysing data. Core M&E team members
should organise meetings with relevant stakeholders and facilitate critical reflection
on problems and successes, understanding the impacts of their efforts, and acting
on what they have learned. Will there be a need for computer-based analysis? Is
there a need for further training/reading for your team on qualitative and/or
quantitative analysis? What becomes critical is how stakeholders actually use
information in making decisions and identifying future action.
How will you ensure participants can provide feedback (verification) on the
information that is collected? Analysis of data should include data validation
among stakeholders. Data should be presented back to participants for verification
and collective analysis. Ways to ensure that feedback and validation occurs can
include workshops and meetings, distribution of reports (with follow-up interviews),
transcripts of interviews returned to interviewees, and so on.
We asked at the beginning of this tool how do you know if behaviour change
communication and social mobilisation are actually making a difference in
emergency situations?
How much of the success (or failure) in an emergency response can we associate
with communication for behaviour change and social mobilisation? Was the
contribution worth the investment? Perhaps without communication and social
mobilisation, the observed changes would have occurred anyway, or would have
occurred at a lower level or at a slower pace.
To definitively prove behaviour change communication and social mobilisation is

making a contribution, we would need “controlled comparisons” (intervention versus
non-intervention) to estimate what happens with communication is in place, versus
what would happen without it. But such evaluation designs have ethical and
resource implications, especially for emergency response situations.
So the question remains: in the absence of a complex evaluation study, how do

we measure contribution?
The first key is to recognise the limits of measurement. Definitively determining the
extent to which communication contributes to any particular behavioural or social
change is usually not possible (even with a meticulously designed evaluation). At
best, we should be satisfied with a reasonable estimate of the magnitude of
impact. Let’s focus less on decimal points and more on what Rapid Appraisal
practitioners describe as appropriate imprecision – not measuring more
accurately than is necessary for practical purposes.1 It is perhaps more useful to
measure trends and directions of change, rather than absolute numbers.
When M&E resources are scarce, our second interest should be in increasing
understanding and knowledge rather than worrying about scientific certainty. We
should embrace uncertainty because we will never eliminate it.2 If you must know
with a high degree of certainty what communication’s contribution is then you will
need a carefully designed evaluation study (and probably a lot of money).
The third key is to acknowledge that there is a problem of linking outputs directly
to outcomes. Many factors are at play beyond specific communication and
mobilisation activities. We need to be realistic about the outcomes we are trying to
influence and acknowledge many potential influences are beyond the control of
strategic communication.3
Any reasonable attempt to measure the contribution of communication in an

emergency response would accomplish at least three things during the planning
stage:
(1) Intelligently map intended behavioural outcomes related to hygiene,
breastfeeding, immunization, vitamin A, safe motherhood, and child protection.
(2) Develop key indicators that either directly measure these outcomes or can
serve as proxies or progress markers towards these outcomes.
(3) Recognise or list those factors communication has no control over.
Collecting information from this point on might therefore show:

n Outcomes appeared at an appropriate time after your efforts began.
n Outcomes faded when your efforts stopped.
n Only outcomes appeared that you should have affected.
n Outcomes appeared only where or when communication activities were
TOOL 2
implemented.
n The biggest outcomes appeared where or when you did the most.
The analytical job is then to explore and discuss (and hopefully discount) plausible
alternatives that might explain these relationships between effort/time/place and
associated outcomes. Identifying what these alternative explanations might be is
usually straight-forward. The core M&E team's job is to provide further evidence that
discounts these alternatives. If there is little evidence that counters other plausible
explanations, then you can possibly conclude that you cannot be sure what the
contribution of communication has been. This unfortunate conclusion, however, is
not usually arrived at if you have gathered additional, relevant evidence. For
example, your communication might have been based on a previously proven
theory and/or field experiences elsewhere, in which case, the associations
between the communication and outcomes are supported by other examples.
Other supporting evidence may be found, not from specific indicators, but from
programme reports, meeting minutes, national surveys, or stories from the field.
Step 6: Use M&E results to re-develop future communication/

social mobilisation activities
How is the data being used and for whose benefit? This step serves as an
important means of disseminating findings and learning from others' experiences.
Core M&E team members should seek agreement with stakeholders (through
meetings) on how findings should be used, and by whom. Several versions of M&E
reports may be required, each tailored to different requirements and capacities of
different stakeholders. Possible areas of future work should be discussed for follow-
up. At this key moment, core M&E team members should also clarify with
stakeholders if the M&E system needs to be sustained, and if so, how. The M&E
system may need to be adjusted accordingly.
Resource bank
Further reading
Participatory M&E
1. Aubel, J., Participatory Program Evaluation Manual: Involving program
stakeholders in the evaluation process, Catholic Relief Services, Dakar, 1999.
2. Estrella, M., with Blauert, J., Campilan, D., Gaventa, J. et al., Learning from
Change: Issues and experiences in participatory monitoring and evaluation,
Intermediate Technology Publications Ltd., London.
3. Feuerstein, M.T., Partners in Evaluation: Evaluating development and

community programmes with participants, MacMillan, London, 1986.
4. Parks, W. with Grey-Felder, D., Hunt, J. and Byrne, A., Who Measures
Change? An Introduction to Participatory Monitoring and Evaluation of
Communication for Social Change. Communication for Social Change
Consortium, South Orange, 2005. http://
www.communicationforsocialchange.org.
5. Whitmore, E., 'Understanding and Practicing Participatory Evaluation', New

Directions for Evaluation, No. 80, Jossey-Bass Publishers, San Francisco,
1998.
Data collection methods for M&E

6. Deepa, N., and Srinivasan, L., Participatory Development Tool Kit, The World
Bank, Washington, D.C, 1994.
7. Gosling, L., Toolkits: A practical guide to monitoring, evaluation and impact

assessment, New Edition, Save the Children Fund UK, London, 2003.
8. Grandin, B.E., Wealth Ranking in Smallholder Communities: A field manual,

Intermediate Technology Publications, London, 1988.
9. Patton, M.Q., Participatory Learning and Action (PLA) Notes and Rapid Rural
Appraisal (RRA) Notes: Qualitative evaluation and research methods, Second
Edition, Sage Publications, Newbury Park,1990.
10. Pretty, J., Guijt, I., Scoones, I., and Thompson, J. A., Trainer's Guide for
Participatory Learning and Action, IIED, London, 1995.
11. Scrimshaw, N.S., and Gleason, G.R., Rapid Assessment Procedures:

Qualitative Methodologies for Planning and Evaluation of Health Related
Programmes, International Foundation for Developing Countries, Boston, 1992.
TOOL 2
12. Srinivasan, L., Tools for Community Participation: A manual for training trainers
in participatory techniques, PROWWESS/UNDP-World Bank Water and
Sanitation Program, Washington, D.C., 1993.
13. Wang, C., Burris, M. A. and Ping, X. Y., 'Chinese village women as visual
anthropologists: A participatory approach to reaching policymakers.' Social
Science & Medicine, 42 (10), 1996, pp. 1391-1400.
14. World Bank, Monitoring & Evaluation: Some tools, methods & approaches,
World Bank, Washington, D.C., 2002.
Web sites
Communication for Social Change Consortium
http://www.communicationforsocialchange.org
Footnotes:
1 Source: Parks, W.
2 Rehle, T., Saidel, T., Mills, S. and Magnani, R., Evaluating Programs for HIV/AIDS Prevention and Care in
Developing Countries: A handbook for program managers and design makers, Family Health International,
Arlington, p. 11.
3 Hamilton, C., Kumar Rai, R., Shestra, R.B. et al (2000) ‘Exploring Visions: Self-monitoring and evaluation
processes within the Nepal-UK Community Forestry Project.’ In Estrella, M. with Blauert, J., Campilan, D.,
Gaventa, J. et al (eds) Learning from Change: Issues and experiences in participatory monitoring and
evaluation. London: Intermediate Technology Publications Ltd. Pp.15-31. (P.29).
4 Davies, R. and Dart, J. (2005) The Most Significant Change ‘MSC’ Technique: A Guide to Its Use. http://
www.mande.co.uk/docs/MSCGuide.pdf.
5 Scrimshaw, N.S and Gleason, G.R. Eds. (1992) Rapid Assessment Procedures: Qualitative Methodologies for
Planning and Evaluation of Health Related Programmes. Boston, MA: International Foundation for Developing
Countries.
6 Aubel (1999) describes 7 phases and 20 steps for participatory evaluation. See Aubel, J. (1999) Participatory
Program Evaluation Manual: Involving Program Stakeholders in the Evaluation Process. Dakar: Catholic Relief
Services.
7 Guijt, I. (2000) ‘Methodological Issues in Participatory Monitoring and Evaluation.’ In Estrella, M. with Blauert,
J., Campilan, D., Gaventa, J. et al (eds) Learning from Change: Issues and experiences in participatory
monitoring and evaluation. London: Intermediate Technology Publications Ltd. Pp.201-216 (p.204).
8 Scrimshaw, N.S and Gleason, G.R. Eds. (1992) Rapid Assessment Procedures: Qualitative Methodologies for
Planning and Evaluation of Health Related Programmes. Boston, MA: International Foundation for Developing
Countries.
9 Mayne, J. (1999) Addressing Attribution through Contribution Analysis: Using Performance Measures Sensibly.
Office of the Auditor General, Canada.
10 Information on Outcome Mapping is drawn from: Earl, S., Carden, F. and Smutylo, T. (not dated) Brochure on
Outcome Mapping: The Challenges of Assessing Development Impacts. http://web.idrc.ca/en/ev-26979-201-1-
DO_TOPIC.html
MOST SIGNIFICANT
TOOL 3
CHANGE TECHNIQUE
The most significant change (MSC) technique is gaining increasing popularity. 1
In MSC:
n All stakeholders in a program are involved in deciding the changes to be

recorded.
n The same questions are asked of everyone.
n Resulting stories are rigorously and regularly collected.
n Stories are then analysed, discussed and filtered (voting), verified, and
documented
There are three essential phases to MSC:

A Determine the sorts of change to monitor.
B Collect stories, review, select, and feedback.
C Compile ‘selected’ stories, analyse, verify and monitor the process.
Phase A and B are often inter-connected.
The MSC technique begins with participants/stakeholders affected by an

emergency being asked a simple question in the context of an emergency
response program:
“Looking back over the last few weeks, in your opinion, what do you think was the
most significant change that took place in the lives of people involved in…[name
of response project/program]?”
To collect a few more details for the story, follow-up questions can be asked such as:
n What happened, who was involved, where did it happen, when did it happen?
n Why is the change the most significant out of all the changes that took place in
the [time period]?
n What difference did it make already, or will it make in the future for you, for your
community?
Stories can be collected from diaries, interviews, group discussions, and

community meetings. Groups of stakeholders then meet to discuss and vote for
the most significant stories out of those collected. An effective MSC system
ensures feedback to storytellers of their selected stories. Some stories can be
used to generate press coverage.
MSC is a valuable way of “dignifying the anecdote” – creating a legitimate space for
storytelling and giving these stories validity. MSC has already been applied in
developed and less developed economies, in participatory rural development
projects, agricultural extension projects, educational settings, and mainstream
human services delivery.
Measuring community participation2

A framework originally proposed by Susan Rifkin and colleagues for measuring
community participation in health programs, may be suitable for adaptation to
measuring community participation in emergency responses. This framework has
been used in Nepal, Cameroon, Indonesia, Sweden, the Philippines, Fiji, Papua
New Guinea, and the United Republic of Tanzania.3
Indicator Questions
Needs assessment 1) How are needs identified?
2) Does identification relate only to health service
needs?
3) Is the affected community involved in needs
identification and assessment?
4) Does the assessment strengthen the role of a broad
range of affected community members?
Leadership 1) Which groups does the leadership represent and

how does it do so?
2) Is the leadership paternalistic and/or dictatorial,
limiting the prospects of wider participation for
various groups in the affected community?
3) How does the leadership respond to the needs of
poor and marginalised people?
4) Do most decisions by the leadership result in
improvements for the majority of the people, for elites
only, or for the poor only?
1) Are new organisations being created to meet defined

needs, or are the existing ones being used?
TOOL 3
Organization 2) Are the organisations flexible and able to respond to
Resource change, or are they rigid, fearing a change in
mobilization control?
Management emergency responses, and do changes benefit
professionals or affected community members?
3) What changes have taken place in the organisations
since the introduction of emergency responses, and
do changes benefit professionals or affected
community members?
1) What is the affected community contributing, and

what percentage is this of the total response costs?
Resource 2) Are resources from the affected community being
mobilization allocated for the support of parts of the response that
would otherwise be covered by government
allocations?
3) Whose interests are served by the mobilisation and
allocation of resources?
1) Are decisions solely in the hands of professionals, or

are they made jointly with affected community
members?
Management 2) Are the decision-making structures changing in
favour of certain groups, and if so, which groups?
3) Are management structures expanding to broaden
decision-making groups?
4) Is it possible to integrate non-health needs?
A ranking for each indicator has to be elaborated to determine the scores assigned
to describe each of the five categories. The findings also rely on visualisations to
help make various dimensions of the assessment clearer.
Needs assessment
Management Leadership
4
3
2
1
Resource mobilization Organization
Health Communication 4
1) Is the affected community involved in planning, management and control of
the communication for emergency response at the community level?
2) Were the felt needs of the community determined at the outset of the
response planning and was notice taken of them in planning the behavioural
objectives?
3) Have local forms of social organisation (e.g., farmer’s cooperatives, clubs,
churches, political organisations, trade unions, etc.) been involved in the
decision-making process and to what extent?
4) Is there a mechanism for dialogue between health system personnel and
community leadership?
5) Is there a mechanism for community representatives to be involved in
decision-making at higher levels and is this effective?
6) Is there any evidence of the external agents changing their plans as a result
of criticism from the community?
7) Are deprived groups, such as poor, landless, unemployed, and women,
adequately represented in the decision-making process?
8) Are local resources used, such as labour, buildings, money?
9) Was the community involved in evaluating the project and in drafting the final
report?
Social connectedness 5
1) As a result of the response, is the affected community better able to deal with
other problems?
2) Are the communication and mobilisation activities building effective
collaborative networks between affected communities, other communities, and
organisations?
TOOL 3
3) Are the communication and mobilisation activities contributing to the affected
community's capacity to deal with issues it faces?
4) Is the affected community being rendered more able to meet its needs or solve
current health problems?
5) Are organisations and worksites in affected communities demonstrating
increased activity in service delivery and emergency response more generally?
6) Is 'social connectedness' or an increase in 'social connectedness' or
networking among community organisations being created as a consequence
of the response?
Measuring communication for social change 6

n Are meeting times and spaces creating opportunities for poor and marginalised
people to speak, be heard and contribute to making decisions?
n In relation to the issues of concern (hygiene, breastfeeding, immunization, vitamin
A, safe motherhood, child protection), what increase or other positive changes
have there been in:
n Family discussion?
n Discussion among friends?
n Discussion in community gatherings?
n Problem-solving dialogue?
n New ways of sharing relevant information?
n Coverage and discussion in news media?
n Focus and discussion in entertainment media?
n Debate and dialogue in the political process?
n Are more people from all affected community groups involved in dialogue about
these issues?
n To what extent do participants listen, evaluate information before they use it,
challenge rumour and articulate their voice in private and public? Have there been
improvements in these areas?
n Who is creating and telling the stories around the issues? Is that changing?
n What are the cultural norms those stories reveal? Are they changing?
n Are new connections between different groups being established within the
community, either through face-to-face encounters or using technology?
n Are members of the affected community making their views known to those who
hold official power? How? Is this changing?
n Are affected community members connecting with outside allies, communities
and groups who support of their efforts?
Footnotes
1 Davies, R. and Dart, J., The Most Significant Change ‘MSC’ Technique: A guide to its use, http://
www.mande.co.uk/docs/MSCGuide.pdf, 2005.
2 Adapted from Rifkin, S.B., Muller, F. and Bichmann, W. ‘Primary Health Care: On measuring participation’.
Social Science and Medicine, 26 (9), 1988, pp.931-940.
3 Bichman, W., Rifkin, S., and Shrestha, M. ‘Towards the Measurement of Community Participation’. World
Health Forum, No. 10, 1989, pp.467-472; Laleman, G., and Annys, S., ‘Understanding Community
Participation: A health programme in the Philippines’, Health Policy and Planning (4)3, 1989, pp.251-256; De
Koning, K., Bichman, W., ‘Listening to Communities and Health Workers: A participatory training process to
improve communication skills of health workers in Cameroon’, Learning for Health, No. 3, 1993, pp.3-7;
Nakamura, Y., and Siregar, M., ‘Qualitative Assessment of Community Participation in Health Promotion
Activities, ’ World Health Forum, 17, 1996, pp.415-417; Bjärås, G., Haglund, B., and Rifkin, S., ‘A New
Approach to Community Participation Assessment’, Health Promotion International, (6)3, 1991, pp.199-206;
Schmidt, D., and Rifkin, S., ‘Measuring Participation: First use as a managerial tool for district health planner
based on a case study in Tanzania’, International Journal of Health Planning and Management, No. 11, 1996,
pp.345-358; Parks, W.J., and Hill, P., Kadavu Subdivision Rural Health Project Post-Project Evaluation Report,
AusAID, Canberra, 1997; Parks, W., ‘Community Participation in Health Program Design: Experiences from
Papua New Guinea’, Health Services Support Program, Health Promotion Working Paper Series, Brisbane,
JTA International,2000.
4 Adapted from Hubley, J., Communicating Health: An action guide to health education and health promotion,
MacMillan,London, 1993.
5 Adapted from: Hawe, P., ‘Capturing the Meaning of ‘Community’ in Community Intervention Evaluation: Some
contributions from community psychology’, Health Promotion International, (9)3, 1994,pp.199-210.
6 Adapted from Hunt, J. ,Notes on Communication for Social Change, in process.
TOOL 4
1
GENDER CHECKLIST
This checklist can help you clarify instances where men and women’s
activities overlap with each other and which ones are gender specific.
It should also give you ways to ensure that women’s views and inputs
are represented in your communication initiative.
1. In consultation with local organisations, community leaders, women’s

representatives, service providers and other relevant individuals who are
knowledgeable on gender and disasters, categorise:
n The specific issues that relate to women.
n Those that relate to boys and those that relate to girls.
n Those that relate to the affected community as a whole (issues shared by
men and women).
2. Identify locally appropriate, effective mechanisms to gather information and
inputs from affected women. Integrate these into the planning, implementation
and monitoring process.
3. Pay attention to the concerns of vulnerable groups within the category of
women and girls (including the landless, widows, disabled, minority ethnic and
religious groups, and others).
4. Ensure that women and girls are not seen as ‘helpless victims’ by paying
attention to the skills and capacities they demonstrate in livelihood and
disaster management processes.
5. Have separate discussions with organisations that focus on women’s concerns
so that the capabilities and strengths of such organisations can be enhanced
through their engagement in the communication initiative.
6. Organise consultations with village-level and community organisations that work

on issues, and initiate discussions for the appointment of both women and men
into leadership positions.
7. Organise and mobilise special women’s groups or societies in the affected
communities where it is culturally prohibited for men and women to work
together.
8. Create and ensure that communication materials have clear graphics and
messages, and that other means of communication are available to women to
address the concern that women are often culturally restrained in public
discussions. Ensure that women and girls are involved in designing graphics
and messages.
9. Ensure that emergency communication initiatives include measures that
address the gender-based concerns specific to the locality and programmatic
issues at hand.
10. Emphasise the importance of sharing and involving both women and men to
achieve more focused action on sustained behaviour change and social
mobilisation within the affected community.
11. Ensure that women are given space and opportunities within the planning,
implementing, monitoring and reporting process to apply their skills and
capabilities in your communication initiative.
12. Ensure that there are gender-sensitised women working in the communication
effort to interact with affected women.
Footnotes
1 Source: Adapted from Ariyabandu, M., and Wickramasinghe, M., Gender Dimensions in Disaster
Management: A guide for South Asia, ITDG South Asia Publication, Colombo, 2003.
TOOL 5
HOW TO CONDUCT
A KEY INFORMANT INTERVIEW
The key informant interview is a standard anthropological method that
is widely used in health related and other social development inquiry.
This is one method used in rapid assessment for gathering
information from the affected community. The term “key informant”
refers to anyone who can provide detailed information and opinion
based on his or her knowledge of a particular issue. Key informant
interviews seek qualitative information that can be narrated and cross
checked with quantitative data, a method called “triangulation”.
Step 1: Choose the interviewer

The interviewer has to remain neutral and must refrain from asking biased or
leading questions during the interview. An effective interviewer understands the
topic and does not impose judgments.
Choose an interviewer who:1
n Listens carefully.
n Is friendly and can easily establish rapport.
n Knows and understands the local customs, behaviours and beliefs.
n Can inspire confidence and trust.
Step 2: Identify suitable key informants

Choose suitable key informants according to the purpose of the interview. A key
informant can be any person who has a good understanding of the issue you want
to explore. The informant can be a community member, teacher, religious or
secular leader, indigenous healer, traditional birth attendant, local service provider,
children and young people or others from the affected community. Interviews can
take place formally or informally – preferably in a setting familiar to the informant.
Step 3: Conduct the interview2

n Based on what you already know about the issue, develop an interview guide
beforehand to ensure that all areas of interest are covered. Use open-ended
questions as much as possible.
n Hold the interview in a place that can put the respondent at ease.
n Establish contact first by introducing yourself.
n Thank the participant for making his or her time available.
n Describe the objectives of the interview.
n Go through the interview guide questions, (recording the proceedings with a
tape recorder only if this exercise is conducted during the emergency
preparedness or recovery phases of your communication initiative), together
with your notes.
n If time allows tape recorder use, be sure to ask permission tape the interview.
n After each interview, transcribe the results of your discussion, using the guide
questions in recording the responses. Remember to write as legibly as possible
to facilitate this step.
n For each interviewee, note down your own observations about the process and
content of the interview.
Do not forget to:

n Assure the respondent of confidentiality.
n Avoid judgmental tones so as not to influence responses.
n Show empathy with the respondent and interest in understanding his/her views.
n Let the respondent do most of the talking.
n Be an active, attentive listener.
n Pace yourself according to the time you have allotted for the interview.
Step 4: Crosscheck information3

In the initial response of an emergency each informant may give you new
information. But later on, informants usually confirm or clarify the data that you
already have. Be sure to confirm that your notes reflect more than one background
or viewpoint. If not, your conclusions may end up one-sided or biased.
TOOL 5
Step 5: Use the data
Information from key informant interviews helps you to further probe the needs,
wants and priorities of an affected community during a rapid communication
assessment exercise. You can use this qualitative information to complement the
findings from the initial assessments undertaken in an emergency situation. It can
also guide you in developing and adjusting your communication initiative.
Footnotes
1 Whitman, C., et al., Rapid Assessment and Action Planning Process, Health and Human Development
Programs, a Division of Education Development Center, Inc. (EDC), The World Health Organization
Coordinating Center to Promote Health through Schools and Communities, p. 7.
2 Whitman, C., et al., op.cit., p.7.
3 Adapted from Needs Assessment Techniques Using Key Informant Interviews, University of Illinois,
Extension Service-Office of Program Planning and Assessment, Chicago, p. 3.
TOOL 6
HOW TO USE A POCKET
OR VOTING CHART
The use of pocket charts is a participatory method that can help you
examine an affected community’s practices more closely, and to
monitor progress. You can lead this exercise in various ways. – a cloth
pocket chart can be made from cotton by
a local tailor. People can vote using tins
or pots, or you place drawings or
photographs showing selected
behaviours on the pocket chart. Once you
have chosen the type of chart to use, ask
each participant to vote accordingly and
as privately as possible. If privacy is not
ensured, participants may change their vote to please others. After the
votes are cast, collate them and discuss the results with the group.1
A step-by-step guide to using

the pocket or voting chart2
Step 1: Ask a participant who is familiar with the pocket chart to facilitate this
activity.
Step 2: Set up the pocket chart with a behaviour that is measured and explain
what it is and how it is used. Place a vote yourself to show how to use
the pocket chart. Make sure you remove your vote and explain that it was
a just a demonstration.
Step 3: Position the chart so that people can vote in private. Then invite people to
approach the chart one at a time to place their votes.
Step 4: Once everyone has had a chance to vote, ask a participant to count the
votes and display the results. Make sure that the counting is in full view of
everyone.
Step 5: Facilitate the group discussion on:
n What the pocket chart has shown.

n The reasons why people voted the way they did.
n Whether this result shows improvement (if this is used as a
monitoring exercise), or need for improvement.
Step 6: Once the comparison has been made, ask the group to discuss:
n What behavioural changes have been successful?

n What behavioural changes have been problematic?
Step 7: Ask the group to record (in drawings or words) the problems and sort
them into three categories:
n Problems the participants do not fully understand.

n Problems the affected community can deal with by itself.
n Problems the affected community cannot solve by itself.
Step 8: Stick the three groups of problems on a wall and ask the participants to
decide:
n For the problems not understood, how they will get more information,
when they will do this, and whose responsibility it will be.
n For the problems the affected community can deal with, what actions
they will take.
n For the problems the affected community cannot solve alone, how
they will get outside help to overcome these problems.
Step 9: Use information from the pocket or voting exercise to assess the
knowledge of the affected community, feed into the initial baseline data
report, adjust your programme to meet the evolving needs of the affected
community and to verify indicators.
Sample charts:
Water use
River/stream
Unprotected
Unprotected
Handpump
Standpost
Protected
TOOL 6
spring
spring
Pond
well
Drinking
Cooking
Washing
Washing utensils
Washing clothes
Making beer
*It may be useful to have two voting rounds or two different voting slips for the wet
and dry season, or for pre-and-post displacement.
Public health practices

Using Covering Hand Hand washing Hand washing Disposing of
bednet drinking washing after cleaning before eating and children’s
water after using baby feeding baby faeces
toilet in latrine
Sometimes
Always
Never
Purpose Most widely used source of water Reasons
1st 2nd
Drinking
Cooking
Washing
Washing utensils
Making beer
Defaecation practices
Latrine Fields Compound River
Women/girls
Men/boys
Girl Children < 8yrs
Boy Children < 8yrs
Old Women
Old Men
Babies’ faeces
Footnotes
1 Adapted from Oxfam UK, Guidelines for Public Health Promotion in Emergencies, Oxfam, London, 2000, pp.
79 – 80. Sample charts adapted from Oxfam.
2 Adapted from Sawyer, R., et al., ‘Part II Step-by-step activities’ as cited in PHAST Step-by-Step Guide: A
participatory approach for the control of diarrhoeal disease, WHO, Geneva, 1998, pp. 90-91.
TOOL 7
HOW TO DO A RANKING EXERCISE
A ranking exercise is a simple, participatory and rapid method for
establishing what the affected community considers its primary
problems and needs. In contrast to simple voting procedures, ranking
can help you identify different priorities and the associated facilities
and activities needed within a camp of an affected community.
Step 1: Know the exercise

Do the preference ranking in six basic steps:1
n Identify participants.
n Draw the matrix.
n Rank the items against each other.
n Document each result in the matrix.
n Count the scores.
n Facilitate a discussion and identify the main actions needed.
Step 2: Diversify your participant group

If participants in this ranking exercise represent various groups affected
by the emergency - primary caregivers, community leaders, health
workers, vulnerable groups such as children, young people, widows,
displaced people and so on - you will be able to establish the different
priorities, associated actions, facilities and services needed.
Step 3: Facilitate the process

The facilitator helps guide the group in identifying and weighing its
priorities as well as identifying and weighing the associated facilities,
services and activities needed; however, the ideas should primarily come
from the participants.
The facilitator should:2

n Introduce the purpose of the exercise and how it will be used.
n Give either a practical example from a previous ranking exercise – or
better – run through it once with one of the participants, where he/she
acts as interviewer and the participant acts as interviewee.
n Divide the participants into sub-groups of three persons.
n Instruct each sub-group to select one interviewer, one informant who
answers the questions and one recorder who writes the reasons that
the informant gave for the preferences. The sub-group exercise works
best when to explain and complete each step before the next step is
started.
n The sub-groups then present their results and observations to the
whole group
Priority Needs Rank Associated Rank

facilities/activities
Preventing Diarrhoea 4 Communal latrines 1
Family latrines 3
Hand washing 2
Clean Environment 2 Solid waste pits 2

Cleaning materials 1
Preventing Malaria 3 Wastewater disposal 2

Bed nets 1
Traditional Funerals 1 Morgue 4

Burial ground 1
Coffins 2
Concrete Grave markers 3
Family Facilities 5 Family latrines 4

Family solid waste pits 3
Cleaning materials 1
Tools 2
The following table shows an sample ranking exercise for sanitation

related needs and priorities. The first priority is ranked as 1, the second 2,
and so on:3
Step 4: Interpret the results
TOOL 7
Priorities may differ greatly and the exercise may produce surprising
results. An important advantage is that participants can see how the main
needs or problems of a person or a group can be determined. In addition,
the affected individuals can learn how to compare the priorities of different
groups within the affected community against another. In the above
exercise, the group was much more concerned with funeral rites than with
diarrhoea.
Step 5: Use the data

For a hygiene promotion programme, you can use ranking to help the
affected community prioritise the most significant problems, understand
the links between seasonal changes and incidence of disease,
understand water sources and use, and sanitation practices. Overall, you
can use information gained from ranking exercises as inputs to planning
and assessment and for subsequent monitoring and evaluation of your
BCC programme.4 Remember that priorities and actions differ depending
on the impact and stage of the emergency.
Footnotes
1 Berg, C. et al., Introduction of a Participatory and Integrated Development Process (PIDEP) in Kalomo District,
Zambia, Vol., 2, Manual for trainers and users of PIDEP,1997.
2 Adapted from Berg, C., et al., op.cit.
3 Harvey, P., et al., Emergency Sanitation: Assessment and programme design, London, 2003, p. 184.
4 Adapted from Oxfam UK, Guidelines for Public Health Promotion in Emergencies, Oxfam, London, 2001, p. 22.
TOOL 8
HOW TO FACILITATE
PARTICIPATORY EXERCISES
The most important thing to remember about being a facilitator is that
you are not a teacher. Your role is to help or “facilitate”.1 In planning
your communication, recognise that command and control, and
participatory processes go hand-in-hand. Human rights demand
participatory processes in which all stakeholders buy in and contribute
to solutions. Participatory processes are valuable in all stages of a
emergency programme cycle – from rapid assessment to monitoring
and evaluation - but such processes need to be integrated and
balanced with command and control procedures during rapidly
changing events that require quick decision-making and action.
With that in mind, when leading focus group discussions, doing a ranking or pocket
chart exercise, a KAP survey or using any rapid assessment or monitoring and
evaluation tool, your role is to help affected individuals and community groups to:
n Identify issues of importance to them.

n Express their problems.
n Analyse their problems.
n Identify possible solutions.
n Select appropriate options.
n Develop a plan to implement the solutions to which they identify and agree.
n Evaluate the outcome of the plan.
So you must not:

n Give information: instead, allow the group to find out information for themselves
(although, it may be that in the initial days after a disaster, people will be
seeking/needing information).
n Tell the group what they should do. Let them discuss and agree on what they
should do and how they would like to do it.
n Make assumptions about what the right response should be to an activity.
Using participatory methods does not reduce the role of the facilitator in an
emergency response situation, but rather redefines it. What you can do is
encourage and facilitate community involvement; and create an environment in
which the participants can discover information for themselves. In so doing,
participants will build the confidence and self-esteem necessary to analyse
problems and work out solutions.
As a facilitator, you are not a leader who directs the group to where you think it
should go. Instead, you help the group to better understand its own situation and to
enable them to make informed decisions on how to improve that situation.
Keep these important points in mind:

All participants are equal
The activities in this guide have been developed so that the participation of each
group member is considered equally important. The participants must view you as
an equal. So you should not present yourself as an authority figure. Information
should flow from you to the group and vice versa. By sharing and receiving
information, you and the group will remain equal. For this type of information
exchange, good listening skills are essential.
There is no one right answer

This means that there can be many correct answers or results. Decisions made by
the group reflect what is right for the group and what the group is prepared to take
responsibility for.
Create the right atmosphere

If your aim is to reach agreement on priorities for activities, or a plan for improving
hygiene behaviours and sanitation, participants must be able to work well together.
This is why participatory sessions often begin with a fun activity, something to
break the ice and make people laugh. You need to make people feel at ease
throughout the planning process. Most cultures have traditional games and songs
that can create the right atmosphere and build group spirit.
Coping with dominant personalities

From time to time the group process may not be able to proceed because one
TOOL 8
individual wants to control the group’s thinking. If this happens, find out whether the
dominant individual is a designated leader, or simply a competitive or aggressive
person with little or no significant support or influence in the group. Competitive or
aggressive persons can either be taken aside and convinced of the importance of
the group process, or given separate tasks to keep them busy and allow the group
to carry on. If the persons concerned are community leaders, approach them
formally or privately – early in the planning phase – explain the process, and try to
gain their support. Hopefully, you will convince them that allowing community
members to fully and equally participate will result in the personal growth of and
better conditions for each participant.
General guidance for all activities:

1. Have all the materials for each activity ready before starting.
2. Make sure the materials are large enough to be seen by all participants.
3. Try to limit the size of your group to no more than 40 persons.
4. Make sure that people can talk to one another easily. Use a circle where
possible.
5. Begin each new session with a warm-up activity such as a game or song.
Provide refreshments where possible.
6. Go through each activity one step at a time and follow the instructions in the
guide.
7. When giving the group its task, use the exact words provided for this purpose.
8. Encourage and welcome the input that individuals make. Remember, there are
no wrong answers.
9. Facilitate the group, do not direct it.
10. Try to encourage the active participation of each participant. Be careful not to
find fault or make critical comments when you respond to people.
11. Take into account the participants’ literacy level and work out ways in which
they can keep record of what is discussed and agreed.
12. Have the group keep the materials and records in a safe place.
13. At the end of each activity, ask the group members to evaluate the activity on
the basis of what they have learned, what they liked and what they did not like.
14. At the end of each session, congratulate the group members on their efforts
and explain briefly what will be covered at the next session.
15. At the beginning of each new meeting of the group, ask the group to review
what it has done so far and the decisions it has taken.
Footnotes
1 Adapted from Sawyer, R., et al., ‘Part I ‘Introduction to the PHAST Step-by-step Guide’ as cited in
PHAST Step-by-Step Guide: a participatory approach for the control of diarrhoeal disease, WHO,
Geneva, 1998, p. 88.
TOOL 9
MONITORING CHART
A monitoring chart can be used to see if the set goals for your
communication initiative have been met.1
Step 1: Have the group look at the monitoring chart to review the goals set
during the initial
emergency response. Then ask them to compare these goals with what
has been achieved since making the chart. The group might want to
make a record of the differences between what was planned and what
has been achieved. Encourage participants to make a comparison in any
way it wants – using pens, paper, drawings, words, etc.
Step 2: Once the comparison has been made, ask the group to discuss:
n Successes.
n Problems.
Step 3: Ask the group to record (in drawings or words) the problems and
sort them into three categories:
n Problems the affected community can deal with by itself.
n Problems the participants do not fully understand.
n Problems the affected community cannot solve by itself.
Step 4: Stick the three groups of problems on a wall and ask the
participants to decide:
n For the problems the affected community can deal with, what
actions they will take.
n For the problems not understood, how they will get more
information, when they will do this, and whose responsibility it will be.
n For the problems the affected community cannot solve alone,
how they will get outside help to overcome these problems.
Step 5: Discuss possible (or adjustments to existing) communication

methods that can help the affected community overcome its
problems. Find out whether existing communication channels are
reaching the target populations in the affected community.
Step 6: Finish with a discussion on what was learned, liked/disliked about

the activity. Investigate
Step 7: Adjust messages, communication channels and behavioural objectives

according to the information received.
Sample monitoring chart
Footnotes
1 Source: Adapted from Sawyer, R., et al., ‘Part II Step-by-Step Activities’ as cited in PHAST Step-by-Step
Guide: A participatory approach for the control of diarrhoeal disease, WHO, Geneva, 1998, p. 88.
TOOL 10
STRUCTURED OBSERVATION
CHECKLIST FOR
COMMUNICATION SKILLS1
n Collect a group of stakeholders to work on developing this checklist:
This will depend on the programmatic issue but stakeholders can include
trainers, relief workers or anyone who is a representative of the people whose
behaviour is being observed. Whoever is chosen needs to be acquainted with
the event to be measured. A research agency might also be involved.
n Observe event to be measured: This can be done in various ways such as a
health worker leading a group meeting or a peer educator doing an individual
interpersonal communication session. Usually, this is done with a role play.
Prepare the person/people doing the role play to demonstrate a “perfect”
example of the communication session to be observed.
n Identify key behaviours or skills observed in the event. Record them on
VIPP cards or flip chart.
n Through discussion (and perhaps repeated demonstration of the event)
reduce the number of behaviours/skills to a few items for the observation
check list. While there is no correct number of items for a check list, you will
need to strike a balance between capturing the essence of a good
communication session, by having a measurement tool that can be correctly
(90 percent accuracy by 100 percent of the observers) and easily used.
Somewhere from five to eight items can be handled by a trained observer who is
scoring a 5-minute event.
n Operationalise each item selected for the list. Operationalising means
making the item easy for multiple observers to check correctly. For example,
the health worker (HW) shouldn’t read the text of the flipchart. The HW must
look at the participants at least half the time while he/she is using or
discussing the flipchart.
n Train observers to reach 90 percent agreement for each item. Use
repeated role plays of the event to score and discuss why each observer did or
did not check the item. If 90 percent agreement cannot be reached, then re-
define the item; clarify exactly what behaviours constitute a “yes”. This can be
done by looking at the group once, three times, half the time. Or calling on one,
two or three participants who have not been talking, etc.
n After field testing, discuss whether getting a perfect score on the check
list does, indeed, capture an adequate, acceptable communication
session. If it does not, consider replacing items with others or adding to the
exercise. Remember, the more items on the check list, the more difficult it will
be to use correctly.
This is a check list to record observed communication skills only. To record the
context of the communication session (time of day, physical conditions, language
used, characteristics of the field worker), use another sheet that can be filled out
before or after the actual observation.
Sample Checklist for Community

Community Nutrition Promoter _______ Nutrition Promoter’s Communication
Skills during a Nutrition Advice Session
Date of Session _________
Community Nutrition Promoter:

Greets all participants Y N
When speaking moves head to make eye contact with Y N

participants
Uses open-ended questions to check for understanding Y N
When using material, keeps it visible to all participants Y N
When using material, asks questions on content of material Y N
Summarises the actions of mothers at end of session Y N
OBSERVER COMMENTS:
Footnotes
1 Source: Graeff, J., Final Report on Behavioural Monitoring Workshop, UNICEF Dhaka, 2005.
TOOL 11
TASKS OF MEN AND
WOMEN IN THE COMMUNITY
This exercise can be done to increase knowledge and understanding of
which household and community tasks are done by affected women,
and which are done by affected men. It can also help identify whether
any change in task allocation would be desirable and possible.1
What to do
1. If there has been a break between this activity and a previous one, start with a
group discussion to review what was learned or decided at the previous
meeting.
2. Ask the participants to form groups from five to eight people.
3. Using the following words, ask the group to carry out the activity:
“Each group will be given a drawing of a man, a woman and a man and woman
(a couple) together, and a set of drawings showing different tasks. Discuss in
your group who would normally do this
task. When you agree,
put the task drawing
underneath the drawing
of the man, woman or
couple based on what
you decide. The
drawing of the man and
woman together means
that both sexes
perform the task”
4 Let the groups work on their own and discuss their findings. They can draw and
add other tasks. You should provide them with blank paper for this purpose.
5 Once the activity has been completed, ask each group to present its selection
to the rest of the participants, explain its choice and answer any questions.
6 Facilitate a group discussion on:
n Who does what tasks.
n The workloads of men and women.
n How differences in workloads might affect task allocation for overcoming the
new problems in the community because of the disaster.
n The advantages and disadvantages of changing tasks done by men and
women.
n The potential for changing the tasks done by men or women.
n Ask the group to identify roles which could be changed or modified in order
to improve sanitation and hygiene, and record these conclusions for use in
monitoring later on.
7 Facilitate a discussion with the group on what it has learned during this activity,
what it liked and disliked about this activity.
Special Note:
During this activity men sometimes complain that drawings of their usual tasks have
not been included in the set. This is because the set focuses mostly on tasks
related to domestic and community hygiene and sanitation, and in most societies
these tasks fall to women. If this happens, ask the men to make drawings of tasks
they perform, and add them to the activity. The group may decide that three drawings
(man, woman, and both together) are not enough and choose to add drawings of
boys and girls. This is fine, but the analysis should focus on gender not age.
Footnotes
1 Adapted from Sawyer, R., et al., ‘Part II Step-by-step activities’ as cited in PHAST Step-by-Step Guide: A
participatory approach for the control of diarrhoeal disease, WHO, Geneva, 1998, pp. 33-35.
TOOL 12
A 12- POINT COMMUNICATION
MONITORING CHECKLIST
1. Was an assessment done to identify:
a. The information gaps among your audience (i.e. health workers, caregivers,
volunteers or other critical groups)?
b. The information-seeking and sharing patterns of the affected communities
(communication network analysis)?
c. The main barriers for affected families and communities to practice the
intended behaviour (e.g. caretakers taking their children to immunization
services, safe hygiene practices)?
2. Did you develop a communication plan that is linked to the service and supply
components of the emergency response?
3. Does the plan clearly state the behavioural objectives you seek to influence?
4. Did you prepare an implementation plan?
5. Does it include opportunities for community participation in areas such as

material preparation, message design and dissemination?
6. Did you establish a monitoring system to keep track of your efforts and gather
feedback?
7. Did you determine the budget?
8. Are messages and materials gender, age and culturally sensitive and appropriate?
9. Did you choose the most appropriate a mix of the most effective
communication channels – interpersonal and mediated?
10. Did you invite and receive feedback from the various audience(s) of the affected
community on your suggested messages and materials (pre-testing)?
11. Do you know if the material and the messages in it reached the people they
were meant to reach (e.g. affected population, health workers, volunteers, etc.)?
12 Do you have a system to share and manage the information with humanitarian
organisations, UN sister agencies, government bodies, professional
organisations and other concerned partners?
TOOL 13
TOOLS TO MONITOR
THE MILESTONES
Chapters 4 through 8 each contains a section on Monitoring
milestones. The section should help you establish simple monitoring
and evaluation systems. Importantly, the inclusion of such a section in
each chapter emphasises the need for early planning of how
communication programmes will be monitored and evaluated. In other
words, M&E must be developed during the communication planning
stage, if not during the pre-planning or “groundwork” stage.
Development of indicators, of course, will depend on specific
behavioural results to be achieved, but the indicators presented in
each section are useful guides.
Chapter 4 – Hygiene Promotion

Each indicator provided in the monitoring milestone sections needs to be
measurable. Some indicators (identified below), may not be measured easily –
so we have provided some measurement tools that can help you measure the
suggested indicators.
Indicators for hygiene practice Measurement tools

§ " People use the toilets available Observation
and children's faeces are disposed Self report
of immediately and hygienically. Focus group discussion
" People use toilets in the most
hygienic way, both for their own
health and for the health of others.
Indicators for hygiene practice Measurement tools

" Household toilets are cleaned and Household observation
maintained in such a way that they Focus group discussion
are used by all intended users and
are hygienic and safe to use.
n Parents (mothers and fathers or Focus group discussion

other primary caregivers) Ranking exercise
demonstrate knowledge of the need KAPS survey
to dispose of children's faeces
safely.
n Families and individuals participate

in a family latrine programme by
registering with the agency, digging Registration records
pits or collecting materials. Observation
n People wash their hands after KAPS survey
defecation and handling children's Demonstration of correct hand-washing
faeces and before cooking and
eating.
n People demonstrate correct hand-
washing and know when to engage
in this behaviour.
Key indicators for design and Measurement tools

implementation of your hygiene
promotion programme
n Key hygiene risks of public health Review of key IEC materials
importance are identified.
n Programmes include an effective Observation of latrine design, camp

mechanism for representative and adjustments
participatory input from all users at Focus group discussions with girls,
all phases, including the initial women and disabled
design and location of facilities - Reports from health workers
Key indicators for design and Measurement tools

implementation of your hygiene
promotion programme
making sure that latrines
TOOL 13
accommodate the disabled; are well-
lit and designed to protect women
from sexual molestation; and provide
girls and women the privacy to
cleanse themselves, wash out
underclothes and sanitary napkins.
n All groups within the affected Observation of latrine design

community have equitable access Focus group discussions with girls,
to the resources or facilities needed women and disabled
to continue or achieve the hygiene Reports from health workers, camp
practices that are promoted. managers, latrine attendants
Key informant interviews
Gender checklist
n Hygiene promotion messages and Pre-and-post testing of materials

activities address key behaviours Participation logs of FGDs, ranking
and misconceptions and are exercises, pocket or voting exercises
targeted for all participant groups. Monitoring chart
Representatives from these groups
participate in planning, training,
implementation, monitoring and
evaluation.
n Participants take responsibility for Observation

the management and maintenance Latrine/facility maintenance reports
of facilities as appropriate, and all Tasks of men and women in the
populations of the affected community.
community contribute equitably.
Chapter 5 - Breastfeeding
Indicator Possible measurement tools/sources
of information
n Health workers, peer educators, birth Register of training events
attendants, midwives and other Structured interview
relevant service providers are trained Structured observation checklist
on infant and child feeding practices, Demonstration
and can communicate and motivate
affected women to breastfeed
exclusively and safely prepare BMS
and cup feed (in exceptional cases).
n Breastfeeding women know the Structured interview

benefits of colostrum, the Structured observation checklist
importance of/how-to breastfeed, Demonstration
and how-to safely prepare BMS and
cup feed - and are doing it.
n The affected community is Semi-structured interviews

mobilised to support breastfeeding Focus group discussions
women via, mother-to-mother Observation of trials
support networks, "safe havens", Observation of women's groups
trials of new feeding practices,
activities in women's groups, etc.
n Infants under six months are Mother's self-report (24 hour recall
exclusively breastfed, wet-nursed interview)
(where acceptable), or in exceptional Demonstration of appropriate use of
cases, have access to an adequate BMS
amount of an appropriate BMS.
n Local governments, humanitarian Structured interview

agencies, camp management and BMS supply records
other service providers know the
international guidelines on the
marketing of BMS, the appropriate
use of BMS in emergencies, and are
supplying it to artificially-fed infants
without undermining the
breastfeeding population at the camp.
Chapter 6: Immunization and vitamin A promotion

Input indicators Possible measurement tools/sources
of information
n Percentage of communication plans Document analysis of communication
TOOL 13
that map resistant or difficult groups, plans.
including "zero-dose" children, and
propose strategies for reaching them
n Is there a communication Emergency response and

component for EPI in the emergency preparedness plans
preparedness and response plan? EPI programme
n Does the communication component Financial documents

to support the EPI programme in an EPI programme proposal
emergency situation include a
budget?
n Number of planned outreach Analysis of communication plan

activities in the affected communities
and camps.
n Number of materials produced. Literature audit
Output indicators Possible measurement tools/sources

of information
n Percentage of emergency Financial plans, budgets
vaccination programme budgets
used for, a) broadcast media, b) print
materials, and c) strengthening of
interpersonal communication skills.
n Percentage of planned activities to Programme reports, field observations,

reach the hard to reach population structured observation checklist
groups actually conducted.
n Number of materials disseminated Observation, material audit, health

and visible/used in health facilities. worker/caregiver self-reports or
interviews
Output indicators Possible measurement tools/sources

of information
n Number of health workers and Training logs
mobilisers trained in immunization Programme reports, observation,
communication. What is the number meeting reports
of training sessions conducted?
n Number of meetings held with Structured interview including

community and faith leaders. photographs (measles symptoms)
n Percentage of health workers/

vaccinators/care-givers who know
how-to recognise measles and
where such a case should be
reported.
Outcome indicators (linked to EPI Possible measurement tools/sources

indicators) of information
n Percentage of health workers/ Exit interviews with caregivers
vaccinators providing key messages Key informant interviews
during immunization sessions. Structured observation checklist
Field observations
n Percentage or caregivers with Vaccination records

vaccination cards. Self report
n Percentage of caregivers who know Key informant interviews

where to go for vaccination and KAP surveys
vitamin A supplementation. Self report
n Percentage of caregivers who know Same as above.

where to take a sick child for
treatment.
n Percentage of households in Field reports

affected communities/camps visited Self report
by community health volunteers/
mobilisers.
Outcome indicators (linked to EPI Possible measurement tools/sources

indicators) of information
n Percentage of budget spent on Financial documents
communication activities according
TOOL 13
to the plan.
Impact indicators (EPI indicators) Possible measurement tools/sources

include: of information
n Percentage of children vaccinated Health centre records, programme
with measles. reports, field reports
n Percentage of children who received
vitamin A supplements.
n Percentage of drop-out rates.
n Percentage of planned outreach
sessions actually conducted.
Chapter 7: Safe Motherhood

of information
n Health workers, midwives, women's Training records; self-report of health
representatives, counsellors and workers, midwives, counsellors and
other relevant stakeholders are women's representatives
trained on maternal nutrition and Demonstration
breastfeeding facts and
communicate the importance of
antenatal and postnatal care visits,
clean and attended delivery, the
warning signs during pregnancy and
danger signs during pregnancy.
n Affected women and their families Health centre registers

know the benefits of eating healthy, FGD with affected pregnant women/new
taking vitamin A supplements and moms/family members
iron; receiving tetanus shots; clean Key informant interviews
and attended delivery; seeking Structured interviews
antenatal and postnatal care - and
are doing it.

of information
n Affected women and their families Same as above.
know the warning signs during
pregnancy; when and where to get
immediate help, and are seeking
medical help when complications
occur.
n The affected community Presence of active support groups in

demonstrates support to pregnant affected community
women via mother-to-mother Established referral systems
support networks, women's group, FGD/structured interviews with
community-based birthing plans community members
and referral systems, etc.
n Local governments and Transportation systems in place

humanitarian agencies have Work plans
allocated the resources needed for Financial documents, approved budgets
adequate care and affordable quality Medicines/clean delivery kits available
services; have established the to women, health facilities
necessary transportation systems,
supplied essential drugs, clean
delivery kits - and have formed
necessary partnerships to supply
these.
Chapter 8 Child Protection

of information
Affected parents/primary caregivers Structured interview
know the importance of recreational/ Focus group discussion
educational activities to the Group mapping (of camp)
psychosocial recovery of children, know Observation of children attending
where these activities are provided in recreational/educational facilities
Registers of children at above facilities
the camp and are sending affected
children.

of information
Affected parents/primary caregivers Structured interview
know not to leave their children Focus group discussion
TOOL 13
unattended, and are aware of the Group mapping (of camp)
unsafe areas for children in the camps. Observation of unsafe areas
Parents/primary caregivers know how- Structured interview

to prevent child separation in the camp, Focus group discussion
during migration or evacuation and are Story with a gap (pictures illustrating
doing it. before and after potential child
separation) - "Story with a gap" is
explained below
Registry of reported child separation
Camp officials know the importance of Meeting reports

lighting latrines, providing adequate Interviews with camp officials
camp security and designating safe Observation of camp adjustments
spaces for women and children and are
making the necessary adjustments.
The affected community knows to Focus group discussion (with affected

report strangers, (suspected) traffickers community members)
that enter the camp and are doing it. Registers of reported "suspected"
traffickers
Parents/primary caregivers who have Structured interview (with parents)

lost children know how/where to go to Register kept at "tracing centres"
register, facilitate tracing.
Separated children know their rights to Focus group (with children)

be involved in the decisions being made Register kept at "tracing centres" and
for them; know where to go to register, essential services
facilitate tracing and receive essential
services

of information
Social workers, camp managers, Structured interview (with social
service providers know the rights of workers, camp managers, service
separated children and how to providers)
communicate these rights to them. Observation checklist of
communication sessions with
separated children
The affected community knows the Structured interview with sample of

signs of abuse, trafficking, molestation; affected community members
how-to report it and are doing it. Registers at centres dealing with
abuse, trafficking and molestation
Affected children know to report abuse Focus group with children

to them or their friends and are doing it Registers at centres dealing with abuse
TOOL 14
HOW TO DESIGN A RADIO SPOT
Depending on the impact of the disaster as well as the availability and
reach of technology, radio might be a very useful channel to quickly
share information and disseminate messages on health, child
protection, immunization, water, hygiene and sanitation, safe
motherhood or HIV and AIDS in an emergency situation. Take care to
find out if the affected community has access to radio and prefers it
as a communication source. This information would be best gathered
in the emergency preparedness phase of your BCC initiative, but it
can be explored in various participatory assessments that you
facilitate in the emergency's initial response.
If you find that the affected community prefers and has access to radio, and you
have to design a radio spot, or judge the quality of drafts presented to you,
consider following points:1
Step 1: Present one idea

Each radio spot should have one main message, which should be repeated several
times during the spot.
Step 2: Choose a credible source of information

Engage and feature a source of information (e.g. a well known public figure) that is
suggested or accepted by the affected communities.
Step 3: Break the mould

Try innovative ideas and formats.
Step 4: Touch the heart as well as the mind of the listener

Make the listener feel something after hearing the spot or programme — happy,
confident that they can do something – but make them feel.
Step 5: Stretch the listener’s imagination

The voices, music and sound effects can and should evoke pictures and create
images in the listener’s mind.
Step 6: Write for the ear

Radio spots should have the same natural, spontaneous sound as conversation.
Step 7: Write to the individual

Imagine the face of a person within your participant group and write for that person.
Step 8: Ask listeners to take action

Be explicit about what the listeners can do to resolve their problem.
Step 9: Provide consistency

Develop a similarity of sound in all of your radio materials, providing continuity to
the radio materials.
Step 10: Plan more than one spot

Plan a serious of spots in concentrated numbers (e.g., 10 spots per evening for a
week – if evening is the preferred listening time, rather than one spot per day).
Footnotes
1 Source: Adapted from United Nations Children’s Fund, ‘A manual on communication for water supply and
environmental sanitation programmes’, Water, Environment and Sanitation Technical Guidelines Series, No. 7,
UNICEF, New York, 1999, pp. 72 - 73.
TOOL 15
HOW TO DESIGN PRINT MATERIALS
Before you develop any print materials, review the behavioural
objectives of your communication initiative and consider the main
groups you want to reach (e.g. affected caregivers, children, health
workers, teachers and/or others); whether they can they read, and if so,
whether they like to read. This would be best done before a disaster
strikes because it would allow for significant pre-testing, translation to
local dialects, and the input of various groups within the affected
community. Working on print materials pre-disaster also allows you to
design materials with greater assurance that the messages and
graphics are culturally, religiously and gender-appropriate.
When designing print materials, keep the following

principles in mind:1
The number one principle is: community engagement
n Involve affected community members in all phases of material development –
this goes beyond pre-and-post testing of your print material. Emergency
preparedness allows you to engage the affected community to the fullest.
Choose a simple, logical design and layout

n Present only one (1) message per illustration.
n Make materials interactive and creative.
n Limit the number of concepts and pages of materials.
n Messages should be in the sequence that is most logical to the group.
n Use illustrations to help explain the text.
n Leave plenty of white space to make it easier to see the illustrations and text.
Use illustrations and images

n Use simple illustrations or images.
n Use appropriate styles: (1) photographs without unnecessary detail, (2)
complete drawings of figures when possible, and (3) line drawings.
n Use familiar images that represent objects and situations to which the affected
community can relate.
n Use realistic illustrations.
n Illustrate objects in scale and in context whenever possible.
n Don’t use symbols unless they are pre-tested with members of the affected
community.
n Use appropriate colours.
Use text to your advantage

n Use a positive approach. Negative approaches are very limited in impact, tend
to turn off the affected community, and will not sustain an impact over time.
n Use the same language and vocabulary as your affected community; limit the
number of languages in the same material.
n Repeat the basic message at least twice in each page of messages.
n Select a type style and size that are easy to read. Italic and sans serif
typefaces are more difficult to read. Use a 14-point font for text, 18-point for
subtitles, and 24-point for titles.
n Use upper and lower case letters.
Provide supervision for material production

n Without careful supervision, materials may end up in wrong colours, incorrect
alignment, or careless print jobs. Have an experienced member of your team
providing close supervision to the printing work.
Special Note:
Combine print materials with small community media, IPC approaches and
other participatory communication strategies.
Printed IEC materials are most effective when combined with other forms of
communication. In the initial response, print media can be used to quickly
dispense life-saving messages to large numbers of affected people. Experience has
shown, however, that print materials are more effective when combined with
interpersonal communication. This allows the affected community to discuss the
new information with someone that they trust.
Footnotes
1 Source: Adapted from United Nations Children’s Fund, ‘A manual on communiction for water supply and
environmental sanitation programmes’, Water, Environment and Sanitation Technical Guidelines Series, No. 7,
UNICEF New York, 1999, p. 74
TOOL 16
PRINCIPLES AND GUIDELINES FOR
ETHICAL REPORTING ON CHILDREN
AND YOUNG PEOPLE UNDER 181
Reporting on children and young people has its special challenges,

especially in emergencies. In some instances reporting on children
places them or other children at risk of retribution or stigmatisation.
The following principles have been developed to assist journalists as they report on
issues affecting children. They are offered as guidelines that UNICEF believes will
help the media to cover children in an age-appropriate and sensitive manner. The
guidelines are meant to support the best intentions of ethical reporters: serving
the public interest without compromising the rights of children.
I. Principles
1. The dignity and rights of every child are to be respected in every circumstance.
2. In interviewing and reporting on children, special attention is to be paid to each
child’s right to privacy and confidentiality, to have their opinions heard, to
participate in decisions affecting them and to be protected from potential and
actual harm and retribution.
3. The best interests of each child are to be protected over any other
consideration, including advocacy for children’s issues and the promotion of
child rights.
4. When trying to determine the best interests of a child, the child’s right to have
their views taken into account are to be given due weight in accordance with
their age and maturity.
5. Those closest to the child’s situation and best able to assess it are to be
consulted about the political, social and cultural ramifications of any news
reports.
6. Do not publish a story or an image which might place the child, siblings or
peers at risk – even when identities are changed, obscured or unused.
II.Guidelines for interviewing children

1. Do no harm to any child; avoid questions, attitude statements,opinions or
comments that are judgmental and insensitive to cultural values, that place a
child in danger or expose a child to humiliation, or that reactivate a child’s pain
and grief from traumatic events.
2. Do not discriminate your choice of children to interview because of sex, race,
age, religion, status, educational background or physical abilities.
3. No staging: Do not ask children to tell a story or take an action that is not part
of their own history.
4. Ensure that the child and the guardian know they are talking with a reporter.
Explain the purpose of the interview and its intended use.
5. Obtain permission from the child and his/her guardian for all interviews,
videotaping and, when possible, for documentary photographs. When possible
and appropriate, this permission should be in writing.
6. Obtain permission in all circumstances to ensure that the child and the
guardian are not coerced in any way and that they understand and agree that
they are part of a story that might be disseminated locally and globally. This is
usually only ensured if the permission is obtained in the child’s language, and if
the decision is made in consultation with an adult the child trusts.
7. Pay attention to where and how the child is interviewed. Limit the number of
interviewers and photographers. Try to ascertain that the child is comfortable
and able to tell his/her story without pressure from anyone, including the
interviewer. In film, video and radio interviews, consider what the choice of visual
or audio background might imply about the child and her or his life and story.
Ensure that the child would not be endangered or adversely affected by showing
their home, community or general whereabouts.
III. Guidelines for reporting on children

1. Do not further stigmatise any child; avoid categorisations or descriptions that
expose a child to negative reprisals - including additional physical or
psychological harm, or to lifelong abuse, discrimination or rejection by their
local communities.
2. Always provide an accurate context for the child’s story or image.
3. Always change the name and obscure the visual identity of any child who is
identified as:
a. A victim of sexual abuse or exploitation.
b. A perpetrator of physical or sexual abuse.
c. HIV positive, living with AIDS or has died from AIDS (unless the child, a
parent or a guardian gives fully informed consent).
d. Charged or convicted of a crime.
4. In certain circumstances of risk or potential risk of harm or retribution, change
the name and obscure the visual identity of any child who is identified as:
TOOL 16
a. A current or former child combatant.
b. An asylum seeker, a refugee or an internally displaced person (IDP).
5. In certain cases, using a child’s identity – his or her name and/or recognisable
image – is in the child’s best interests. Take note, that when the child’s identity
is used, the child must still be protected against harm and supported through
any stigmatisation or reprisals.
Some examples of these special cases are:
a. When a child initiates contact with the reporter, wanting to exercise his/her
right to freedom of expression and his/her right to have their opinion heard.
b. When a child is part of a sustained programme of activism or social
mobilisation and wants to be so identified.
c. When a child is engaged in a psychosocial programme and claiming his/her
name and identity is part of his/her healthy development.
6. Confirm the accuracy of what the child has to say, either with other children or
an adult, preferably with both.
7. When in doubt about whether a child is at risk, report on the general situation
for children rather than on an individual child, no matter how newsworthy the
story.
Footnotes
1 Sources: The Convention on the Rights of the Child; Child Rights and the Media: Guidelines for Journalists,
International Federation of Journalists; Media and Children in Need of Special Protection (internal document),
UNICEF’s Division of Communication; and Second International Consultation on HIV/AIDS and Human Rights,
United Nations Secretary-General.

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BEHAVIOUR CHANGE COMMUNICATION

For every child

© United Nations Children’s Fund

Parts of this publication may be reproduced or quoted without permission

For further information and copies, please contact

Concept development, field research, co-writer and coordination:

Writer and researcher:

Designed & Processed by: WordScape, 5520755

Natural disasters in South Asia 15

Behaviour change communication in emergencies 27

Promoting measles vaccination and vitamin A supplements 101

Promoting safe motherhood 123

Supporting child protection and psychosocial recovery 141

How to develop SMART behavioural objectives / results 167

How to develop indicators based on behavioural results 171

Most significant change technique 189

Gender checklist 195

How to conduct a key informant interview 197

How to use a pocket or voting chart 201

How to do a ranking exercise 205

How to facilitate participatory exercises 209

Monitoring chart 213

Structured observation checklist for communication skills 215

Tasks of men and women in the community 217

A 12- point communication monitoring checklist 219

Tools to monitor the milestones 221

How to design a radio spot 231

How to design print materials 233

Principles and guidelines for ethical reporting on

Preparing and responding successfully to emergencies require that evidence-based

Experience has shown that affected members of communities can become

Notwithstanding the extensive and valuable contributions of the above-named

UNICEF ROSA gratefully acknowledges the funding provided by the Japanese

WHAT IS IN THE TOOLKIT?

PART II: PROGRAMMATIC AREAS

PART III: TOOLS

WHY WAS THIS TOOLKIT DEVELOPED?

WHO IS THE TOOLKIT FOR?

HOW WAS THE TOOLKIT DEVELOPED?

HOW TO USE THIS TOOLKIT

Behaviour change communication (BCC) in emergencies is a consultative process

BCC is grounded on the human-rights based and results-based approach to

mobilisation and participation in preparing and responding to disasters. That

WHAT IS IN THE TOOLKIT?

You do not have to be a

Part II: Programmatic areas

We selected these programmatic areas based on UNICEF's Core Commitments for

n Essentials about the subject

n Principles in promoting the subject

n Doing the groundwork

n Getting the message right

SRI LANKA: (Left-right) Grade 2 students

n Communication actions to promote the subject

PART III: TOOLS

that are meant to help with the range

WHY WAS THIS

While a tenet of communication is to provide information, past experiences show

SRI LANKA: A girl washes dishes with other children at a temporary

© UNICEF/ HQ05-0033/Jeremy Horner

HOW TO USE THIS TOOLKIT