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26 April 2017

Strengthening Household and Community Action for the Prevention and Control of Arboviral Diseases in

the Caribbean

Dialogue Summary

Strengthening Household and Community Action for the Prevention and Control of Arboviral Diseases in the Caribbean


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Dialogue Summary Strengthening Household and Community Action for the Prevention and Control of Arboviral Diseases

in the Caribbean

26 April 2017


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Caribbean Public Health Agency

Legally established in July 2011 by an Inter-Governmental Agreement signed by Caribbean Community Member States, the main objectives of CARPHA are to promote the physical and mental health and wellness of people within the Caribbean; to provide strategic direction, in analyzing, defining and responding to public health priorities of the Caribbean Community; and to support solidarity in health, as one of the principal pillars of functional cooperation, in the Caribbean region.

Author Andrea C. Yearwood, PhD, Senior Health Policy Analyst, Caribbean Public Health Agency.

Funding The funding for the stakeholder dialogue (and the evidence brief that informed it) were both provided by the Caribbean Public Health Agency (CARPHA) and the Pan American Health Organization (PAHO).

Conflict of interest The author declares that she has no professional or commercial interests relevant to the dialogue summary.

Acknowledgements

The author thanks the CARPHA Planning Team, comprising: Ms. Kevah Alexander, Ms. Shelly-Ann Hunte, Ms. Jaselle Neptune, Mr. Anthony Simmons, and Ms. Patricia Virgil, for assistance with organizing the stakeholder dialogue.

Citation

Yearwood, AC. Dialogue Summary: Strengthening Household and Community Action for the Prevention and Control of Arboviral Diseases in the Caribbean: Caribbean Public Health Agency, 26 April 2017.

Dialogue The stakeholder dialogue about Strengthening Household and Community Action for the Prevention and Control of Arboviral Diseases in the Caribbean was held on 26 April 2017 at The Guyana Marriott Hotel, Block Alpha, Battery Road, Kingston Georgetown Guyana, West Indies.

Product registration numbers

ISSN 2518-413X (Print) ISSN 2518-4148 (Online)


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Table of Contents SUMMARY OF THE DIALOGUE ....................................................................................................................................... 5

SUMMARIES OF THE DELIBERATIONS ............................................................................................................................ 6

OVERVIEW ................................................................................................................................................................ 6

DELIBERATION ABOUT THE PROBLEM ...................................................................................................................... 6

ISSUES RELATED TO PROBLEM FRAMING ................................................................................................................. 8

DELIBERATION ABOUT OPTIONS TO ADDRESS THE PROBLEM ............................................................................... 10

DELIBERATION ABOUT IMPLEMENTATION CONSIDERATIONS ............................................................................... 13

DELIBERATION ABOUT NEXT STEPS FOR DIFFERENT CONSTITUENCIES ................................................................. 14


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SUMMARY OF THE DIALOGUE Dialogue participants agreed that achieving the sustained involvement of households and communities in source reduction efforts was challenging because: i) some individuals are not well able to identify Aedes aegypti breeding sites; ii) residents are not reminded to perform source reduction activities on an ongoing basis; iii) norms of acceptable and unacceptable environmental behaviour are not clearly provided and/or enforced within community spaces; and iv) households are often not provided with feedback about their compliance with community norms, or about the impact of their actions or inaction. The participants agreed that these issues need to be addressed, however, they noted that other issues also required examination. The volatility of national vector response campaigns, sub-optimally designed public information announcements; weak Local Government systems, and poor community infrastructure were highlighted as other possible factors contributing to the problem. In addition to this, the participants felt that the definition of the ‘community’ and the role communities need to play, in identifying problems and developing solutions were also issues to be re-examined. Several participants agreed that a conceptual framework was needed to guide analysis of the issue and the selection of interventions to address them. It was also suggested that a human-centered approach, involving the community, should be taken to develop and design interventions that met the needs of governments, communities and households. Options for addressing the problem, such as the use of ICT tools to strengthen household capabilities and the use of incentives to stimulate appropriate behaviour should be considered within the wider conceptual framework. Limited financial resources and inadequate skills of health professionals were identified as barriers that could constrain the implementation of a holistic response to address the issue. The participants nevertheless saw the threat posed by the possible resurgence of yellow fever, and its potential to impact the economic resilience of Caribbean States, as windows of opportunity for promoting awareness and increasing funding for arboviral disease prevention activities.


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SUMMARIES OF THE DELIBERATIONS OVERVIEW On April 26, 2017, the Caribbean Public Health Agency convened a stakeholder dialogue to discuss problems, solutions and implementation considerations related to the strengthening of household and community action for the prevention and control of arboviral diseases in the Caribbean region. An evidence brief on this topic was pre-circulated to the dialogue participants, and this brief was used as the starting point of the deliberations. The evidence brief recognized the Aedes aegypti mosquito as the main vector for transmitting dengue, chikungunya, and zika, the tree main arboviruses circulating among the Caribbean population. The brief also noted that ecological, biological, and social factors influence Aedes aegypti breeding and viral transmission, and that national vector control programs in several countries, face severe structural and operational challenges, which impact their efficient functioning. While these were all noted as significant problems, the main challenge explored in the brief was the difficulties involved in achieving sustained household and community action, to eliminate sources of vector breeding. A summary of the problems presented and discussed in the evidence brief is illustrated in Figure 1. DELIBERATION ABOUT THE PROBLEM

Generally, the participants agreed with the problems identified, however, several other issues were raised, which they felt needed to be explored. These issues converged around three themes: 1) challenges related to public information dissemination; 2) quality and effectiveness of the national response; and 3) system and structural deficiencies. Public information dissemination Some participants felt that arboviral diseases were not perceived as serious illnesses by the population, and consequentially, public information announcements about source reduction often went unheeded.

Box 1: Background to the stakeholder dialogue

The stakeholder dialogue was convened to support a full discussion of relevant considerations (including research evidence) about a high-priority issue in order to inform action. Key features of the dialogue were: it addressed an issue currently being faced in the

Caribbean; it focused on different features of the problem; it focused on approaches or options for addressing

the policy issue; it was informed by a pre-circulated evidence brief

that mobilized both global and local research evidence about the problem, options for addressing it, and key implementation considerations. The evidence brief did not include recommendations for action;

it brought together many parties who would be involved in or affected by future decisions related to the issue;

it ensured fair representation among policymakers, stakeholders and researchers;

it engaged a facilitator to assist with the deliberations;

it allowed for frank, off-the-record deliberations by following the Chatham House rule; and

it did not aim for consensus, so that the reasons for and the implications of specific points of disagreement could be understood.

Participants’ views, experiences and the tacit knowledge they brought to the issues at hand were key inputs to the dialogue. The dialogue was designed to spark insights that can only come about when all of those who will be involved in or affected by future decisions about the issue work through it together. The dialogue was also designed to generate action by those who participate in the dialogue, and by those who review the dialogue summary and the Topic Overview.


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This led some participants to conclude that there is a need to explicitly ‘raise the emotional intensity’ associated with mosquito-borne diseases. While some concurred, others cautioned about this approach, noting that a high emotional reaction to arboviruses already existed in some countries, unfortunately however, the reaction was based upon misleading information provided to the public by apparently credible sources, such as politicians and Talk Show hosts. Some of the other participants questioned the extent to which existing government health education and promotion messages were effectively designed, and suggested that sub-optimally designed messages could have the unintended effect of reinforcing inappropriate behaviours in the community. After much deliberation, some of the participants concluded that government sponsored public information announcements were in competition with other household information sources, and that these other sources had a greater influence on households. Governments therefore needed to review their public information strategies.

Figure 1: Dimensions of the Problem, discussed in the evidence brief

Source: Graphical depiction based upon: Yearwood AC, Polson-Edwards K. Evidence Brief: Strengthening Household and Community Action for the Prevention and Control of Arboviral Diseases in the Caribbean. Port of Spain, Trinidad and Tobago: Caribbean Public Health Agency, 26 April 2017

National vector control campaigns The existing vector control response, led by the State, was also critiqued as a possible factor contributing to inappropriate household and community behaviours. Firstly, participants noted that national vector control campaigns tended to be volatile in nature, heightening in intensity whenever there was an emerging outbreak. It was felt that this ‘hyper-vigilant,’ yet transitory approach was not conducive to sustained behaviour modification, as it did not reinforce the message that vector management was a long-


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term endeavour. Secondly, the current strategy used in many countries to link control activities to social events, such as carnival was questioned. It was felt that this approach did not produce sustained action. Thirdly, some participants felt that the government was guilty of enlarging the role of perifocal fogging in an attempt to satisfy the population, and this created population dependence on State-led action. Finally, the government’s approach to the development and implementation of community-based vector control initiatives was described as ‘paternalistic’ because it did not support the active involvement and ownership of interventions by community members themselves. In the words of one dialogue participant: “the government behaves as if the problem is theirs. They design programs and move into communities and own these programs.” Systems and structural deficiencies Dialogue participants expressed the view that the health and Local Government systems did not provide a supportive environment to sustain households and community action. Weak physical infrastructure in communities, inadequate waste disposal, and irregular water supplies, were cited as deficiencies, which not only provided fertile conditions for vector breeding, but also undermined the positive efforts which households may initiate. Some participants felt that the Local Government system was not well equipped to play the required role in educating and empowering residents. Reform of the Local Government system was therefore needed to facilitate its role as a change agent. The absence of a comprehensive government approach towards environmental management was felt to be responsible for incoherent policies and practices across various arms of the State. One participant gave an example in which discarded tyres by one ministry were transferred to another for use. It was therefore suggested that all government departments needed to be re-oriented towards better environmental management practices. Another participant quickly reminded the meeting, however, that Integrated Vector Management (IVM) was an agreed strategy in most Caribbean countries and that this approach called for collaboration between health and other sectors, so the relevant issue therefore, was implementation of the IVM. Notwithstanding this, the participants noted that the lack of functional structures for multi-sectoral engagement was a main constraint, which made implementation of the IVM strategy difficult. ISSUES RELATED TO PROBLEM FRAMING In addition to the three thematic issues discussed above, three other matters were raised during the deliberations, which the participants felt were fundamentally important to arriving at a complete picture. These were: 1) the definition of community; 2) engagement of affected populations; 3) use of an appropriate conceptual framework. Definition of the community The evidence brief discussed the community in the traditional sense of a group of persons living within a defined geographical space. One participant noted that communities exist wherever there are individuals with shared attitudes, interests and goals. This participant went on to question whether the way the community is defined, would influence the framing and understanding of the problem. Several other


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participants agreed and suggested that a broader view of the community should be adopted. Consensus seemed to emerge around the concept of relationship-based communities. Some did acknowledge, however, that difficulties may arise when using this outlook. For example, individuals often live in one area but work in another, as such, there may be multiple community networks of which a person may be a part. Need for the community’s involvement in problem identification and the co-creation of solutions The factors identified in the evidence brief accounting for the lack of adherence to appropriate environmental management behaviours, were synthesized from available research, particularly, findings from knowledge, attitude and practice studies done for countries in the Caribbean. Dialogue participants agreed that this literature provided key insights into the issues, however, they noted that significant heterogeneity would exist across countries and across communities. The need for in-depth qualitative studies to understand the specific issues in various localities was therefore stressed. In addition to this, the importance of involving residents and members of various ‘communities,’ however defined, in the design, planning and joint-production of solutions was underscored. One participant suggested that deliberative dialogues, like the stakeholder dialogue, should be held with representatives of households and communities. Need for a conceptual framework The dialogue participants viewed the lack of sustained community involvement in vector control, as a manifestation of deficiencies in several areas— for example, national policy incoherence, deficiencies in the Local Government systems and lack of IVM implementation. One participant therefore suggested that an overarching conceptual framework, within which the issues could be reviewed, was needed. This participant proposed examining the problem from three levels: At the strategic level, issues related to governments’ commitment to integrated vector management and the application of community approaches should be examined. The participant felt that a clear strategic vision was lacking. At the tactical level, formal approaches for engaging communities in decision-making and for supporting them to make the necessary change should be in place. Again, the participant questioned the extent to which existing policies throughout the region were supportive of this approach. Once the issues were clarified at these higher levels, various community-based interventions could then be operationalized. This approach gained traction with several other participants who emphasized that behaviour change was not only relevant at the individual level. Other factors required to support behaviour modification, such as supportive policies and institutional changes, must also be considered.


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DELIBERATION ABOUT OPTIONS TO ADDRESS THE PROBLEM Three elements of an approach to address the problem were proposed in the evidence brief: 1) Integrate environmental management for vector control with community social participation; 2) strengthen household and community capabilities to undertake source reduction and other environmental management activities; and 3) create and use incentives to foster compliance with community environmental management standards. There was no discussion directly related to the first element, and discussions around Element 2 and Element 3, were focused on providing insights into how the proposals could be operationalized. The participants also spent some time deliberating the process that should be used to select various interventions. Element 2 – Strengthen household and community capabilities to undertake source reduction and other environmental management activities The participants agreed that the use of information and communication technology (ICT) was a promising tool to support education and motivational activities; that it would be cost-effective in the Caribbean setting; and that it could be deployed to achieve objectives in other parts of the health system. Some participants, however cautioned about the sole reliance on ICT tools, noting that community members sometimes have access to devices, but not to internet connectivity, either because it is not available in their communities or because it is unaffordable. Parallel approaches for strengthening the capabilities of these individuals should also be explored. With respect to mobile phone technology, privacy issues related to SMS text messaging services were raised. The use of voluntary opt-in programs was suggested as an alternative to address this issue. The use of the school curriculum was suggested as another possible avenue through which knowledge about mosquito-borne illnesses and control measures could be increased, however, there was no consensus around the use of this medium. All participants seemed to agree that the sharing of good practices among CARPHA Member States would be very helpful to support the strengthening of community capabilities. Specific calls for a knowledge sharing platforms across countries in the region were therefore made. Element 3 – Create and use incentives to foster compliance with community environmental management standards There was lengthy discussion about the possible merits and de-merits of positive versus negative incentives to achieve behaviour change. Some participants felt that there were good experiences in the Caribbean region with the use of negative incentives, such as penalties for driving without seat belts. They therefore felt that fines and other penalties, which incurred heavy costs on individuals, would be more effective. Others felt that negative incentives should be coupled with positive or material incentives, such as the provision of water storage containers with lids, or government-sponsored recycling programs. There were others who felt that it would be more important to create feedback mechanisms within the community, so that residents could understand the inter-relationship between their actions and the incentive system. Furthermore, the incentive program would have to be widely communicated. Targeting incentives at the community versus the household level was also discussed. Some dialogue participants felt that community-based incentives would be more appropriate to achieve behaviour change pertaining to vector control and suggested the use or re-introduction of community award programs. Other


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participants noted that incentives should also be directed at the State, to influence positive government-wide action. Deliberations about the approach to select interventions Dialogue participants noted that the options contained in the evidence brief were pitched at the household and community level, and some of them reminded the meeting that actions at all levels impacting households and communities, were required to bring about behaviour change. This led to questions and discussions about the role of social marketing. One participant explained the importance of the social marketing concept and stressed that it worked best when audiences were clearly segmented. The participant suggested three audiences that were relevant to the discussion of arboviral disease prevention and control: governments, the community and households. This participant also suggested that the user-centered design approach could be used to identify specific behaviour change interventions that addressed the needs of these three audiences. Another participant reminded the meeting about risk communication, an approach often used in public health during disease outbreaks, which seeks to purposefully disseminate information to specific target audiences. The similarities between social marketing and risk communication were recognized by the participants, and several of them agreed that interventions for strengthening household and community action in arboviral disease prevention and control, should be aligned to the needs of various group segments. It was then suggested that the conceptual framework that was proposed for problem identification, could also be used to inform the selection of interventions. In Figure 2, a graphical representation of the consolidated framework for problem definition and intervention selection, as discussed by the dialogue participants, is illustrated.

Figure 2: Conceptual framework for problem identification and intervention selection

Source: Author’s illustration


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In addition to the conceptual approach, the participants also spent some time deliberating the characteristics that should accompany a well-designed community-based intervention. Three main characteristics were identified:

Scalability – Some participants felt that a successful intervention in a community should be capable of being scaled-up into a national program.

Measurability – There was consensus among the participants that all interventions should have objective indicators of behaviour change which should be tracked.

Co-created with the community – There was also consensus among the participants, that diverse groups within the community should be brought together, to identify, agree upon, and jointly participate in the production initiatives to achieve desired community outcomes. It was also agreed that in this regard, Belize could be used as a model for other countries, because that country routinely conducts multi-cultural dialogues with communities to identify needs and to arrive at solutions that are community-informed.


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DELIBERATION ABOUT IMPLEMENTATION CONSIDERATIONS

Implementation Barriers The dialogue participants acknowledged that implementing the approach outlined in Figure 2 would not be without challenges. Several possible barriers were identified. Firstly, some noted that including the community as a joint partner in the development of solutions, is quite different from the traditional public health approach to disease management, and it was felt by some, that policymakers in the region may not readily embrace this concept. Significant effort would therefore have to be invested to generate the required awareness. Related to this, the extent to which health professionals possessed the relevant competencies to engage with the population in this manner was questioned. It was felt that health professionals are trained to provide information to individuals and not necessarily to engage with them. They would therefore need to acquire new skills to equip them to collaborate with community members. Added to this, the interdisciplinary nature of participatory-community approaches would also require health personnel to find more effective ways to engage persons from other disciplines. Available resources for community-based programs was also seen as an implementation barrier. Some participants felt that vector-borne diseases were not a priority when compared to other public health issues, such as non-communicable diseases, which also required a community-based focus. Participants saw the possibility of competing with higher priority issues for resources. Windows of Opportunities The resurgence of yellow fever in some countries in the Americas, and the possibility of this occurrence in the Caribbean, if mass vaccination programs were not upheld, was cited by one participant as a consideration that may persuade governments to pay greater attention. Other participants agreed and noted that regional governments tend to be concerned about the potential of diseases to affect their small, open, tourism-dependent economies. It was felt that the time was right to present the economic arguments associated with arboviral diseases—the loss of productive working days at the microeconomic level, and the possible loss of revenue from tourism at the macroeconomic level—to decision-makers, as part of advocacy efforts. The successes of existing behaviour change models, such as the model used by Population Services International, could be studied and applied to vector control. New communication channels such as social media were also seen as avenues to facilitate deeper community engagement. Partnerships with the private sector were likewise seen as an avenue to increase the reach and effectiveness of community-based initiatives.


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DELIBERATION ABOUT NEXT STEPS FOR DIFFERENT CONSTITUENCIES The dialogue brought together policy officials, individuals from the research community, and other stakeholders with backgrounds in insect vector control; health promotion; environmental health; social marketing; information technology; and behavioural sciences. The participants identified multiple problems influencing community participation in vector control. As a result, they suggested that change beyond the household and community level was required. All factors impacting household and community action, such as the functioning of institutions and the presence of supportive policies, should be examined. To achieve this, the participants suggested the user-centered design approach be adopted, to identify behaviour change requirements of governments, the community and households. This would further require careful consideration of the issues related to: i) governments’ vision and policy framework for integrated vector management (IVM) and community participation in IVM (strategic issues); ii) identification and prioritization of programs for community involvement and the assignment of community roles (tactical issues); and iii) the specific types of interventions to be implemented in communities (operational issues). Against this background, 14 priority actions for accelerated implementation were identified by the group.

Four main recommendations were made at the strategic level:

Renew the focus on integrated vector management through the establishment of functional intersectoral groups.

Strengthen multi-sectoral participation in environment management and vector control through the pursuit of joint planning and budgeting.

Review the structure and functioning of national vector control programs, with the aim of integrating vertical programs into the wider health system, where possible.

Commission a study on the ‘economic burden of arboviral diseases in the Caribbean.’ Use the findings from this study to build support for policy and advocacy.

At the tactical level, 5 key next steps were identified:

Develop and implement a qualitative research agenda to update understanding of the constraints facing households and communities. Use the results to design appropriate community-based interventions and to inform the most effective means of communicating and delivering messages to households and communities.

Evaluate existing vector-control health promotion and education campaigns and community-based interventions, in use throughout the region, to determine the efficacy of these programs and interventions. Use effective country programs as models for the region.


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Review the competencies needed by Environmental Health and Insect Vector Control Officers, to allow them to play a greater role in supporting community education and community-based activities. Re-tool the skills of existing staff in accordance with revised competency requirements.

Increase the use the Communication for Behavioural Impact (COMBI) methodology to develop the skills of program staff in countries. All program staff in countries in the region should receive some minimum level of exposure to this training;

Conduct discussions with the Caribbean Examinations Council and Ministry of Education officials, in countries to identify the best means of using the school curriculum to support vector control education and awareness.

The following recommendations pertaining to the implementation of community interventions (operational issues) were made:

Undertake a pilot study of the use of incentives, as a mechanism to strengthen household and community action. The pilot study should include analysis of cost effectiveness, and the results should be used to determine adaptability and transferability of this approach, throughout the Caribbean.

Make maximum use of ‘Mosquito Awareness Week’ as a period for intensified action to improve education and awareness.

Examine how "informal leaders,” such as influential persons who may be outside the formal Local Government system, could be formally included in community-based activities. Consider the merits of partnering with village councils and related networks.

Finally, recommended actions for strengthening the collective regional response to arboviral diseases, were also made:

Expand the activities of the Regional Network on Research and Control of Emerging Vector-Borne Diseases in the Caribbean, to include a discussion forum for members, to support peer-learning, and develop a repository of best practices to provide a platform for knowledge sharing among countries.

Link the work of CARPHA initiatives, namely, the work of the Regional Network on Research and Control of Emerging Vector-Borne Diseases in the Caribbean and the work of the Regional Health Communication Network, to create synergies and to pursue joint objectives, where possible. Further, use the findings from the stakeholder dialogue to inform upcoming CARPHA activities, such as the social marketing training on ‘Co-creating a marketing solution to Zika in the Caribbean.’

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