Assessment of hygienecommunication plan in theaftermath of the 2005earthquake in PakistanFarooq Khan and Rabia Syed, North WestDevelopment Associates, Deirdre Casellaand Rutger Verkerk, IRC InternationalWater and Sanitation Centre

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The devastating earthquake on 8 October 2005

caused the immediate death of more than

70,000 people with injury and displacement to

millions more. UNICEF played a major role to

ensure provision of safe water and sanitation,

within which a comprehensive communication

plan was formulated and implemented. The

plan aimed to create awareness and motivation

on water and sanitation related diseases and

their prevention. Multiple channels were used

to convey specific messages, adapted as much

as possible to a response phase. The

assessment considered the effectiveness of the

various initiatives and made recommendations

on activities to be continued in future; activities

not to be pursued further for lacking

effectiveness; and those activities to be

continued with some adjustments, based on

the lessons learnt for future emergencies.

Abstract

BackgroundThe devastating earthquake of 8 October 2005caused the immediate death of more than 70,000people, injured some 80,000 more and severelyaffected the lives of more than three million. Manypeople became homeless and displaced, essentialinfrastructure such as roads and water schemesgot damaged, and public (health) services weredisrupted.

The local, national and international communityeach responded to the earthquake within theircapacity and with distinguished constraints andopportunities. Once the scale and impact wereknown in the rest of the country, donations weregenerous and various professionals from elsewherein Pakistan moved to the area to assist – often ona voluntary basis. A mountainous area of nearly30,000 square km, with vast and various needsamong the many affected men, women and children,was rapidly becoming largely inaccessible as winterapproached.

UNICEF assisted (and financially supported)implementing partners in a number of emergency

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relief and rehabilitation projects to provide safewater and sanitation in the affected areas. Inconjunction and collaboration with relevantGovernment of Pakistan line-ministries and othersector clusters, a comprehensive communicationplan was formulated and implemented, aiming tocreate awareness and motivation on water andsanitation related diseases and prevention. Multiplechannels were used to convey specific messages,adapted as much as possible to a response phase.

UNICEF commissioned this assessment to assessthe hygiene promotion activities and products itsupported in the aftermath of the earthquake. Theassessment was intended to provide an impressionof the effectiveness and possible success of thevarious hygiene related activities and products,subsequently assuming a potential for impact.Additionally, the assessment method and resultswere considered a sector-wide learning opportunitythrough documenting of the specific response –particularly emphasising the hygiene promotionproducts and communication channels used. Theassessment was conducted between December2006 and March 2007; as the response activitiesbeing assessed took place between the date whenthe earthquake struck and March 2006, thisassessment was carried out about one year later.

The multi-disciplinary team assessment comprisedIRC International Water and Sanitation Centre1, anINGO based in Delft, Netherlands, and staff2 at NorthWest Development Associates (NWDA), a Pakistanbased development assistance consulting firm.

The paper explains the assessment objectives,framework and constraints, followed by pre- andpost earthquake scenarios to help understandUNICEF’s programme response. The paper then

presents key findings for products, services andchannels used for hygiene promotion, followed byconclusions and recommendations.

Assessment methodologyAssessment objectives

To evaluate on the ground all approaches forhygiene promotion supported by UNICEF:

focusing in particular on the programmecommunication and participatory hygienepromotion and transformation activitiesidentifying on the basis of evidence gathered,which activities are working and consequentlyshould continue or be strengthenedwhich activities are not working and shouldconsequently be discontinued, andto make evidence-based recommendations asto how the various aspects of hygiene promo-tion can be better integrated into an effectiveapproach to change key hygiene behaviours.

A final objective of the assessment was tocontribute learning and knowledge sharing to theemergency water supply and sanitation sector. Thiswould include: participatory methods for assessingeffective hygiene promotion and communicationactivities in post-emergency settings, which focuson greater planning and investments efficiency,through the development and implementation ofmore appropriate, relevant, coherent, achievableand effective efforts from the outset.

Scope of the assessment

The assessment report was based on the qualitativeand quantitative data collection and assessmentmethods described in this section. It had thefollowing boundaries:

1 http://www.irc.nl2 http://www.nwda.org.pk

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The hygiene promotion activities andproducts assessed were those listed inUNICEF’s Earthquake Relief & RehabilitationCommunication Plan.The assessment period ran from the earth-quake on 8 October 2005 until 31 March 2006,when the majority of the Internally DisplacedPersons (IDP) camps formally closed.Therefore, only those hygiene promotionactivities developed and/or implementedbefore the IDP camps emptied could beassessed.The area assessed covered four main affecteddistricts: Bagh and Muzaffarabad, Azad JammuKashmir Province (AJK), and Battagram andMansehra, North Western Frontier Province(NWFP).It was not within the remit of the assessmentto evaluate the overall emergency responseprogramme or to provide judgements on itsquality.A lack of baseline data on health indicatorsand incidence of disease, combined with thedispersion of IDP camp residents to theirvillages of origin after 31 March 2006. It wasbeyond the scope of the assessment budgetand timeframe to assess the direct healthimpact resulting from UNICEF’s hygienepromotion and communication programme.

Limitations of the assessment

The following limitations will have influenced thevalidity of the assessment results:

The sample size for the ground survey wasinfluenced by time and budget constraintsThe timing of the assessment – almost oneyear after closure of the IDP camps – made ita challenge to trace key informants and IDPs.

Staff turnover in emergencies proved to bealmost total, leaving the ground surveyreliant on the memory of IDPs at times ofhigh stress following disaster.The existence of different phases in emer-gency response is acknowledged, however, itremains difficult to construct a ‘scene’ someten months after an emergency interventionand to interpret effectiveness of certainapproaches. What may now seem illogicalmay well have been the best choice consider-ing the circumstances in the immediateaftermath of the earthquake.A number of key programme documentsproviding specific dates and figures were notavailable to the assessment team.

While recognising the impact of these limitationson the validity of the findings, stakeholder meetingswith UNICEF staff and partners involved inimplementing the communication plan, as well asrepresentatives of local government and end-users,resulted in the validation of the overall findings;while providing some contradictions and dissentingviews. Based on these meetings, the assessmentteam believed that the risk to the findings’ validitywas low to moderate.

Assessment methodology

The ground survey sample size was primarilydictated by the available time and budget for theassessment and was not statistically significant.However, the use of non-probability samplingmethods, such as availability and purposive samplesin the affected areas, do allow for conclusions andrecommendations. These are based on crosschecking (triangulation) of findings and differentstakeholders’ views, and perceptions gathered

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through various data collection methods and multi-stakeholder meetings, where initial findings werecross checked for validity.

Data collection methods comprised semi-structured key stakeholder interviews, impromptusmall group discussions, structured observations,and focus group discussions, conducted with endusers of the hygiene promotion products andservices, and using a selection of ordinally scoredscenarios adapted from the QualitativeParticipatory Assessment (QPA)3 methodology. Hardcopies of printed Information, Education,Communication (IEC) materials, developed underthe auspices of the UNICEF programme, weregathered and rated to assess whether end-userswere familiar with the IEC products, understoodthe messages being promoted and could conductthe promoted behaviours. Also, six assessmentquestionnaire formats guided the data collection.Following the orientation visit to three of the fourdistricts, the formats were further adjusted to thelocal situation. A review of project documentationwas conducted to obtain a better understandingof the situation during the first months of theemergency response.

Assessment framework

To enable the success of various hygiene promotionactivities (ie, messages, products, services andchannels) to be assessed, the assessment teamdeveloped an appraisal framework to assess eachactivity for appropriateness, relevance, coherence,achievability and effectiveness. The analysis andreporting is based on this set of criteria. It reflectshow the individual communication campaign

3 Ordinal scoring of descriptive categories or scenarios (ie, each score represents a given scenario or situation on the ground) are usedfor participatory assessment purposes in the Qualitative Participatory Assessment (QPA) and Methodology for Participatory Assessments(MPA) methodologies which IRC and its partners have developed and applied in a range of different settings.

components measured up in light of findings fromkey stakeholder interviews, end-users’ viewsexpressed in focus group discussions and findingsfrom the literature reviews: including official projectreports and communications.

Finally, though not the main focus of the study, anumber of cross-cutting variables were consideredfor their impact on the communication campaigncomponents and their relative success. Theseincluded:

Financial-administrative issuesTechnical support and expertiseCoordinationLogisticsMonitoring and evaluation

Setting the scenePre-earthquake

The population of the hilly and mountainous areasof AJK and NWFP is not homogeneous in regardsto origin and language, although they have acertain isolation and remoteness in common. It isa relatively conservative Muslim area, particularlyin NWFP, and cultural behaviour and perceptionsare deeply rooted. Informal institutions – such asreligious leaders, village elders and landowners –are strong and influential. Women are thecustodians of life, but advocating gender issues inNWFP (and AJK) is very sensitive.

Before the earthquake, latrine coverage in AJK andNWFP was 25-30% and access to safe drinkingwater 65-70% (Ahmad et al, 2006; Personalcommunication Director, LG&RDD). Latrine coveragein rural areas is assumed to be less than the average

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coverage. Simple dry pit latrines are not a widelyused latrine option as water is used for ablutionsand anal cleansing - a practice that does not gowell with pit latrines. Besides, the hilly terrain mostoften does not allow easy pit digging and hence,latrine (wherever present) are those which not onlyallow use of water but possibility of a prolongeduse such as pour flush, twin-pit leaching latrinesetc. latrines. Interestingly, there is no word forsanitation in Urdu; health and cleanliness is theclosest approximation.

The local government department had a programmeon rural water supply, with only a minor sanitationcomponent. Hygiene education and promotion wasnot adequately addressed. This was due to lack ofadequate capacities regarding manpower andunavailability of channels of mass communicationin parts of affected areas, because the mountainousterrain makes communication and access difficult.So, after the earthquake, when people arrived inthe IDP camps, their knowledge and/or practices ofsafe hygiene were quite low – this was particularlythe case for those from the more remote and ruralareas. Additionally, the challenge of promoting safehygiene behaviour was further compounded by theloss of capable staff and the relatively low capacityof agencies due to prior isolation, in particular thatof AJK province. Interviewed stakeholders said that,as a result, and in the immediate aftermath of theearthquake, neither the agencies nor the beneficiarieswere prepared for the promotion of safe hygienebehaviours in a rapid and coherent manner.

Earthquake

In addition to the human casualties, suffering anddisplacement, the earthquake caused an almostcomplete collapse of health services and vast

Appropriateness

Relevance

Coherence

Achievable

Effectiveness

Familiarity with channel, product, service

(before the earthquake)

In line with culture, tradition, religion

and language (hence preferred and/or

accepted)

Affordable and/or accessible to user/

target group

Needs-based (based on evidence/

assessment)

Specific (tailor-made, targeted to a

specific group and/or phase)

In line with programme objectives (ie,

with reference to core corporate

commitments of UNICEF for

emergencies and WASH)

In conjunction and simultaneously with

hardware/software component

In collaboration/coordination with key

stakeholders (ie, line-departments and

UN clusters)

Realistic in regards to general

programme planning

Timing

Logistically achievable

Expertise/background key staff/IPs (HR

quality)

Human resources (HR quantity)

Access (to target group)

Community feedback on effective use

of channels, products and/or services:

Do people recall channels used for

hygiene messages

Do people recall hygiene messages

Do people still use products, or have

they used them

Anecdotal: Have people changed

hygiene behaviour

What is the access to services; eg

latrines, water supply O&M, health

facility

TABLE 1 Elaboration of key appraisal criteria

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damage to water and sanitation systems in the4,000-plus villages and small towns that wereaffected. Outbreak of diseases and even epidemicswere anticipated, as highlighted in the initialEarthquake Relief & Rehabilitation CommunicationPlan4, reproduced below:

Diarrhoea, dysentery and measles – in theearly months of camp settlementScabies and neo-natal tetanus – poorhygiene and limited water availabilityRespiratory diseases and TB – commonamong IDPsMalaria – living in the openAnaemia and other nutritional deficiencies –limited food supplies(Psychological) trauma, hypothermia, flu,gastroenteritis and other infections

Specific disease trends do show some peaks inthe months after the earthquake, possiblyindicating some (minor) outbreaks (MOH/WHO,2006): jaundice, scabies, Accute Respiratory Illness(ARI), watery diarrhoea and acute watery diarrhoea.Eventually, it was concluded that no major outbreakor epidemic occurred in the affected area duringthe year after the earthquake and that diseasepatterns may have remained within endemic trends.

Different phases can be distinguished after theearthquake’s immediate impact. Phase one of TheEarthquake Relief & Rehabilitation CommunicationPlan looked ahead and described three phases,ending on 31 March 2006. When the communicationplan was revised for phase two, the benefit ofhindsight was used to revise the phasing – nowending on 30 June 2006. Phasing for activities weredescribed in different ways in the time since theearthquake. This report uses phasing based ongeneral characteristics of the emergency response:

1. Impact to emergency – October 20052. Emergency to stabilisation – November and

December 20053. Stabilisation to recovery – January to June

20064. Recovery to rehabilitation – July 2006 to June

2008

1) First phase: Impact to emergency(October 2005)This, as would be expected, was the most chaoticphase, with the onset of a two-week rescueoperation. Hereafter, (international) organisationsstarted arriving and the response slowly unfolded.But during this stage, there was confusion, oversightor a lack of information. Access and supply problemswere a great constraint, with not enough equipmentand material and no electricity. The priority wasshelter, food and general survival. No significantspecific hygiene promotion activities were carriedout in the first month after the earthquake, because“people did not even have a tent”. Generally,people found it very hard to recall and talk aboutthe first month as they were highly traumatised andhad spent the time fighting for survival.

Regular country programmes were halted as staffand supplies were diverted to the responseactivities. A rapid appraisal was carried out in mid-October 2005, looking specifically atcommunication constraints and opportunities.

2) Second phase: Emergency to stabilisation(November – December 2005)In this phase, rescue teams were replaced by(international) emergency organisations thatrapidly grew in number and diversity. The prioritywas provision of shelter material and non-fooditems as the approaching winter was regarded as

4 UNICEF developed this plan soon after the earthquake, as required by its obligations under its core corporate commitments toemergencies, to allow for a systematic fuller response at different levels.

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the main threat. Coordination mechanisms wereestablished, but it is appears that it took until theend of December to establish clarity regarding whowas actually doing what. More than 150 IDP campswere established, many of them in a spontaneousmanner on unfavourable locations, which weredifficult to access and service. The camps rangedfrom a few tents to 5,000 people. Camp managementwas generally weak and lacked specific expertiseand capacity. This also applied to hygienepromotion, which was started merely as an addon to the provision of water and sanitationhardware, but which, by then were beingaccelerated. General camp hygiene conditions werepoor and a need emerged to promote the properuse of latrines, particularly as they started to beused as washing facilities. Implementation of thecommunication plan commenced; boy scoutsbecame an important instrument in the hygienepromotion campaign, Ministry of Health (MoH)hygiene education teams carried out a range ofactivities, FM radio stations were used or even setup, IEC material was distributed, etc. Some hygienemessages were spread well before they weresupported and facilitated by the distribution ofthe required supplies, eg soap, hygiene kits,household filtration means and latrine slabs. Apartfrom initial batches of soap, those distributionsonly became significant after mid-December.

3) Third phase: Stabilisation to recovery(January to June 2006)IDPs became more accustomed to camp life, whilemore and more villages became less accessibledue to the (rather mild) winter. The earthquakeresponse evolved into one of the largest logisticalexercises for some of the emergency organisations.In February, it was announced that the IDP camps,

with a total caseload of 84,000 people (Personalcommunication UNICEF Hub Muzaffarabad), wereto be closed by 31 March 2006. In April, manycamps emptied while service provision shifted fromcamps to villages. For many organisations, theirsix-month emergency funding expired before thetime camps needed to close. As a consequence,camp hygiene promotion activities were merelystopped and organisations left or shifted focus. Inthe camps with a residual caseload, the hygienesituation deteriorated rapidly – to the extent thatit triggered an international emergencyorganisation to commission an internal evaluationof their water and sanitation response.

The first phase of the communication plan endedand a second phase ensued. IEC material wasreviewed in January 2006 and a second batch ofmore locally adapted material was developed,including stickers, leaflets and posters. An ambitious‘Rahbar’ programme started (see below), involvingthe boy scouts, and germ glow shows5 wereintroduced in the camps. UNICEF-supported radioshows stopped broadcasting, just when a specificTV programme started. However, by then campswere closing and distributions halted. Therefore, anumber of planned activities under phase two ofthe communication plan did not materialise.

4) Fourth phase: Recovery to rehabilitation(July 2006 – June 2008)The assessment took place in the phase thatemphasises rehabilitation of water supply schemes.Water and sanitation at schools and in communitiesare a second and third component – in thatsequence and with similar (budget) priority. Somecamps still exist or were re-established after theflash flooding in August 2006, but the emphasis is

5 Basically an ultraviolet lamp reflecting dirt, etc, in paler-coloured hands when seen under the lamp, signifying the fact that hands canstill be dirty and carrying germs even if they apparently look clean, and hence the need for regular hand washing

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6 In 2006, as part of UN reforms the Inter Agency Standing Committee IASC designated UNICEF to lead the inter agency cluster workinggroup on water and sanitation in emergencies. The cluster working group includes among others WHO, Oxfam, IFRCs, The InternationalCommittee of The Red Cross, The IRC, and WFP.

clearly on the villages. Caseload of IDPs in campswas 33,000 in January 2007.

Stakeholders

Figure 1 maps the range of stakeholders involvedin the Hygiene Promotion CommunicationCampaign, adapted from the perspective of theHousehold Centred Approach to sanitation. If thecampaign’s aim was understood to be improvedhygiene behaviours of women, men and childrenin IDP camp and village households, the outlyingspheres and their relevant actors and processes(including individuals, agencies, and policy/strategyframeworks) can be understood as the enablingenvironment for realising this aim.

Coordination

UNICEF had a presence in the affected area beforethe earthquake and hence a good relationship withauthorities. After the earthquake, an inter-sectoral

Emergency Relief & Rehabilitation CommunicationCommittee was formed to plan and executeprogramme communication support, involving keyministries such as health, environment, social welfareand international partners. An Emergency Relief &Rehabilitation Communication Centre was set up inthe Health Education Cell at the Ministry of Health.

As part of UNICEF’s global mandate6 to lead thewater and sanitation sector cluster of agenciesworking in emergencies, it established a water andsanitation cluster in both NWFP and AJK. Hygienewas part of the health cluster, shared by the WorldHealth Organisation (WHO). Water and sanitationcluster meetings were often filled with quantitativeupdates or technical discussions: dedicated timefor hygiene promotion was scarce. Eventually,hygiene sub-clusters were established. InMuzaffarabad they turned out to be beneficial, butin Mansehra they proved to be a dead end. Hygienesub-cluster meetings in Battagram only started inMay 2006. The UNICEF emergency response teamhad separate funding and staffing to the countryprogramme. All UNICEF hubs fell under theemergency team, while the provincial officesremained responsible for the country programme.The emergency programme will be shifted to theUNICEF country programme in 2008.

FindingsMessages

The Earthquake Relief & RehabilitationCommunication Plan, drafted in October 2005,shaped the strategy for communication andpromotion of hygiene messages in the immediate

FIGURE 1 Hygiene communication stakeholder map

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aftermath of the earthquake. The messagesdisseminated in phase one were based on earlieremergency response efforts and needs, as well asresults of a rapid three-day assessment in mid-October. Key messages disseminated were:

Public defecation promotes the spreading ofdiseases such as diarrhoea, jaundice andcholera.Every household should construct a low-costlatrine for prevention of diseases and to savefamily members the inconvenience ofdefecating in the open.Hand washing could save many lives.If you don’t wash your hands after using thetoilet, they become a superhighway fortransmitting microbes from one person toanother. Make habit of washing your handsevery time.Faeces contain billions of virus and bacteria.They are the number one public enemy inspreading diseases. Persuade everyone todefecate only in latrines. If latrines are notavailable, the faeces should be covered withearth.Diarrhoea can be prevented through use ofsafe water, toilets and regular washing ofhands with soap and water, especially aftertoilet use and before touching food andfeeding children (UNICEF, 2005).

Notable omissions from the above are personalhygiene behaviours such as face washing, whichalso contributes to lower incidence of ARI andspread of infectious eye diseases.

Products

UNICEF distributed a range of personal andhousehold hygiene products to support improved

hygiene behaviours, doing so through implementingpartners, including Local Government & RuralDevelopment Department (LG&RDD). Soap bardistribution, from existing stocks in UNICEF Pakistanwarehouses began in affected areas during thesecond week of November. In the second week ofDecember 2005, hygiene kits and latrine slabs werefirst received and distributed by the UNICEF HubOffices. In mid-December, radios and waterpurification units began to be distributed in bulkin the four districts.

Distribution of soap for personal and clotheswashing was conducted in support of the hygienemessages being promoted and in response topeoples’ needs for basic hygiene products. ThePakistan Boy Scouts Association, with UNICEF,distributed 100,000 bars of soap (provided byUnilever) and another 1.5 million bars (purchasedby UNICEF) among IDP camps and villages. Tofurther stimulate attention and awareness, soapwas used as prizes in waste collection campaigns(PBSA, 2006).

Soap bar distribution was a highly appropriateand relevant component of the Hygiene PromotionCommunication Campaign. People were familiar withuse of soap – even those unable to afford soapwere generally familiar with its uses. The availabilityof soap three weeks after the earthquake meantthat the promoted behaviours could actually becarried out by end-users. Key informant interviewsin shops near IDP camps revealed that demandwas felt to have increased by up to 50% in thepast year.

UNICEF-supplied hygiene kits included washingand bathing soaps, toothbrushes, toothpaste, anail cutter, women’s sanitary cloths, towels, combs,

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FIGURE 2 FGD with children: Recall of hygienepromotion campaign components, Baghdistrict

FIGURE 3 Adult literacy-NWFP, 2004-2005% of population aged 15 yrs and above

small water container and mug. The distribution ofthese kits is an example of a highly relevantproduct. Issues around appropriateness of somekit contents were, however, raised during keystakeholder interviews. Key ‘appropriateness’problems were:

Inclusion of ‘western’-design feminine hygieneproducts (eg, sanitary cloths and underpants)not commonly or traditionally used by thesewomenDistribution of the hygiene kits by male teammembers preventing women from being ableto collect the kits; andLengthy three-month lead times from order todelivery of hygiene kits to the Hub Officesresulted in distribution delays to end-users.

While this component of the communicationcampaign was relevant in terms of fulfilling the

basic personal hygiene and public health neededfor improved sanitation to control open defecationin the IDP camps, the promoted latrine technology,simple pit latrines, were neither familiar nor indemand by end-users across the board. Otherqualitative and quantitative information providesevidence that the following problems were also

associated with latrines, their construction, use andmaintenance in general:

Poor quality superstructures that could notwithstand extreme weather conditions acrossseasonsLack of sense of ownership of latrines(especially for maintenance and cleaning)Delays in delivery of latrine slabsPreference among users is for pour flushlatrinesUse of water for cleansing led to latrinesfilling too quickly and no specific educationon proper use of pit latrines in the commu-nity; andInsufficient development of capacity amongend-users for future latrine relocating andnew construction.

Despite these shortcomings, achievements were alsonoted such as IDPs taking latrine slabs with them,and continued latrine use, on return to their villages.

The first UNICEF-supplied radio sets weredistributed by mid-December 2005. The purposeof distributing radios was to disseminate healtheducation and hygiene messages (including hygienepromotion) and information on available services.In affected districts, with relatively low literacy

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rates, particularly among women and in rural areas,radio was popular before the earthquake: renderingradio transmissions and programmes anappropriate medium of communication (see Figure3 for NWFP – rates are generally higher for AJK)(GoP, 2006).

Results indicate that before the earthquake, radioprogrammes were among the top five traditionalsources of hygiene information for women and men.Roughly 81% of households had radios before 8October 2005 and although more than half weredestroyed, a snapshot survey by Internews foundlistenership increased from 28% two weeks afterthe earthquake to 70% by February 2006 (InternewsNetwork, 2006). Figure 4 shows a slight variationbetween women’s and men’s traditional hygieneinformation sources.

Limitations to the effectiveness of the radiodistribution component of the CommunicationCampaign included issues around quality of theradios provided by UNICEF and the range of the

FM frequency in the affected areas. The use of FMradio transmission versus AM is addressed in furtherdetail in the section on channels, below.

The quality of the radios distributed by UNICEFwas poor. UNICEF-distributed radios were, in someinstances, even returned to UNICEF due to nonfunctioning (Intra-office Communication, MansehraHub Warehouse, Abbotabad, January 2007). Wherefunctional, the battery operated radio sets provedto have a lifespan of around three weeks and nobatteries were provided. In contrast, householdobservations found durable quality radio setsdistributed by UNHCR still present, functioning andincluded other useful implements such as compassand flashlight.

Household Water purification and storage

Products to support the treatment and purificationof water for drinking included Nerox emergencywater filters, Utility Bags for water storage, waterpurification tablets and PUR sachets. In the contextof UNICEF’s response to the emergency, over 50,000Nerox filters were donated by Norway, about 27,000families received the filters while seven million waterpurification tablets and six million PUR sachetswere distributed among the affected populationthrough CBOs, NGOs and LG&RDD (Ahmad et al,2006). In general terms, means for household waterpurification are highly appropriate products fordistribution, and in the quantities realised byUNICEF and its partners, in response to a majordisaster.

Of equal importance is the accompanying hygienepromotion and awareness raising; an integral partof this awareness raising relates to safe handlingand storage of water. Communication campaign

FIGURE 4 Traditional hygiene information sourcesby sex

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FIGURE 5 Water/hygiene in household/tent,Mansehra district

FIGURE 6 Water hygiene in household / tent,Muzaffarabad district

components that sought to address this aspect ofhygiene practices took place in the form of trainingsfor camp or vil lage WatSan committees,demonstrations by boy scouts, IPs, etc. These arecommented on separately below.

Despite these efforts, household surveys at thetime of this study found that safe water handlingand storage practices differed greatly acrossdistricts, as evidenced by Figures 5 and 6 below.While not a reflection on the success of the UNICEF-supported awareness raising and skills buildingactivities alone, these results provide a snapshot ofhouseholds’ current safe water handling and storagepractices. People affected by the earthquake didn’tadopt or sustain all behaviours they may have beenexposed to in the post earthquake setting. Ofparticular concern are the relatively low rates of visiblehand soap near food preparation areas.

Finally, a key area identified for improvement isthe English language printed on the Nerox filterkits in an area where, as seen above, literacy ratesare not high and English is neither the mothertongue, nor the local lingua franca of the majorityof the population.

Activities/Services

Pakistan Boy Scouts AssociationWithin a week of 8 October 2005, the Pakistan BoyScouts Association (PBSA), drawing on their existingprogramme resources, initiated an emergencyresponse campaign, dispatching boy scouts fromacross the nation to the affected areas, to assist inthe rescue efforts and with crowd control efforts.

PBSA had a known presence in much of the affectedarea before the earthquake and in particular in areascloser to urban settlements. Key stakeholder interviewshave indicated that the boy scouts provided invaluableassistance with their rescue efforts.

This exposure to, and familiarity with, PBSA meantthat the scouts had access to households in moreconservative areas where traditional culture andfaith-based practices do not permit women to leavethe home or interact with men outside the family.As a means for conveying hygiene promotionmessages, PBSA proved to be an appropriate andeffective channel. In support of this statement,assessment results from all four districts in Figure 7indicate that among the most important traditionalsources of hygiene information are community

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motivators and school children – a neat combinationof the defining characteristics of boy scouts.

Particularly effective were the tent-to-tent visitsby boy scouts to disseminate hygiene promotionmaterials. The post earthquake collaboration withUNICEF - building on past cooperation on otherprogrammes in the country – sought to benefitfrom PBSA’s profile, which was achieved by playingan active role in the rescue phase and their abilityto access all community members.

Additionally, the wall-chalking component of thecampaign and tent-to-tent dissemination of hygienemessages were particularly memorable to focusgroup discussion participants in this study.

Identified weaknesses in the activities and servicesconnected with the collaboration between UNICEFand PBSA relate mainly to cross cutting issues suchas logistics, coordination and programme coherence.

Each district had four scout patrols each consistingof eight scouts (between 16-18 years old). In total

1,197 scouts were deployed during three months,excluding field coordinators.

Each base camp was equipped with one minibusfor transporting scouts to villages and camps toconduct hygiene promotion activities. This was alimiting factor in the amount of time a scout patrolcould spend in each location, hence the observationof one key stakeholder that “…wall paintings andputting up banners were 15 minute activities, then[the boy scouts] were gone again. This was notseen as a very practical help…” (Project Manager,Implementing Partner Organisation, Muzaffarabad,January 2007).

Other mitigating factors in the effectiveness of PBSAactivities concerned logistics and timelines ofpayment disbursements as per signed agreements.This included late or non-delivery of agreed supplies,eg IEC materials for Rahbers (see below) to distribute,visibility clothing and gear, and programmemanagement tools such as computers and printers.

Lady Health WorkersOne recommendation of the mid-October 2005 rapidassessment was to reach out to households andcommunities with health and hygiene messagesthrough Lady Health Workers (LHW). Their tasksincluded mobilising health committees and arrangingcommunity gatherings. Interpersonal communicationbetween LHWs and those affected was intended toraise awareness of health and hygiene, as well asprovide information to households.

Though the LHW concept is coherent with theprogramme approach in its emphasis oninterpersonal communication, and appropriategiven the programme’s established presence(70,000 registered LHWs in Pakistan), relatively

FIGURE 7 Traditional sources of information abouthygiene, combined district results

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little information could be gathered on theeffectiveness of the LHW programme. This mayreflect in the finding that in terms of traditionalsources of information about hygiene LHWs didnot rank high in any of the four districts.

Rahber ProgrammeThe Rahber Programme was a partnership betweenthe Ministry of Environment, Ministry of Health,UNICEF, WHO, National Volunteer Movement(NVM), Pakistan Boy Scouts Association, NationalRural Support Programme, National Commissionfor Human Development, Muslim Aid, Al-RahmanTrust and Pakistan Girl Guides Association. In Urdu,‘rahber’ means ‘one who shows the ‘path’, or ‘guide’.

With support from UNICEF, NVM provided overallsupport and facilitation, while the boy scouts wereresponsible for overall coordination andimplementation in allocated areas. Other partnersimplemented the programme in other allocated areas.

The MoU was signed on 20 January, 2006 and underthe six-month programme, teams of three Rahbers,aged 12 and older, were assigned 10-15 family tentsin both organised and spontaneous camps, whichthey would visit daily to carry out interpersonalcommunication for hygiene, sanitation, safe water,better health and children’s protection issues.Rahbers were also to organise camp cleanlinessdrives. Orientation programmes were to beprovided along with visibility and informationmaterials to support their efforts.

Orientation meetings held with UNICEF inIslamabad, and the orientation sessions with campand tent Rahbers, were effective in establishing acommon understanding and core competencies forthe planned activities. Additional training for camp

and tent Rahbers, along with distribution of Rahberfield manuals were planned.

Despite these effective preparatory andcoordination efforts, similar to the PBSAprogramme, the Rahber programme facedlimitations in terms of delays in payments, latedelivery of visibility clothing, protective gear andIEC materials (arrived at the end of the project)hampering Rahbers ability to gain access tohouseholds due to lack of identification as officialcommunity mobilizers. Key stakeholder interviewswith Camp Management Organisationrepresentatives also indicate that the Rahberprogramme was not consistently implemented inthe four districts surveyed. Figure 9 below illustratesthe Rahber programme was non-existent in Baghdistrict with similar results for Muzaffarabad.

Finally, though conceived with a timeframe forimplementation up until June 2006, the programmesuffered when camps officially closed on the 31March 2006 and trained Rahbers were dispersedor returned to their places of origin.

Health Education Corners (HEC)Health Education Corners (HEC) were establishedin relief health facilities and major relief camps ineach of the affected districts (MOH/UNICEF, 2005).Similar to the Lady Health Worker programme,relatively little evidence on the relevance oreffectiveness of the health corners could be traced,apart from the fact that the planned HEC wereimplemented in the four districts surveyed.

The potential of HEC was high given the evidencepresented previously about people’s preferencefor interpersonal communication channels. Effortsto carry out the activity over a longer period with

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corresponding monitoring of effectiveness andoutreach would have benefited the programme asan appropriate and coherent activity that hadstrong links among sectors (Health and WES).However, commenting on the effectiveness of theactivity is not possible, given the low recall amongend-users about HECs and the relative dearth ofinformation to trace them ten-months after theclosure of IDP camps.

Information, Education and CommunicationMaterials

UNICEF-supported Information, Education andCommunication (IEC) materials were developed,produced and disseminated as part of the variousprogramme components such as the PBSA, Rahber

FIGURE 8 Planned vs. implemented UNICEF-supported hygiene promotion communication campaigncomponents: 8 October 2005 - 31 March 2006

Mass

Household

Health and hygiene message posters

and stickers

MEENA Poster series on hygiene

Let Life Smile Again' slogans and

banners

Mosque hangings

Wall chalkings

Let Life Smile Again' poster stickers

and leaflets

Prayer cards with Quran quotes on

personal hygiene behaviours these

quotes were specifically designed for

mosques, they were not part of HH

material

MEENA Special Protection Package

TABLE 2 Overview of mass and household level IECmaterials

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FIGURE 9 Hygiene communication channels recalledby household members - Mansehra district

and other activities. Household level, as well asmass communication, IEC materials were developedand include:

The IEC materials were developed to disseminatea wide range of relevant messages. The materialswere appropriate for most, though not all, districtsas they were printed in Urdu. Although, phase onematerials – largely text-based – were less relevantand effective in areas with high illiteracy levels.

A second round of printed materials was based onimages and messages adapted for the IDP campsetting. However, these were less relevant in Battagramwhere socio-cultural patterns and practices differ fromthe other districts. Depiction of local customs, languageand images from Battagram would have made theIEC materials more acceptable and relevant in thatsetting (Personal communication, UNICEF Project staff,Battagram, January 2007).

Despite the appropriate and coherent idea behindadaptation of the images and messages to the IDPcamp setting, the decision to close IDP camps by31 March 2005 was taken while the second batch ofIEC materials were being produced. Though attentionhad shifted to the repatriation process, Hub Officestaff reported arrival of batch two materials occurredwithout advanced notice. This, coupled with lowlevels of demand from Implementing Partners (IPs)for the materials, limited their potential effectiveness.This disconnect between national and hub levels ofprogramme activity impacted on the effectivenessof the potentially worthwhile IEC activities.

Camp hygiene committees and cleaningcampaignsNGOs and IPs active in the IDP camps promotedthe establishment of camp committees, which were

formed as a means of coordinating and mobilisingcommunity members around general issues, andhygiene promotion information in particular. Theseefforts were met with varying success acrosslocation and different end users.

Channels

Interpersonal communicationResults from the FGD with women and menregarding recall of interpersonal communicationchannels indicated in most cases that these channels– including tent-to-tent, face-to-face, communitymeetings, and specific programmes such as theboy scouts – varied across the districts and bygender. Community meetings were wellremembered by men in particular while women’srecall of tent-to-tent/face-to-face visits was stronger.

Where hygiene products were distributed throughinterpersonal channels, it was found thatdissemination of corresponding information waspractical as the messages about clothes- and hand-washing, water purification, oral rehydration,treatment, etc were matched with the requiredhardware to conduct the promoted behaviour.

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Implementing partnersIPs provided hardware for drinking water supplyand latrine construction along with hygiene kits,jerry cans, aqua tabs, buckets and other suppliesto support the hygienic behaviours being promoted.

Capacity development efforts of IPs resulted inthe formation of CBOs & Hygiene sub-committees,as well as training for the members on hygienepromotion communication. Support was alsoprovided for community level demonstrations onuse of Nerox filters, hand washing, etc.

Key stakeholder interviews, with more than 15 IPrepresentatives across all four districts, alsohighlighted a number of cross-cutting areas forimprovement such as coordination, capacitydevelopment and logistics. In particular, not all IPstaff received orientation on use of materials -either from UNICEF or from their own organisation.Another example related to coordination is thatstrategies for implementation varied across IPs.This lack of uniformity in selecting IPs and theirproposed strategies may have stemmed from ageneral dearth of qualified staff and agencies inaffected areas. Finally, even where monitoring wasan agreed IP activity, it was not conducted regularlyor in a timely manner so that necessary adjustmentsto programming, based on monitoring findings,could be implemented.

Religious leadersTraditionally religious leaders were not a leadingsource of information about hygiene for men andwomen. However, the concept of involvement ofreligious leaders in promotion of hygiene/healthmessages existed before the earthquake and acurriculum – based on those messages thatcorrespond to the Quran – had been developed.

Though this channel started only at the end of March2006, and was not universally mobilized across thefour districts, religious leaders did play a positiverole in hygiene promotion in Mansehra andBattagram districts. Hub Office staff in those areasexpressed that they now regard them as trainedresource for future emergencies. As with thecollaboration with IPs, monitoring of the effectivenessand impact of the capacity building was weak.

EntertainmentEntertainment events were largely reported asappropriate and effective means of communicatinghygiene promotion messages. Plannedentertainment events including Germ Glow shows,drama, and films were held in each district andconsidered welcome diversions to thecircumstances for audiences. Additionally, messagespackaged in entertainment channels were wellreceived. Thus, in terms of appropriateness,relevance and coherence, entertainment activitiesperformed well.

However, in terms of effectiveness, issues surroundingsufficient numbers of Germ Glow machines (1 per district),the fragile and easily damaged components of the GermGlow machines and inability to quickly or easily go toscale with entertainment programmes such as drama,film, etc, did crop up. This said, children’s recall ofentertainment events across the districts is quite high.

NewspapersAdvertisements disseminating key messages aboutgastroenteritis, malaria, tuberculosis, immunisation,nutrition, maternal health and disaster relatedstress, water, environment, sanitation and childprotection first appeared in newspapers on 3November 2005. In the 14-day campaign, sevendifferent ads appeared twice in seven newspapers.

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Though the timeliness of these messages wasappropriate, appropriateness and relevance of thischannel, expressed in terms of newspaperreadership in affected areas, are low; with only21% of people (not disaggregated by gender orage) – surveyed by Internews – reported as relyingon newspapers as a main source of information bythe end of October 2005 (Internews, 2006).

Key informant interviews with shopkeepers duringthe field study indicated that supply of newspapers– even local newspapers are mostly printed inRawalpindi and Islamabad – was problematic forbetween six and eight weeks after the earthquake.

Additionally, as a traditional channel for hygienemessages, newspapers did not feature among thetop five sources in the districts surveyed. However,information gathered from newspapers by thosewho do read them is shared through mouth-to-mouth channels during daily gatherings of maleand female social groups. Despite this secondarychannel, end-users expressed that advertisementsare usually skipped over during reading.

RadioRadio was popular, especially in rural areas, beforethe earthquake – although FM coverage was notavailable in the rural areas of NWFP and in AJKbecause FM broadcasting licenses were not easilyobtained. In response to the disaster, and in lightof the relative popularity of radio, ten temporarynon-commercial licenses were issued.

Broadcasting was supported through the widedistribution of radios by many organisations inthe affected areas, making it possible for peopleto access the newly established stations. As notedin the findings on distribution of radio sets, listener

coverage had reached up to 70% in IDP campsand villages by February 2006.

Stations that collaborated with UNICEF to providehygiene promotion information included: FM 100;FM 105; University of Punjab FM 104 and Sachal,though the latter was not recalled by assessmentrespondents. In Abbotabad, Radio Buraq had acontract for 36 programmes to broadcast.Broadcasting from these stations started between10 December 2005 and 1 January 2006.

Radio, as a communication channel, can therefore besaid to be an appropriate and relevant choice in theemergency response. Constraining factors to theeffectiveness and coherence of the use of the channelincluded: the limited reach of the FM frequency inremote areas, unforthcoming support in terms ofexpertise from UNICEF in programme contentdevelopment, delays in payments for services, andthe fact that programming was conducted primarilyin Urdu, rather than in the various languagesrepresented in the diverse targeted areas.

Finally, considering the popularity of radios as achannel of information and entertainment, therelatively short duration of programming(dissemination of hygiene promotion messages viavarious stations took place between 10 ofDecember 2005 and the third week of March 2006)was an opportunity missed. Messages abouthygiene behaviours in this setting – ie their villagesof origin – could have served to reinforce thosedisseminated while the displaced persons werestill living in the IDP camps.

TVTraditionally speaking, TV was not a major sourceof hygiene information before the earthquake.

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Though about 52% of the population in the affectedarea had televisions, they were virtually alldestroyed by the earthquake (Internews, 2006).As a channel for hygiene promotion communication,TV was not among the most appropriate orrelevant options in the immediate aftermath.

The TV-based initiative of MoH, UNICEF and Atv -an Islamabad-based ‘free to air’ television network- to develop and transmit 30 weekly programmeson relevant health and hygiene topics commencedon 1 April 2006. The activity was also intended tofacilitate the IDP repatriation process. Programmes,featuring prominent celebrities and public figuresconducting entertainment events about health andhygiene issues with affected people, were tapedlive in different camps. Viewer call-ins to theprogramme were possible and popular with callsand letters from around the country.

Finally, key stakeholder interviews indicated thatthe effectiveness, relevance and coherence of useof this channel were compromised due to thefollowing factors:

lack of baseline information gathering aboutthe target audience (including information onthe availability of TVs in the affected areas)lack of impact monitoring for makingimprovements and adjustments to program-minglack of agreed support from UNICEF inidentifying hygiene experts as per thecooperation agreementdelays in reaching cooperation agreementsand processing of paymentsnon-provision of agreed equipment formobile TV recording unitslack of programming in a variety of locallanguages, not only Urdu.

Pakistan Earthquake Relief & RehabilitationCommunication websiteThe campaign website – www.pakquakecommunication.org/site/ – became active on 5December 2005 (and was still available when this paperwas being produced). Stemming from UNICEF’s mandateto lead the WES Cluster, the site provides informationand knowledge management services primarily for thecollaborating agencies involved in the emergencyresponse, relief and rehabilitation efforts.

As a proxy indicator for the effectiveness of thewebsite, the number of site visitors – a total of2,070 by February 2007 – is low given the overallnumber of everyone involved. What was notpossible to trace during the assessment periodwas the spread of hits over time (eg were sitevisits concentrated in the first months after theearthquake), specific pages that received most hits,and who, and from which agencies, were the most/least frequent site visitors?

Conclusions andrecommendationsBased on the findings detailed above, a numberof main conclusions and recommendations can bedrawn with specific attention to UNICEF’s HygienePromotion Communication Campaign.

Generally speaking, it can be concluded that whilemessages were pertinent and diverse, and significantefforts were made to equip end-users with therequired information and products to practice safehygiene behaviours, the strategy and responsedeveloped suffered from a lack of a clearcommunication link between the WES Clusteractivities at national and hub levels. This disconnectbetween actors at different levels resulted in delaysin activities, delays in development and distribution

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of products, different approaches being developedlocally without material or concept support andreduced effectiveness of overall programmeobjectives.

Messages

The hygiene promotion messages selected were basedon previous experience with response to humanitariancrises and outcomes of the rapid assessment conductedfrom 15 – 17 October 2005 that intended to appraisethe availability, reach and access of media and potentialcommunication channels.

While highly relevant messages about safe water,sanitation and personal hygiene behaviours, andpractices were among those disseminated; messagessuch as those regarding malaria and handling ofsnake bites – of less relevance in a mountainousregion with winter approaching – were included asstandard elements of the communication campaignin the first phase of the emergency.

Messages about the importance of face washingto reduce incidence of ARI and eye infections(particular among children) were missing amongstthose detailed in phase one of the EarthquakeRelief & Rehabilitation Communication Plan.

RecommendationsConduct rapid pre-testing of messages fordissemination with various stakeholders fromthe affected area to ensure appropriateness.This includes cross-checking with locallanguages (eg no word for ‘sanitation’ in Urdu,‘health and cleanliness is closest approxima-tion’), relevance to diverse populations andcommunity members, and potential effective-ness of messages.

Focus on a limited number of practical, simple,‘do-able’ messages that are context specific inthe impact and emergency phases to ensurerelevance. As more means/services will be inplace in later phases, conducting promotedbehaviours will become more realistic.Consult WHO/national data on seasonaldisease patterns for the affected area, aspart of a rapid assessment and duringimplementation. In an area where the HealthInformation System is not functioningoptimally, or where a large part of it hasbeen disrupted due to the earthquake, asubstitute system needs to be used.

Products

The products distributed were generally found tobe appropriate and relevant in the given context.However, constraining factors in achieving optimalresults were poor product quality and delays inproduct delivery. Additionally, information andskills sharing between IPs and end-users onappropriate product use was inconsistent.

RecommendationsMake instructions for use of products quicklyavailable in all relevant local languages. Alsotake into consideration that a large part of thepopulation is illiterate, so also provide visuals.Set and adhere to minimum quality stan-dards of different products that are locallypurchased and commonly required inemergency response.

Hygiene promotion activities and services

The emphasis given to activities based oninterpersonal contact to disseminate hygiene

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products and promote safe hygiene behaviours, wasregarded a great strength and one of the successesof the Hygiene promotion communication campaign.The various activities of the boy scouts, Rahbersand religious leaders were not only relevant in termsof their familiarity as traditional sources ofinformation, but also in line with a preference forface-to-face interaction as a motivating factor inadopting new behaviours. On the other hand, a keyfactor in success is the ‘repetition rate’ of deliveringthe same message, through different channels.

Cross cutting issues that impacted on the efficiencyof the activities/services include:

insufficient coordination between hub andnational level actors regarding the campaignstrategy and componentsminimal involvement of IPs in WES ClusterHub Coordination meetings anddelays in processing time of project coopera-tion agreements and payments.

The above led to delays in implementation andmay indicate disconnect between local and nationalprogramme operations, hampering realisation ofthe campaign’s potential for greater effectiveness.Even at the local level, a lack of coordinationbetween other ongoing local activities and theactivities of PBSA meant that promising initiativessuch as the Rahber programme were not assuccessful as they could have been.

RecommendationsBaseline information gathering to identifyneeds and existing practices of end users,including appropriate personal hygieneproducts in the given context (by gender,culture, ethnicity, etc). Consider facilitating thedevelopment of a simplified method,

fundamentally based on PHAST, which can beused by various organisations to determineessential baseline information in the earlyphases of an emergency response. Emphasiseand create greater programme coherency interms of provision of corresponding software(hygiene awareness raising) and hardware(provision of supplies and facilities to conducthygienic behaviours) simultaneously.As UN Cluster Head for WES, advocate forintegrated programming; where hygiene,sanitation and water go together, carried outthrough a public health lens.Build in, and observe agreed time frames formonitoring, reporting, evaluation and paymentfor IPs in project cooperation agreements.Ensure the timely provision of agreedsupport in LoU and MoU such as identifyingexperts, defining programming topics andsupplying technical equipment.Revise monitoring protocols and formats foremergency WES-related activities imple-mented by IPs. The protocol and formatsshould include qualitative feedback from IPs(and beneficiaries) about project impacts,effectiveness, etc.

Channels

Among the most relevant, appropriate and effectivechannels for communicating hygiene messages inthe aftermath of the South Asia earthquake were(FM) radio, interpersonal communication andentertainment events. People could access thesechannels because they were available throughdistributed products (though radios were ofquestionable quality), various face-to-faceinitiatives and through events organised for differentgroups in camps at various times.

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Newspapers and television were less relevant andappropriate in the immediate aftermath of theearthquake, as the affected areas did not havemuch access to newspapers.

RecommendationsTo reach more and different populationgroups, radio (and television) programmingshould be conducted in other relevant locallanguages in addition to Urdu.Involve existing informal institutions – egreligious leaders, village heads, land ownersand teachers – as quickly as possible and ina coherent manner as they potentially serveas important information channels. Stronglinks with informal institutions in communitiesare needed, also in non-emergency times.Maintain emphasis on interpersonal communi-cation activities and face-to-face outreach toaccess difficult to reach groups; eg remote,dispersed, handicapped.Use hygiene products as channels by clearlydisplaying hygiene promotion messages onthe products distributed. Names and/or logosof agencies are often printed on materials ofall types.

An under-used channel is that of massdistribution itself. Mass distributions oftentarget all registered households, hencepresent an opportunity to disseminate acertain message or to conduct a rapid‘baseline’ assessment.Avoid limiting the radio programmingconcepts in the MoU with IPs. Clauses inMoUs prevented promotion of messages inprogrammes funded by other donors, asthough UNICEF wanted to have the exclusiverights to the concept and/or channel. Instead,the concept should be further developed, asmany radio channels as possible should beencouraged to buy in.Monitor the use of audio, visual and digitalchannels and integrate this into projectcooperation agreements.Explore the use of AM radio frequency, whichhas greater reach in remote areas, providedthat the radios distributed are of reasonablequality to avoid wasting funding on non-functioning supplies, and help avoid frustra-tion among survivors and emergency reliefworkers.

ReferencesAhmad T et al (2006) WatSan response to earthquake in Pakistan, Paper presented at the 32nd WEDC Conference, Colombo, Sri Lanka,13-17 November 2006GOP (2006) Pakistan Social and Living Standards Measurement Survey (PSLM) 2004-05, Federal Bureau of Statistics, Statistics Division.Islamabad, February 2006 http://www.statpak.gov.pk/depts/fbs/statistics/pslm0405_district/pslm0405_district.htmlInternews Network (2006) Creating waves, literallyhttp://www.internews.org/pubs/humanitarian/20061029_thenews_rehmat.shtm, November 29, 2006MOH/UNIC (2005) Report on Earthquake Relief & Rehabilitation Health Education and Communication Campaign, Islamabad, Pakistan, Nov- Dec 2005MOH Pakistan and WHO (2006) The Weekly Morbidity and Mortality Report (WMMR), Epidemiological Week N01 (31 December 2005 - 06January 2006), 10 January 06, Vol. 7, No. DEWS-7PBSA (2006) Rahber Health Education and Programme Communication, Unpublished Report February - March 2006PBSA (2006) Health Education and Programme Communication on Health, Hygiene, Sanitation, Unpublished Bi-Monthly ReportUNICEF (2005) Earthquake Relief & Rehabilitation Communication Plan 2005-2006: Phase I

DisclaimerThe views expressed in this paper are solely personal views of the authors and do not necessarily reflect the views of IRC Netherlands/NWDA nor UNICEF Pakistan.