Integrating Communication for Development within Malaria Programming to Control Malaria’s Impact among Children and Pregnant Women

UNICEF Web-based Orientation Series for Programme and Communication Specialists

Pre-workshop reading for participants

Version of 14 April 2011

Contents

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Preface Abbreviations and acronyms

Chapter 1. Key benefits, issues and challenges of malaria prevention and treatmentMalaria burden and impact

Figure 1. Malaria causes 7 percent of child deaths worldwideMalaria prevention and treatment: Overview and benefitsCurrent prevention methodsCurrent treatment methodsNew tools and directions for malaria controlOverview: Key issues and challenges of malaria prevention and treatment

Figure 2. Households (%) that own at least one insecticide-treated net, African region, 2005−09 Key issues and challenges: Malaria preventionKey issues and challenges: Malaria treatment

Box 1. Vocabulary related to malaria: Northeast Tanzania and Burkina FasoBox 2. Volta Region of Ghana: Gender perspectives in malaria managementBox 3. Malaria and HIV

Integrated, multi-Level programmes can make progressFigure 3. Major increases in use of ITNs for African children under five, early and late 2000sTable 1. Roll Back Malaria communications assessment: Challenges and opportunities identified

Chapter 2. Malaria and communication programming: A shift in approachThe Communication for Development approach

Table 2. Comparison of previous approaches and C4D approachBox 4. Main findings: Distribution of free LLINs during vaccination campaigns in Ghana, Zambia and Togo

The C4D and approach: Changing individual behaviours and social practicesKey elements in a C4D strategyFigure 4. Coordinating across levels to effect change

Chapter 3. C4D in action: Distribution campaign for insecticide-treated nets in Okavango Sub-District of Botswana

Chapter 4. Malaria: Integrating C4D into programme planningAssessmentAnalysis

Box 5. Making sure recommended behaviour is feasibleDesign of communication strategy

Table 3. Sample of programme and behaviour objectives for malaria control, based on C4D valuesBox 6. Key messages about malaria: What every family and community has a right to knowPre-testing messages, materials and communication channelsBox 7. Home treatment kits: Process and lessons learned in TanzaniaCommunication tips for malaria prevention and treatment Box 8. Fitting communication channels to participants and messages

Chapter 5. Malaria: Incorporating C4D into programme evaluationOutcomes and impact

Table 4. Shifts in measurement of outcomes and impactBox 9. Effects of civil unrest on malaria control in Madagascar

Answering the central questionBehavioural monitoringFigure 5. Monitoring C4D results

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Chapter 6. Maintaining change through social transformationBuilding in sustainability

Keeping partners and participants engagedMaking changes commonplace

AnnexesAnnex I. Distribution campaign for insecticide-treated nets in the Okavango Sub-District of Botswana Annex II. Community capacity development and malaria in Mozambique: A participatory approachAnnex III. Social and behaviour change communication for the prevention of malaria in Madagascar

Resources

References

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Preface

Malaria control (prevention and treatment) was chosen as the subject of this module because of its large impact on children, especially but not exclusively in Africa, because malaria-related indicators are monitored by all malaria-endemic countries and because it is relevant to nearly all the Millennium Development Goals. The module on Integrating Communication for Development within Malaria Programming to Decrease Incidence Rates among Children and Pregnant Women consists of this manual and a Web-based orientation programme. Participants should read this manual before they take the Web-based workshop and have it with them during the workshop. Together, these two parts of the module provide an introduction to:

• Key issues and challenges of malaria prevention and treatment,• The shift to a Communication for Development (C4D) strategy integrated with other malaria control

programme activities,• Key aspects of incorporating a C4D approach into malaria programming to reduce incidence rates among

the two most vulnerable populations (children and pregnant women) and• Why both community empowerment and social transformation are necessary to achieve and sustain

improvements in malaria control.

“Social transformation” is an evolving term. Current understanding in UNICEF is that social transformation is the outcome we hope to achieve when systems, policies, institutions, services, supplies, human resources are in place and people in society at all levels initiate and participate in sustained actions that address positive behaviors – knowledge, attitudes and practices – that would ultimately transform into social norms, and other key factors that cumulatively promote good individual and social practices, such as those related to malaria prevention, treatment and control and, many other behaviours that are in the best interests of the child.

The module contains information that decision-makers in Ministries of Health and other national-level offices, funding agencies and development organizations, as well as UNICEF staff, will find helpful in designing policies and programmes to reduce the toll of malaria—incidence, morbidity and mortality—especially among children and pregnant women.

In addition to background information about the subject, the module presents lessons learned, the “dos and don’ts” from programmes that have made significant progress in reducing malaria rates and associated human and social costs, as well as lessons from less successful efforts.

At the end of this workshop, participants will:• Be able to discuss key benefits of core malaria prevention and treatment approaches as well as key issues

and obstacles on these areas,• Understand the shift to the C4D approach, • Know the major elements of interventions to decrease incidence, morbidity and mortality of malaria—

especially among children and pregnant women,• Be able to discuss how to integrate C4D principles into major elements of the programme and• Understand why both individual and community empowerment and social transformation are necessary

to achieve and sustain improvements in malaria prevention and treatment practices.

Abbreviations and acronyms

ACTs artemisinin-based combination therapiesALMA African Leaders Malaria AllianceBI Bamako InitiativeC4D Communication for DevelopmentEPI Expanded Programme on ImmunizationIMNCI Integrated Management of Neonatal and Childhood Illness

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IPTi intermittent preventive treatment (of malaria) for infantsIPTp intermittent preventive treatment (of malaria) for pregnant womenIRS indoor residual sprayingITNs insecticide-treated netsLLINs long-lasting insecticide-treated netsM&E monitoring and evaluationMCH Maternal and Child HealthMDGs Millennium Development GoalsMVI Malaria Vaccine InitiativePMI President’s Malaria InitiativeRBM Roll Back MalariaRDTs rapid diagnostic testsSP sulfodoxine-pyrimethamineWHO World Health Organization

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Integrating Communication for Development within Malaria Programming to Control Malaria’s Impact among Children and

Pregnant Women

“Participatory communication in malaria control matters because without genuine community understanding and engagement with the problem of malaria, external efforts will fail….”

—Alison Dunn, Exchange/Healthlink Worldwide1

Chapter 1. Key benefits, issues and challenges of malaria prevention and treatment

Malaria burden and impact

Malaria is an ancient infection that remains a debilitating and deadly disease. In a few short years, international focus on malaria has reduced its estimated annual toll from 350 million to 250 million cases and from 1 million to 850,000 deaths.2 Although this trend is encouraging, the global burden of malaria is still unacceptable for a disease that can be prevented and treated effectively. Its heaviest impact is in developing countries, and children and pregnant women are at highest risk of infection.

Today somewhere in the world, malaria kills a child every 45 seconds. The disease accounts for 7 percent of all under-five childhood deaths globally (Figure 1), but this burden is not equally distributed. The majority of these deaths—89 percent—are in Africa, where malaria kills roughly one in six young children (16 percent).3,4 Malaria also contributes greatly to anaemia among children, a major cause of poor growth and development. When pregnant women contract malaria, it can cause severe anaemia and other serious conditions, which can lead to maternal deaths and low birthweight in their newborns, a major risk factor for infant mortality and suboptimal growth and development. Malaria prevention and treatment are among key interventions for child survival and well-being, as reported in Facts for Life, which “aims to provide families and communities with the information they need to save and improve the lives of children.”5

As reported by the World Health Organization (WHO), malaria accounts for 7 percent of child deaths worldwide (see Figure 1)—the third leading killer of children. Such a disproportionate toll on the very young makes control and prevention of this very severe illness a fundamental children’s rights issue, essential to achieving the right of all children to survive and thrive. Its disproportionate impact in developing countries, especially sub-Saharan Africa, makes it a social justice issue as well.

“Many lives can be saved by preventing malaria and treating it early. Children and their family members have the right to quality health care for prompt and effective treatment and malaria prevention.” –Facts for Life6

1 Dunn, Alison, ‘Participatory communication in malaria control: Why does it matter?’ Findings, 2005;4:1-6.2 Roll Back Malaria, World Malaria Report 2005 and World Malaria Report 2009.3 WHO, World Malaria Report 2009.4 WHO, The global burden of disease: 2004 update.5 UNICEF, WHO, UNESCO, UNFPA, UNDP, UNAIDS, WFP and the World Bank, Facts for Life, April 2010. (available at: http://www.unicef.org/publications/index_53254.html)6 Ibid.

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Figure 1. Malaria causes 7 percent of child deaths worldwide

Sources: WHO, World Malaria Report 2009; WHO, The global burden of disease: 2004 update.

An estimated 1 billion people are at risk for malaria in India, the largest number outside Africa. Throughout Southeast Asia, a number of countries have substantial populations at risk for malaria; these include Timor-Leste, Nepal, Bhutan, Thailand, Indonesia and Myanmar. A number of countries in the Americas and Europe—Brazil, Haiti, Kyrgyzstan, Tajikistan and Azerbaijan, among others—also have populations at risk. Outside the African Region, effective coverage with interventions is more difficult to measure for several reasons:

• First, the target population for each intervention (treatment, indoor residual spraying, insecticide-treated nets) may be different within a country and is not standard for all countries, and many interventions such as indoor spraying and treated bed nets are often targeted to hard-to-reach or mobile populations that are most at risk (e.g., migrants, workers in mining and forest areas).

• Second, surveys are less useful in areas with focalized malaria and are conducted less often. As many countries approach the point of eliminating malaria, however, they are also more likely to undertake

active case detection and thus to measure their malaria burden more closely.

Beyond the suffering it brings to individuals and families, malaria has serious economic impacts in developing countries and perpetuates the cycle of poverty. Sickness keeps children from school and parents from work; malaria mortality in parents burdens households and communities. In malaria-endemic areas in Africa, malaria consumes more than 25 percent of family income7 and approximately 40 percent of public health expenditures.8 As incidence and mortality rates drop with more widespread and successful malaria control campaigns, those resources can be used for other pressing family and national needs. For example, dramatic declines in the number of malaria patients in Tanzania and Zambia allowed medical staff and facilities—previously overburdened by malaria care—to tackle other life-threatening illnesses.

“It is estimated that a rapid and widespread scale-up of malaria interventions in Africa would increase economic output by up to $30 billion and prevent 672 million malaria cases over a five-year period.”

–Roll Back Malaria9

7 Roll Back Malaria, ‘Zambezi expedition: Questions and answers on malaria’. (available at: http://rbm.who.int/worldmalariaday2008/docs/zambezi_QAmalaria.pdf)8 President’s Malaria Initiative, Working with communities to save lives in Africa, Third Annual Report, March 2009.9

Roll Back Malaria, ‘Global Health and Business Leaders announce 36-month effort to expand malaria control in Africa; 3.5 million lives could be saved in five years, study finds’, press release, 25 January 2008. (available at: http://rbm.who.int/globaladvocacy/pr2008-01-25.html)

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There are six species of malarial parasites that infect people, but two are responsible for the most illness and death: Plasmodium falciparum is the most lethal type, and P. vivax is the most common cause of recurring malaria. One type or the other is usually the primary agent in areas where the malaria burden is intense. P. falciparum is prevalent in sub-Saharan Africa, South and Southeastern Asia, Oceania and Haiti. In India, the Middle East and Central America, P. vivax is the dominant infection. In many places such as Ethiopia, mixed-malaria infections (co-infection with more than one species of Plasmodium, particularly P. falciparum and P. vivax) are possible.10

Efforts to map the risk of malaria in Africa (and elsewhere) undergo periodic refinement,11,12 particularly as disease patterns change, for example, from:

• Development of drug resistance among the Plasmodium parasites; • Development of resistance to commonly used insecticides by mosquitoes; • Global climate change that extends the range of mosquito-friendly environments; and • Entry of non-immune populations to highly malaria-endemic areas (e.g., refugee flows).13

Mapping Malaria Risk in Africa/Atlas du Risque de la Malaria en Afrique has developed maps of endemic areas, which are available through the organization (e.g., at http://www.mara.org.za/mapsinfo.htm and http://healthcybermap.org/HGeo/mara_arma.htm).

Malaria prevention and treatment: Overview and benefits

The tools that are now available can effectively prevent and cure malaria. Malaria control and prevention will make a major contribution to several Millennium Development Goals (MDGs), chiefly goals 4 and 6. The MDG 4 target is to reduce the mortality rate among children under five by two-thirds by 2015 (indicators 4.1 and 4.2 deal with under-five and infant mortality rates). The MDG 6 target is to have halted and begun to reverse the incidence of malaria and other diseases by 2015 (indicators 6.6, 6.7 and 6.8 deal with malaria incidence and death rates, proportion of under-five children sleeping under insecticide-treated nets and with fever treated with appropriate anti-malarial drugs, respectively). Additionally, maternal mortality (MDG 5), school attendance (MDG 2) and poverty (MDG 1) are affected by malaria.

In 2000 the Abuja Declaration reconfirmed an international commitment to reduce the toll of malaria. Forty-four of Africa’s 50 malaria-affected countries attended the conference in Abuja, Nigeria, and all signed the Declaration. In doing so, they pledged to undertake several actions. One was to catalyze efforts at regional levels to ensure implementation, monitoring and management of the goals set by Roll Back Malaria (RBM), an alliance of more than 90 organizations including UNICEF, WHO and the World Bank, which was created in 1998.14

To meet RBM objectives, these countries agreed to take “appropriate and sustainable action” to strengthen health systems to ensure that

• At least 60 percent of people with malaria have access to, and can correctly use, affordable and appropriate treatment within 24 hours of onset of malaria symptoms

10 ‘New estimates of the global population at risk of Plasmodium vivax malaria’, Science Daily, 4 August 2010. (available at: http://www.sciencedaily.com/releases/2010/08/100803174854.htm)11 Snow, Robert W., et al., ‘The Public Health Burden of Plasmodium falciparum malaria in Africa: Deriving the numbers’, Disease Control Priorities Project, Working Paper No. 11, Bethesda, Maryland: Fogarty International Center, National Institutes of Health. August 2003. 12 ‘Most Detailed Malaria Map Ever Highlights Hope And Challenges Facing Global Community’, Science Daily, March 30, 2009. (available at: http://www.sciencedaily.com/releases/2009/03/090323211913.htm)13 Mahmoud, Zainab, ‘Malaria control and prevention: A global perspective’. (available at: http://www.cwru.edu/med/epidbio/mphp439/Malaria_Control.pdf)14 The Abuja Declaration: The African Summit on Roll Back Malaria, held in Abuja, Nigeria, 25 April 2000. (available at: http://www.rollbackmalaria.org/docs/abuja_declaration.pdf)

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• At least 60 percent of at-risk groups, especially children less than five and pregnant women, benefit from “the most suitable combination of personal and community protective measures” such as insecticide-treated nets

• At least 60 percent of at-risk pregnant women, especially those in their first pregnancies, have access to preventive drugs

Since the Abuja Declaration in 2000, international aid and development organizations, in concert with Roll Back Malaria and its public- and private-sector partners, have stepped up malaria control activities in many African countries. These efforts have reduced incidence and mortality, but more work is needed to ensure full coverage of children and pregnant women in endemic regions for prevention and treatment measures.

After the UN Secretary General in 2008 called for “universal coverage” with all malaria interventions by 31 December 2010, the African Leaders Malaria Alliance (ALMA), created in 2009 by 30 African heads of state, committed to a focus on five areas:15

• Aggressively promoting universal coverage with effective interventions,• Securing sustainable funding for malaria control,• Promoting the removal of taxes and tariffs on anti-malarial commodities and• Achieving support for production of anti-malaria commodities by African manufacturers.

The original RBM goals have therefore been superseded, and there is now a “Global Malaria Action Plan” to ensure that countries are supported to achieve universal coverage and put them firmly on the road to the attainment of the Millennium Development Goals by 2015.

Current prevention methods

“The long-lasting insecticide net is seen as offering African countries the best chance in malaria prevention. Not only is it cheaper in the longer term, but it comes factory pre-treated and retains its repellent efficacy throughout the normal lifespan of the netting material itself, which can be anywhere between two to five years.”

–UNICEF, 2004 16

Insecticide-treated nets (ITNs) kill mosquitoes and provide a physical barrier between humans and the mosquito, which is provided by a conventional untreated net. Scientifically controlled trials have confirmed the much greater efficacy of ITNs. The large-scale use of ITNs markedly decreased the numbers of mosquitoes present in homes where ITNs had been hung, thereby markedly decreasing the transmission of malaria and markedly improving child survival.17 There is evidence that when ITNs are used consistently and correctly, they can save six child lives per year for every 1,000 children who sleep under them.18 The key is correct and consistent use. Nets need to be used nightly wherever people sleep (including outside, during the dry, planting and/or harvest seasons) and tucked in securely under a sleeping mat to keep mosquitoes out.

Large-scale use of ITNs also benefits households where nets are not hung. When a large proportion of the community uses ITNs, non-users who live near ITN-using households have lower rates of infection. This effect is mostly due to the high local concentration of insecticide caused by those who are using their nets, which has a repellent as well as a mosquito-killing effect that significantly reduces the local population of parasite-carrying mosquitoes.19 This effect is usually noted where at least 60 percent of the community uses effective ITNs every night.

15 Phumaphi, Joy, “With concerted efforts and policies, we can stop malaria deaths’, 9 August 2010. (available at: http://allafrica.com/stories/201008100192.html)16 UNICEF, ‘Call for increased production of long lasting insecticidal nets for malaria control’, press release, 23 September 2004. (available at: http://www.unicef.org/media/media_23447.html)17 Roll Back Malaria, World Malaria Day 2010: Africa update.18 UNICEF, ‘Malaria: How does UNICEF help?’ (available at: http://www.unicef.org/health/index_malaria.html)19 Roll Back Malaria, World Malaria Day 2010: Africa update.

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High cost and low supply have often been barriers to significantly increasing access by all to ITNs, and many groups have been working assiduously to address both obstacles. From 2004 to 2009, worldwide production of ITNs grew from 30 million to 150 million,20 and during 2007−09, according to manufacturer data, almost 200 million ITNs, most of them long-lasting insecticide-treated nets (LLINs), were delivered to African countries through various channels—enough to cover more than half the at-risk populations where malaria is endemic.21 An estimated 350 million are needed for universal coverage in Africa. By the last quarter of 2010, financing was being sought for only 25 million LLINs in order to reach universal coverage with nets by the end of 2010 and meet part of the UN Secretary General’s call to action.

The most common type of net provided, especially in Africa, is the long-lasting insecticide-treated net, and most ITNs are now of this type.22 Previously ITNs required re-treatment at regular intervals to maintain the benefits provided. This presented another barrier: when ITN users are expected to buy the insecticide themselves and remember to re-treat nets (which must be done at regular intervals), re-treatment rates are low. To circumvent the problem of re-treatment, manufacturers developed the LLIN which lasts on average of about three years or 20 conventional washes. The cost of this type of net is about $10, which includes purchase of the net, transport to countries, distribution within countries, teaching communities how to hang and care for their nets and monitoring use. RBM expects that as demand for LLINs continues to increase, competition and economies of scale will continue to improve the performance of these products and reduce prices.23 (Note: In this manual, the term ‘ITN’ is used as a blanket term for all insecticide-treated nets but mostly refers to LLINs. Although some ITNs that require re-treatment are still in use, most have been replaced by LLINs, which have been widely distributed.)

“I am delighted with my … net because it is treated with long lasting insecticide. My old net had to be re-treated and there was a chance I could miss a stage in the treatment process. No one in my family has had malaria since I received my new net.” −Mercy Matemba, who received a free net after giving birth to her second child at a Malawi government clinic 24

Indoor residual spraying (IRS) is another insecticide-based prevention tool. With IRS, long-lasting insecticide is applied to indoor walls where people sleep. IRS has been the centerpiece of successful anti-malaria campaigns because it can rapidly and effectively decrease mosquito populations and rapidly reduce malaria transmission. It has the greatest efficacy when it is applied (1) before malaria transmission season, which is annually or twice per year, depending on local conditions and mosquito life cycles, and (2) by trained workers who spray entire communities.25 This prevention method requires a high level of community cooperation to make sure that all houses are sprayed.26 There are also concerns about toxicity because the insecticides used necessarily are highly pervasive.

The high level of human and financial resources required to undertake successful IRS campaigns have tipped the balance in favor of using ITNs as the primary method of prevention rather than residual spraying. Nevertheless, many countries that have the capacity to undertake complete and regular IRS campaigns often use IRS as a complementary approach in specific areas.

A preventive intervention specifically for pregnant women involving intermittent drug treatment is addressed in the next section, ‘Current treatment methods.’

20 UNICEF Supply Division 2010, based on estimates from ITN manufacturers, with 2007−09 data based on estimated production capacity.21 Roll Back Malaria, World Malaria Day 2010: Africa update.22 Roll Back Malaria, World Malaria Day 2010: Africa update, Progress and Impact Series, 2010;2:10.23 Roll Back Malaria, ‘About long lasting insecticidal nets.’ (available at: http://www.rollbackmalaria.org/rbm/Attachment/20041117/rps_Info17-11-2004.pdf)24 USAID, ‘Success story: Treated nets protect vulnerable groups. (available at: http://www.usaid.gov/stories/malawi/ss_mwi_nets.html)25 Roll Back Malaria, World Malaria Day 2010: Africa update.26 Facts for Life: Malaria, 4th edition. (available at: http://www.factsforlifeglobal.org/10/1.html)

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Current treatment methods

With malaria, prompt treatment is vital: More than half of childhood malaria deaths occur within 48 hours.27 Rapid and effective treatment can prevent life-threatening complications.

As with many other diseases, drug resistance has become a clinical issue in malaria treatment. The P. falciparum parasite is resistant to chloroquine, once the most widely used anti-malarial drug, nearly everywhere in the world, and there is increasing evidence of growing resistance to sulphadoxine-pyrimethamine (SP), which replaced chloroquine as first-line treatment for P. falciparum infections. P. vivax has been considered resistant to pyrimethamine for some time but still generally responds well to chloroquine. Drug resistance is a more serious issue with P. falciparum because it accounts for more than 70 percent of malaria cases globally and is the deadliest strain, but spreading resistance in P. vivax is a problem that may worsen and cause greater clinical challenges where that parasite predominates (e.g., India).28

To address this problem, at least 68 countries, under the guidance of WHO, have changed their national treatment protocols to incorporate the new artemisinin-based combination therapies (ACTs),29 which are highly effective against the malaria parasite. By 2008, most African countries had adopted a policy of ACTs as a first- and second- line treatment for malaria. ACTs work quickly and well, but with a full course for an adult averaging $6, cost has often been a barrier. Still, progress has been made: procurement of ACTs increased from 5 million doses in 2004 to 160 million doses in 2009,30 mostly due to increased financing. The challenge now remains to ensure access to ACTs by the most vulnerable populations, namely poor and rural children.

The percentage of children less than five years old who are receiving any anti-malarial drugs for fevers varies dramatically across Africa. At the top and bottom of the scale, eight countries reach more than 50 percent of under-five febrile children with anti-malarial drugs, and eight reach 10 percent or less.31 Surveys conducted since 2007, however, show that relatively small percentages of these children are being treated with an ACT. It is hoped that as ACT supplies become more widely available in endemic areas, and particularly at the community level, these numbers will drastically improve.

“Together with regular use of LLINs, ITPp is key to preventing malaria in pregnant women in malaria-endemic settings.” –Roll Back Malaria32

27 WHO, ‘The Roll Back Malaria strategy for improving access to treatment through home management of malaria’. Geneva, document no. WHO/HTM/MAL/2005.1101.28 Vogel, Gretchen, ‘New map illustrates risk from the ‘other’ malaria’, Science, 2010;329:618.29 UNICEF, ‘Malaria: How does UNICEF help?’30 Roll Back Malaria, ‘Agreed key messages for World Malaria Day 2010.’31 Roll Back Malaria, World Malaria Day 2010: Africa update, Figure 3.2.32 WHO, The Roll Back Malaria strategy.

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It is estimated that at least 10,000 women and 200,000 infants die every year because of complications from malaria during pregnancy and that at least 125 million women in at-risk areas become pregnant every year.33 Intermittent preventive treatment during pregnancy (IPTp) is recommended in highly endemic areas (mostly in Africa). This method crosses prevention and treatment lines, using drug treatment during pregnancy to avert negative health impacts of malaria for the mother and newborn with at least two doses of an anti-malarial drug delivered during the second and third trimesters, whether or not the woman shows signs of malaria. This approach has been shown to be highly effective in preventing maternal anaemia, placental malaria and other effects of malaria during pregnancy such as premature births and low birthweight.34

Sulfadoxine-pyrimethamine is currently indicated as the safe and appropriate drug for preventive treatment during pregnancy.35 The international Making Pregnancy Safer initiative and national antenatal care services have expanded access to high-quality antenatal care and reproductive health services, during which time effective malaria prevention interventions, including IPTp and ITNs, are delivered. In Tanzania, a study to reduce malaria during pregnancy found that knowledge, wealth and age were all independently predictive of ITN use, but only participation in health education at a Maternal and Child Health clinic was associated with use of intermittent preventive treatment with SP.36

New tools and directions for malaria control

Intermittent preventive treatment of malaria in infants (IPTi), a concept similar to IPTp, is under investigation. IPTi is administered as an anti-malarial drug two or three times during the first year of life during visits for routine childhood vaccinations, whether or not the child has malaria. Clinical trials of IPTi have been conducted in Gabon, Ghana, Kenya, Mozambique and Tanzania. UNICEF is implementing IPTi on a pilot basis in Benin, Ghana, Madagascar, Malawi, Mali and Senegal, and WHO is considering recommending IPTi for control of malaria in areas of moderate to high malaria transmission.

The PATH Malaria Vaccine Initiative (MVI) is a global programme established in 1999 to accelerate the development of malaria vaccines and ensure that they are available and accessible in the developing world. MVI’s first focus is on a vaccine for P. falciparum malaria. In Phase II testing, the leading candidate vaccine provided 50 percent protection. Phase III (late-stage) testing of this vaccine, targeted to infants and young children, began in Africa in 2009. In 2010 MVI launched a collaboration to develop a vaccine against P. vivax malaria.

These are promising developments, but widespread availability of vaccines is years away. In the meantime, existing malaria control mechanisms are effective and are increasing their impact. As malaria-intense areas and malaria cases dwindle in number, national and global surveillance will become more important. The year 2010 is a milestone for achieving malaria targets, and many countries have scheduled national surveys for 2009−1137 and bolstered local health information systems to gauge their progress. Malaria intervention programmes in these countries will be able to take advantage of these new resources for planning, monitoring and evaluation activities.

Overview: Key issues and challenges of malaria prevention and treatment

“Many African children with fever taking anti-malarial medicines are treated with drugs obtained at home; less than 60 percent are treated in a health facility. Thus, as countries try to improve malaria treatment and assure that

33 ‘125 million pregnancies globally at risk for malaria every year’, Science Daily, January 26, 2010. (available at: http://www.sciencedaily.com/releases/2010/01/100125202553.htm)34 WHO, The Roll Back Malaria strategy.35 Ibid.36 Nganda, Rhoida, et al., ‘Knowledge of malaria influences the use of insecticide treated nets but not intermittent presumptive treatment by pregnant women in Tanzania’, Malaria Journal, 2004;3:42. (available at: http://www.malariajournal.com/content/3/1/42)37 See Roll Back Malaria, World Malaria Day 2010: Africa update, Figure 5.1, for a map of 26 or so countries that have planned national representative household surveys.

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the recommended first-line treatment [ACTs] is received, they must improve treatment practices both in health facilities and in homes.” –Roll Back Malaria 38

Early anti-malaria efforts targeted prevention through indoor spraying. Current approaches have moved from an emphasis on killing the mechanism of transmission (eradication) to using bed nets and treating infections that occur (control). Control will lead to “elimination” of malaria as a public health problem and can be provided over larger areas with fewer unexpected effects on the environment and the parasite. This strategy is in line with the global recommendations to raise coverage with ITNs and ensure that everyone has access to prompt (early) and effective treatment with combination drug therapy involving an artemisinin-based derivative and a partner drug. As a result, malaria control activities have undergone two important changes: They have been integrated into primary health care systems, and they rely on the participation of communities.39

These changes present both challenges and opportunities. Like malaria itself, ITN coverage and access to appropriate treatment vary greatly across Africa. For example, among the 36 countries listed in Figure 2, ITN coverage now ranges from 4 percent to 62 percent, with nine countries reaching a coverage level of 50 percent or more.

Figure 2. Households (%) that own at least one insecticide-treated net, African region, 2005−09

Source: UNICEF global malaria databases 2010

Figure 2 shows household ownership of some form of treated bed net, but it does not show whether the nets• Are used (they can be too uncomfortable for use in hot and humid climates),• Are used properly and consistently (hung correctly and used every night year-round) or

38 Roll Back Malaria, World Malaria Day 2010: Africa update, p. 29.39 Dunn, Alison, 2005.

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• Are used by the most vulnerable household members (young children and pregnant women rather than husbands and respected elders).

For the nets to have an impact, they must be used, and used correctly. To have maximum impact, they must be used by household members at highest risk. These actions require specific knowledge: why nets work, why it is important to use them every night, why young children and pregnant women should have first claim on them, how to attach them and tuck them in and how to clean them. Finally, that knowledge must trigger specific behaviours in use and care of ITNs.

Similarly, malaria diagnosis and treatment still present many challenges. Because malaria shares symptoms with common illnesses such as the flu and upper respiratory infections, as well as a whole-host of other fever-creating illnesses, accurate diagnosis requires a thick blood smear, which is read on a microscope by a trained technician, or a rapid diagnostic test (see ‘Drug resistance’ section in this chapter). Typical symptoms include slight fever and chills, headache, muscle and joint pain, nausea and vomiting and anaemia; symptoms usually appear 10 to 15 days after a bite from an infected mosquito. When malaria is severe, it can cause enlargement of the spleen and liver, kidney failure and cerebral ischemia leading to coma. Unfortunately, too often malaria is misdiagnosed or treated as a common fever. Diagnosis for every suspected case, of all ages, is now the global recommendation.

“The biggest challenge is to find a way to make people understand that they need to treat the disease malaria, not just a fever.” —Alison Dunn40

What parents do when they think a child has malaria can depend on whether the community perceives malaria as a major childhood problem.41 In Africa as in most of the world, mothers are chiefly responsible for care of sickness in the family, and fevers are fairly commonplace. The challenge is to engage mothers so they will know what to look for when they make decisions about treating symptoms at home, understanding that many will choose to seek care from traditional remedies and healers before they approach a health care facility.

Community-based management of malaria is an important strategy to improve prompt delivery of effective malaria treatment in Africa.42 With this approach, trained community members distribute easy-to-use, prepackaged anti-malaria drugs so that febrile children can be treated within the community, preferably at home. When mothers in an Ethiopian community acted as coordinators to recognize and treat malaria, there was a three-fold decline in malaria-related mortality and a 40-percent drop in all-cause childhood mortality.43 On Kenya’s remote eastern coast, a programme that relied on community health workers to ensure effective treatment at home showed improved access to ACTs.44

Cost, supply and access are central issues in malaria prevention and treatment. ACTs are now the favored front-line treatment for malaria, but chloroquine, SP, artemisinin monotherapies (which puts increased pressure on the parasite to develop resistance) and other drugs are still in common use.45 Other challenges to outreach activities for malaria control include local practices, beliefs and traditions; socioeconomic factors, including gender issues; drug resistance; early and accurate diagnosis; and malaria and HIV (see Box 3).

40 Dunn, Alison, 2005.41 Munguti, K.J., ‘Community perceptions and treatment seeking for malaria in Baringo district, Kenya: Iimplications for disease control’. East African Medical Journal, 1998;75:687–91.42 Pagnoni, Franco, ‘Incentives for medicine distributors in home-based management of malaria programmes: An overview of TDR experiences’, Bulletin von Medicus Mundi Schweiz, April 2009;112.43 Kidane, Gebreyesus, and Morrow, Richard, ‘Teaching mothers to provide home treatment of malaria in Tigray, Ethiopia: A randomized trial’, Lancet, 2000;356:550−55.44 International Federation of Red Cross and Red Crescent Societies, ‘The winning formula to beat malaria’, in World Malaria Day report, 2nd edition, April 2010.45 Roll Back Malaria, World Malaria Day 2010: Africa update, Figure 3.3.

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“…many malaria cases do not present promptly and many infected people may seek care outside of formal health structures. This means that programmes must examine opportunities to identify and treat malaria cases in the variety of places where they present.” –Roll Back Malaria46

Key issues and challenges: Malaria prevention

Local practices, beliefs and traditions. Distributing ITNs to at-risk households is only the first step in a net-based prevention campaign. Even if people have a bed net, they are not likely to use it unless they believe it is an effective tool to protect them from malaria. For that, they must understand the connection between mosquitoes and malaria. Many communities demonstrate a lack of knowledge on this point, citing causes of malaria such as bathing in the river, lack of sanitation, sunrise, contagion (transmission from one person to another), ibou birds (nocturnal birds generally seen only during night-time hours when mosquitoes bite most often) and “impure water.”47,48,49

When nets are not valued, they are likely to be sold for funds to buy items of higher perceived benefit, discarded or turned to some other use. (Bed nets have been used as wedding dresses, fishing nets, curtains and water filters.50) If people are still awake and away from their bed nets at times when mosquitoes are most likely to bite (dusk to dawn/sunset to sunrise), the nets will have limited benefit. Some communities give men and the elderly preference for ITN use, and many people still tend to use bed nets only during the rainy season and not year-round—including the dry season—as recommended.

Interventions often make only limited efforts to integrate home remedies with ITN use, which conveys respect for local cultures. In some communities in Ghana, for example, people prefer to protect themselves from mosquito nuisance by burning coils and herbs and other methods. Showing respect for these methods and helping community members integrate them with ITN use may facilitate adoption of both prevention and treatment methods.51

46 Roll Back Malaria, World Malaria Day 2010: Africa update, p. 11.47 Okrah, Jane, et al., ‘Community factors associated with malaria prevention by mosquito nets: An exploratory study in ruralBurkina Faso’, Trop Med Int Health, 2002;7(3):240−48.48 Agu, A.P., and Nwojiji, J.O., ‘Childhood malaria: Mothers' perception and treatment seeking behaviour in a community in Ebonyi State, South East Nigeria’, Journal of Community Medicine and Primary Health Care, 2005;17(1):45−50.49 Schiavo, Renata, ‘The Marketing and Distribution of Insecticide-Treated Mosquito Nets in Angola – A National Program’, 4 May 2000. UNICEF, National Malaria Control Programme, Luanda, Angola.50 Bean, J., ‘Can we roll back malaria?’ The Health Exchange, December 2001. [cited in Dunn, Alison, 2005.]51 Ahorlu, Collins K., et al., ‘Malaria-related beliefs and behaviour in southern Ghana: implications for treatment, prevention and control’, Tropical Medicine & International Health, 1997; 2(5):488−98.

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Socioeconomic factors. Cost is always a factor for poorer households, in purchase or replacement of a bed net. For ITNs, re-treatment presents issues of cost plus access to insecticide and training in proper re-treatment methods.

Cultural Issues. Many users cite heat, airlessness and difficulties in hanging the nets as reasons not to use them. These perceived barriers (temperatures inside and outside the net are often the same) can be overcome with social mobilization. Many will prefer to use a net when they realize that it will also prevent other nuisance insects from biting or landing on sleeping areas, in addition to malaria-prevention benefits.

Care of LLINs. Nets must be properly cared for. LLINs are effective for 20 standard washes, and after washing, they must be properly dried and re-hung. Any holes that appear in the net must be mended, or mosquitoes can fly through those openings. Because the insecticide is highly active when the net is removed from the protective packaging, recipients must be carefully instructed to “air” the net for a short time before they hang it for use, to prevent any possible reactions from direct skin contact with the net.

Indoor residual spraying. Sprayers must be allowed into all houses to spray all indoor surfaces; this can cause problems if a woman is home alone and will not allow a strange man into the house. Also all household effects, particularly food, must be removed from the home to make sure that none of the insecticide can settle on their surfaces. These inconveniences must be carefully managed through communication to ensure that all households in an area are protected.

Key issues and challenges: Malaria treatment

Local practices, beliefs and traditions. Communities have traditional perceptions about what causes disease and how to deal with it. Some illnesses are considered appropriate for Western medicine; others are seen as the domain of traditional healers (see Box 1).52 The many names for malaria and its stages and symptoms (e.g., paludism in Angola, asra or atridi in Ghana), some of which appear in Box 1, further complicate communications.

Box 1. Vocabulary related to malaria: Northeast Tanzania and Burkina Faso

A study in northeast Tanzania found that the following Kiswahili terms are used, and some have specific associated beliefs and actions:53

• Homa is any febrile illness, joto kali is high fever and homa kali includes strong febrile illness sometimes with vomiting, diarrhoea and/or convulsions.• Mchango is illness with convulsions that has or starts with kustuka, which means startled, frightened or shocked. Mchango is feared because without treatment, it may develop into kifafa, grand mal seizures, but this can be avoided by herbal prevention and treatment given during symptoms and at each following new moon, as tea, baths and fumigations of mother and child. • Kulegea means weakened body, becoming soft like an overripe fruit, and is often accompanied by vomiting and diarrhoea. When breast-milk is vomited or refused, the milk is considered bewitched by a person with evil eyes—a feared form of witchcraft called zongo, which is also the name of the illness. Because speaking about the dreaded zongo is a matter of trust, and it took time for the investigator to understand and adapt information to this concept.

A study in rural Burkina Faso found that local disease categories affected both treatment and provider choice.54 In Dioula, the local language spoken and understood by the majority of the population, there are four main concepts

52 Nchinda, Thomas C., ‘Malaria: A reemerging disease in Africa’. Emerging Infectious Diseases, 1998;4(3).53 Winch, P.J., et al., ‘ Local terminology for febrile illnesses in Bagamoyo district, Tanzania and its impact on the design of a community-based malaria control programme’, Social Science and Medicine, 1996;42:1057–67.54 Beiersmann, Claudia, et al., ‘Malaria in rural Burkina Faso: local illness concepts, patterns of traditional treatment and influence on health-seeking behaviour’, Malaria Journal, 2007;6:106.

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related to malaria:• Sumaya is uncomplicated malaria, • Dusukunyelema is respiratory distress syndrome, • Kono is cerebral malaria and • Djoliban is severe anaemia.

Although sumaya is usually treated by a combination of traditional and modern methods, dusukunyelema and kono are preferably treated by traditional healers, and djoliban is preferably treated in modern health facilities. The researchers concluded that local concepts of illness strongly influence treatment and choice of provider and need to be considered when malaria control programmes are developed.

Limited or no inclusion of local cultures, home treatment and drug shops in malaria control strategies leads to reduced effectiveness of interventions and missed opportunities to widen impact. “Malaria control policies should recognize the role of home treatment and drug shops in the management of malaria and incorporate them into existing control strategies”55 so that communities will become engaged and able to discern the benefits of ACTs over the remedies they have been using for milder illnesses. It is also important to recognize the role of the private sector, because in many countries, up to 60 percent of the population seeks care outside the public health sector, if they seek care at all.

Local opinion leaders, gender roles and relationships, access to health care and attitudes toward health care providers also influence the way people treat fevers, the principal early sign of malaria.56

Socioeconomic conditions, status and gender. The people who have the highest risk for malaria infection—poor and rural populations—are also the hardest to reach. Connecting with them across cultural barriers and physical distances presents challenges. For ITNs, cost is an issue for individual households and a resource constraint to large-scale subsidy programmes. Nevertheless, equitable distribution of ITNs is necessary to achieve coverage targets. Some countries have done an impressive job in this area primarily because they have had widespread campaigns to distribute free nets in regions of high malaria transmission, and in the meantime, complement campaigns with distributions during routine visits for antenatal care Expanded Programme on Immunization.57

In Nigeria, a study of treatment-related socioeconomic differences in behaviours under the Bamako Initiative (BI) found that community members used private and public health care facilities equally for the treatment of malaria and that self-diagnosis and self-treatment for malaria was common but practiced more by the poorer households. The least poor groups were more likely to seek treatment at BI health centers, hospitals and private clinics and to use laboratory procedures. They also used patent medicine dealers and community health workers less often for both diagnosis and treatment. Factors that encouraged people to use services in BI health centers include availability of good services, proximity to the homes and polite health workers.58 That formula highlights the issues of supply, access and training.

Low suspicion and recognition of signs and symptoms of malaria among mothers and other family members contribute to delays in seeking treatment when it can save lives. In too many communities, families rely on home treatment and over-the-counter drugs to treat only the fever. The involvement of community leaders and health workers can help bridge the gap in knowledge (and related behaviours) created by different socioeconomic conditions. For example, easy-to-understand information about prevention and treatment, delivered by trained

55 Ahorlu, Collins K., et al., ‘Effectiveness of combined intermittent preventive treatment for children and timely home treatment for malaria control’, Malaria Journal, 2009;8:292.56 Dunn, Alison, 2005.57 Roll Back Malaria, World Malaria Day 2010: Africa update.58 Uzochukwu, Benjamin and Onwujekwe, Obinna, ‘Socio-economic differences and health seeking behaviour for the diagnosis and treatment of malaria: A case study of four local government areas operating the Bamako initiative programme in south-east Nigeria’, Int J Equity Health, 2004;3(6)

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people and trusted channels, can induce the desired behaviour. In Uganda, when people received clear instructions and advice from a health care worker, 90 percent of them complied with the right treatment.59 And survey data highlight the impact of household visits by community volunteers: net use is generally 10 to 23 percentage points higher in households visited by a volunteer than in those that were not visited (e.g., 22 percent in Sierra Leone, 2007 survey; 23 percent in Togo, 2009 survey).60

Gender issues also influence care-seeking behaviours (see Box 2). The Malaria Knowledge Programme found that women’s treatment-seeking behaviour for children with malaria is significantly influenced by their access to resources and health services and their bargaining power within the household.61

Box 2. Volta region of Ghana: Gender perspectives in malaria management62

In 2000, the Malaria Knowledge Programme helped district-level government workers in Ghana’s Volta Region to explore the influence of gender on how parents and caregivers seek treatment for children with malaria. It found that behaviour is influenced at the household level by the social and economic power of women and men at different levels of seniority. Women who lacked short-term or long-term economic support from relatives or disagreed with their husbands or family elders faced difficulties in accessing appropriate treatment for children with malaria.

The majority of people in the study used herbal or traditional treatment or drugs bought from local sellers (rarely in correct dosages) as a first step in treating fever in children. Reasons given for not using formal facilities included non-availability of services, lack of cash for transport to facilities and for treatment, long waiting times, negative attitudes of providers and the perceived efficacy of herbal and home treatment.

Drug resistance. Malaria parasites can rapidly develop resistance to anti-malarial drugs, and drug resistance patterns are constantly changing. WHO recommends artemisinin-based combinations, which are highly effective in curing malaria when both drugs are taken as directed. The combination involves an artemisinin-based therapy along with a partner drug. These can be co-formulated (both drugs are contained in a single pill) or co-blistered (the two drugs are provided in separate tablets in single pack). Artemisinin as single-agent therapy (monotherapy) is discouraged to reduce the risk of resistance. The choice of which ACT to use in a country depends on the severity of disease and pattern of drug resistance (especially to the partner drug) of the dominant parasite in the area.

Drug resistance is a worrisome spectre for the continuing effectiveness of all current and new anti-malarial regimens. Mothers and other family and community members need to know what the correct dose is and how long to take it. Too often, people don’t take appropriate drugs in the right amount or stop taking them when they feel better. In part because of the cost of ACTs, families also keep pills they should take to complete a course of treatment and save them for the next malaria episode.63 These practices increase the risk that the parasites will develop drug resistance. People must understand why it’s important for them to take all their pills, including the partner drug, which can make patients feel somewhat nauseated and often tastes bitter.

The African heads of state who are part of ALMA have resolved to prevent artemisinin drug resistance for as long as possible by enforcing the ban on the importation, production, distribution and use of artemisinin monotherapies.

59 Fogg, C., et al., ‘Adherence to a six-dose regimen of artemether-lumefantrine for treatment of uncomplicated Plasmodium falciparum malaria in Uganda’, American Journal of Tropical Medicine and Hygiene, 2004;71(5):525−30.60 International Federation of Red Cross and Red Crescent Societies, April 2010. 61 Malaria Knowledge Programme, Policy Brief: Gender perspectives in malaria management; cited in Dunn, Alison, 2005. (available at: http://www.healthlink.org.uk/PDFs/mkp_perspectives.pdf)62 Ibid. 63 Heggenhougen, HK, et al., ‘The behavioural and social aspects of malaria and its control: An introduction and annotated bibliography’, UNDP/World Bank/WHO/TDR, cited in Dunn, Alison, 2005.

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Early and accurate diagnosis. WHO, which is encapsulated by RBM, states that “Programmes must use diagnostics to limit and focus drug use to those in need, and they must monitor the efficacy of their drugs over time to ensure that they are using the most effective drugs available.”64 Currently, accurate diagnosis comes from microscopy and rapid diagnostic tests (RDTs). Microscopy services often are not available in low-resource areas, where so many of the most vulnerable populations live. RDT kits can be extremely helpful in such areas, identifying which fevers need anti-malarial therapy and which have other causes and need other treatment. UNICEF has developed a guide for selecting RDT kits.65 Still, it must be remembered that suspicion of disease always occurs first within the family and community—a fact that points yet again to the importance of participatory communication at the family and household levels.

Box 3. Malaria and HIV

Evidence is growing that where they occur together, malaria and HIV infections interact. Malaria increases HIV viral loads in adults and pregnant women, may speed progression to AIDS and might increase the risk of HIV transmission between adults and between a mother and her child. In adults with low CD4 cell counts and pregnant women, HIV infection appears to make malaria worse.66

UNICEF and its partners support better communication about the increased risks people with HIV face from malaria and the need for intensified prevention and treatment. That includes providing ITNs through routine services to people who are living with HIV, especially pregnant women. A third course of IPTp is also recommended for pregnant women who are HIV positive in highly malaria-endemic areas. Recent evidence suggests that prophylactic treatment with co-trimoxazole, a sulfonamide antibiotic, for all people with HIV as part of a basic care package, along with ITNs, has the potential to reduce mortality and morbidity and to delay the need for anti-retroviral therapy.67

Prevention and treatment of malaria share a number of issues and challenges, including:• Lack of engagement and participation at community, household and key stakeholder levels, • Inclusion of communication in the process as an afterthought or add-on68 and• Lack of access to effective malaria control tools (e.g., LLINs, ACTs, RDTs), which reflects conflicting

priorities at donor and government levels and the need to engage local communities in advocacy efforts

P. vivax is often seriously debilitating but rarely fatal. It is also recurrent because part of the parasite is often sequestered in the liver and can be released at a later date, causing a new episode of malaria without re-infection through a new mosquito bite. However, re-infection with either parasite (P. falciparum or P. vivax) is possible. Although some level of immunity often develops, especially in persons over five years of age in areas that are highly malaria endemic, infection is possible at any age. Having had an episode of malaria earlier does not provide protection against a new episode if that person is bitten by a mosquito carrying the malaria parasite. And whatever Immunity develops can be lost if a person leaves a highly endemic area for a long period of time. Finally, recent reports linking P. vivax infections to deadly complications may add to the complexity of malaria control.69 All these factors highlight the importance of prevention every night for every age, and of prompt treatment when infection occurs.

Integrated, multi-level programmes can make progress64 Roll Back Malaria, World Malaria Day 2010: Africa update, p. 11.65 UNICEF, Malaria diagnosis: A guide for selecting rapid diagnostic test (RDT) kits, 1st edition. (available at: http://www.unicef.org/supply/files/Guidance_for_malaria_rapid_tests.pdf)66 UNICEF, ‘Malaria: How does UNICEF help?’67 Ibid.68 Dunn, Alison, 2005.69 ‘New estimates of population at risk of Plasmodium vivax malaria’, Science Daily, 4 August 2010.

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Rapid and large decreases in malaria cases and deaths are possible through prevention and treatment interventions. A WHO survey of 34 African countries in 1999 to 2004 showed that only 3 percent of children less than five years old slept under bed nets.70 More recent data reveal significant gains. Across the 26 countries shown in Figure 3, ITN use by children rose to 22 percent in 2008 (scale-up activities for ITN use in most of these countries began around 2005).

As more African countries scale up malaria interventions, they are seeing progress. Nine countries—Bioko Island (Equatorial Guinea), Eritrea, Ethiopia, The Gambia, Ghana, Rwanda, Sao Tome and Principe, Zambia and Zanzibar—have seen morbidity and mortality drop 30 to 95 percent.71,72 Through major campaigns to increase access to various forms of malaria control:

• Zanzibar reduced malaria-specific mortality and malaria hospital admissions for children under five by more than 70 percent.

• Sao Tome and Principe reduced malaria-specific mortality by more than 90 percent and under-five hospital admissions by nearly 9 percent.

• Zambia reduced malaria-specific mortality by almost 70 percent.• Rwanda reduced malaria-specific deaths by 67 percent and all-cause mortality for children under five by

33 percent over a multi-year phased scale-up of interventions.73

Between 2003 and 2009, total malaria deaths dropped from an estimated 1 million to 850,000.74 Ongoing malaria control efforts now save an estimated one life every three minutes.75 Nevertheless, much remains to be done:

• Although many countries are approaching universal coverage with LLINs by the end of 2010, there will still be a need for net distributions through routine channels such as immunization and antenatal care programmes.

• The nets distributed in 2009−10 will need to be replaced at the end of their useful lifespan in about three years.

• Access to treatment and diagnosis is still lagging far behind gains in LLIN coverage.

Gains have resulted from integrated, multi-level programmes of advocacy and social mobilization that made progress in behaviour and social change at individual, cultural, institutional and governmental levels. Greatly increased financing, particularly from the three major donors (the Global Fund to Fight AIDS, Tuberculosis and Malaria, the World Bank and the US President’s Malaria Initiative) has been an important component of this formula for progress.

Figure 3. Major increases in use of ITNs for African children under five, early and late 2000s

70 WHO, World Malaria Report, Geneva. (available at: http://rbm.who.int/wmr2005/)71 Roll Back Malaria, World Malaria Day 2010: Africa update, Figure 4.2.72 Otten, Mac, et al., ‘Initial evidence of reduction of malaria cases and deaths in Rwanda and Ethiopia due to rapid scale-up of malaria prevention and treatment’, Malaria Journal, 2009;8:14. (available at: http://www.malariajournal.com/content/8/1/14)73 Roll Back Malaria, Malaria funding and resource utilization: The first decade of Roll Back Malaria, 2010.74 Based on a comparison of data from World Malaria Report 2005 and World Malaria Report 2009.75 Roll Back Malaria, ‘Agreed key messages for World Malaria Day 2010.’

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Source: UNICEF global malaria databases 2010

The World Malaria Report 2009 documents reductions of more than 50 percent in malaria cases in 38 countries: nine in Africa and 29 outside of Africa charts changes from 2000 or 2001 to 2008 in Eritrea, Sao Tome and Principe, Rwanda and Zambia.76

Common to most of these successful country initiatives is the large-scale implementation of comprehensive programmes to promote and support malaria control interventions, with strong government leadership and broad partnerships. The programmes involve action across levels:

• The national level − including garnering national and international commitments to stock adequate supplies of effective anti-malarial drugs and ITNs, which will involve seeking sustainable, predictable financing.

• The health system level – including, for example, counselling and support to help ensure that the most vulnerable household members have bed nets and know how to use them and receive appropriate early treatment.

• The community level − including counselling and communication by family members, community leaders, community health workers and other community cadres to support prompt treatment-seeking behaviours for malaria symptoms, and door-to-door follow-up visits to ensure regular and proper use of bed nets.

Further, successful programmes implement a comprehensive communication strategy that uses multiple channels to address barriers to malaria prevention and treatment in specific regions or among specific participant groups. Successful approaches to increase the impact of malaria control activities emphasize interventions to change behaviour and social norms—to clear up false beliefs, lower barriers and increase social support for the practice. These results can be achieved only through a combination of strategic communication activities that will result in: (1) supportive national policies and legislation; (2) increased number of health care providers who have skills in counselling and communication and work within a responsive health system; (3) community participation and support of malaria prevention and treatment behaviors; and (4) continuous communication efforts at all levels. 76 World Malaria Report 2009, p. 31.

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Table 2. Roll Back Malaria communications assessment: Challenges and opportunities identified77

Challenges• Limited understanding and knowledge of development communications (an interdisciplinary approach

centered around people’s right to a voice, people’s right to information, freedom of all communication channels, participation, ownership of knowledge, accountability in governments and societies and people’s improved ability to put informed choices into practice)

• Absence of basic malaria communication strategies• Poor visibility of national malaria control programmes• Lack of regional coordination and information sharing• Limited coordination and implementation capacity at the sub-district level• Limited capacity of Ministry of Health departments that are responsible for health education• Limited communications research and training• Lack of involvement of communities in defining their needs and priorities• Absence of health communications monitoring and evaluation protocols• Poor planning and development of messages• Lack of continuum approaches to practice in communications programmes (focus on specific individual

practice rather than long-term and larger-context behaviour change)• Limited strategies to meet the needs of poor and marginalized groups.

Opportunities• Commitment from partners to develop and implement malaria communication strategies• Community health volunteer structures already in place• National coverage provided by radio infrastructures• Evidence of positive development and participation practice• New and significant investments in marketing and distribution of bed nets

To that end, a shift in approach is needed to a process that: • Is systematic, strategic, evidence-based and participatory,• Has measurable objectives and integrated communication strategies,• Reflects values, local and larger contexts• Has potential for children to be agents of change,• Focuses on social transformation for sustainable results and• Is based on human rights principles.

Figure 3 shows significant increases in ITN use in 26 African countries for children less than five. Even though only two of the countries have increased ITN use for young children to more than 50 percent, the percentage increase in use in most of the other countries is considerable. Similar progress is seen for ITN use by pregnant women. Through ITN coverage alone, an estimated 908,000 malaria deaths were prevented between 2000 and 2010 in 35 African countries.78

Despite these encouraging trends, malaria control behaviours are not changing fast enough. ITN coverage is still well below target levels, and too many people do not receive prompt treatment. Ultimately, sustainable gains in overall child survival, growth and development require interventions that are evidence-based, effective, comprehensive and at scale to decrease malaria incidence rates among children and pregnant women. C4D incorporates many of these factors and, when integrated with existing strategic communication models and other public health strategies, can help achieve these goals faster.

77 Ibid.78 Roll Back Malaria, World Malaria Day 2010: Africa update, Figure 4.1.

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“Investment in malaria control is saving lives and reaping far-reaching benefits for countries, but without sustained and predictable funding, the significant contribution of malaria control towards the achievement of the Millennium Development Goals could be reversed. Today, with approximately one-third of the global investment needed, country programmes are saving a child's life every three minutes. This is very positive. We cannot afford to relax our efforts.” −Awa Marie Coll-Seck, Executive Director, Roll Back Malaria Partnership79

Chapter 2. Malaria and communication programming: A shift in approach

Many programmes have used communication interventions to help promote malaria control practices. These programmes typically relied only on communication materials, media campaigns and health education sessions to inform people about the benefits of bed nets and anti-malarial drugs. Although they have generated some improvements, in many countries these approaches have not produced desired changes in malaria control behaviours to achieve Millennium Development Goals.

As with many other sectors and communication models, C4D has evolved over time and today is focused on the participation and empowerment of individuals and communities and less on the one-way, top-down sharing of knowledge (see Botswana case study in Annex I). This is also the general model for changing behaviours described in Facts for Life.80

Messages and materials developed through broad participation can increase knowledge of:• How malaria is transmitted and prevented, • The connection between bed nets and prevention, • Malaria symptoms and at-risk groups, • The importance of seeking prompt treatment and full compliance with treatment and • The dangers of malaria in pregnancy and the need for antenatal care that includes LLINs and possibly

IPTp.81

The Communication for Development approach

An examination of some earlier efforts identified specific areas that limited the success of communication strategies. Table 2 shows key areas of previous communication approaches and the changes made in response to lessons learned from large-scale programmes. This is a generalization and does not apply to specific interventions or communication planning models and frameworks that may already reflect many of the key tenets of the C4D approach.

Table 2. Comparison of previous approaches and C4D approach

Aspect of strategy Some previous (and still-used) approaches

C4D approach*

Objective • To increase knowledge as health • To change behaviour and social

79 UN News Centre, ‘Anti-malaria efforts in Africa bearing fruit, but challenges remain’, 19 April 2010. (available at: http://www.un.org/apps/news/story.asp?NewsID=34411&Cr=malaria&Cr1=)80 UNICEF, WHO, UNESCO, UNFPA, UNDP, UNAIDS, WFP and the World Bank, Facts for Life, April 2010. (available at: http://www.unicef.org/publications/index_53254.html)81 Roll Back Malaria, Global malaria action plan, Part IV: The role of the RBM Partnership – 8. Communication and behavior change methodologies. (available at: http://www.rollbackmalaria.org/gmap/4-8.html)

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intervention norms as part of a social transformation process that involves households, communities and other key participant groups (e.g., older children, community leaders, health workers, governments, etc.)*

Interpersonal communication • Generally top-down and one-way (didactic)

• Two-way dialogue with active participation across levels

View of ITN use

View of care-seeking for malaria

• Coverage is issue (having ITN means proper use by most vulnerable household members)

• Most malaria cases treated symptomatically (re: fever)

• Coverage as first step; proper use as behaviour that requires support of family, community, clear instructions by health workers and community leaders, door-to-door training, etc.• Two-part approach: in-home care and prompt drug treatment tailored in implementation to local attitudes about traditional and pharmaceutical treatment

Messages • Treated participants as a single, uniform group

• Tailored to circumstances of different groups of women (e.g., poor, rural), other participant groups (e.g. households, health workers, governments, community leaders), gender roles

Materials • Too general, technical, confusing• Not relevant to local circumstances

• Are specific to participant groups• Use clear, non-technical language• Use locally appropriate delivery channels• Position ITN use and prompt malaria care and treatment as a children’s right

*See UNICEF working definition of social transformation earlier in this manual. More information on social transformation and system shifts processes is available in the C4D Webinar module, as well as in the full course on C4D.

Between 2002 and 2004, the International Federation of Red Cross and Red Crescent Societies conducted an innovative project to distribute free LLINs as part of a vaccination campaign in three malaria-endemic African countries. Major findings from that study reinforce the value of the broadly cooperative and participatory approach that is at the heart of C4D (see Box 4).

Box 4. Main findings: Distribution of free LLINs during vaccination campaigns in Ghana, Zambia and Togo82

• There is growing scientific evidence to demonstrate that combining mosquito net distribution with follow-on “hang up” campaigns, carried out by trained volunteers in their own communities, increases rates for net use and significantly reduces incidence of malaria.

82 International Federation of Red Cross and Red Crescent Societies, April 2010.

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• Combining net distribution with follow-on support and training at household level is crucial to reach the most vulnerable groups with limited or no access to government health services (e.g., those living in remote areas, refugees, people affected by stigma and discrimination).

• Trained volunteers who live in the same community as the beneficiary population and speak the same local language are ideally placed to help families overcome social or cultural barriers that could prevent the correct hanging and nightly use of nets.

• Since 2002, as a direct result of net distributions carried out by National Red Cross and Red Crescent Societies, supported by the International Federation of Red Cross and Red Crescent Societies, more than 300,000 malaria deaths have been averted and 18.2 million people have been protected against malaria.

• Significant progress has been made toward universal coverage (providing nets to every household to protect all persons at risk of malaria), and innovative new techniques are showing promising results (e.g., home management of malaria in Kenya), but sustainable funding needs to be available to carry the success forward, to strengthen community involvement.

• There is a need to expand operational research to determine the most effective and cost-effective prevention and treatment packages.

This manual, along with a Web-based interactive session, provides a preliminary overview of how to design, monitor and sustain a comprehensive Communication for Development strategy in UNICEF programmes. It should be used in conjunction with another manual and Web-based session, Using Communication for Development in Child Survival and Development Programmes: Integrating Children’s Rights and Social Transformation Perspectives in Communication Planning, which provides a more detailed description of basic C4D principles.

The C4D approach: Changing individual behaviours and social practices

“Community involvement and participation is important for every communication intervention. The community, in this sense, may include health workers, medical vendors, teachers, government officials, caregivers, people living in the village, etc., all of whom can provide invaluable insight to help make programs successful.”

−The Alliance for Malaria Prevention83

“When community-based volunteers provide knowledge, prevention and treatment options, communities are genuinely empowered to be the most effective first responders to this ancient scourge.”

–International Federation of Red Cross and Red Crescent Societies84

The Communication for Development approach is designed to change behaviours and social norms across levels and to create a sustainable process of social transformation. It is a participatory process built on value-based strategies, messages and activities to promote social transformation by changing health systems, public systems and social norms through ongoing efforts.

Key elements in a C4D strategyTo improve malaria prevention and treatment practices and change the social norms that influence them, Communication for Development should be comprehensive and include the following elements.

Communication strategies 83 The Alliance for Malaria Prevention, A toolkit for developing integrated campaigns to encourage the distribution and use of long lasting insecticide-treated nets. September 2008. (available at: http://pdf.usaid.gov/pdf_docs/PNADM837.pdf)84 International Federation of Red Cross and Red Crescent Societies, April 2010.

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• Connect with people and create local partnerships to encourage participation, generate demand for ITNs and create a long-lasting process of social transformation. Include vulnerable populations and consider children as key agents of change whenever possible (e.g., school-based interventions to teach children how to protect themselves, involvement of community leaders and women’s groups to support care-seeking behaviors and proper use of bed nets, etc.).

• Use a two-way dialogue and a problem-solving approach when communicating with mothers and others about using treated bed nets and seeking care for malaria symptoms (e.g., ask about their experiences and opinions).

• Use contact points with the health system and community groups and networks to inform, counsel, support and encourage use of ITNs and rapid treatment of malaria symptoms (e.g., doctors, nurses, community health workers, mother support groups, teachers and other school staff). In Malawi, introducing bed nets at government health clinics produced unexpected benefits of increased attendance of pregnant women at prenatal clinics and increased numbers of clinic-based births.85

• Engage family decision-makers creatively—expand traditional roles to support mothers who are making health-care decisions about their children (e.g., fathers, grandmothers, mothers-in-law, perhaps older children as well).

• Create opportunities for dialogue among community members, networks and organizations about how they can support women in protecting their children with ITNs and prompt medical attention for malaria symptoms (e.g., identify influential elders and other formal or informal social structures).

• Address social norms to improve the social acceptability of targeted malaria prevention and treatment behaviours (e.g., if husbands have a traditional claim on the best food and other resources and claim a household’s only ITN, use of home treatment together with recommended ACT therapy, etc.).

• Sustain the activities of field workers (NGO, government, volunteers) with training in communication skills and supportive supervision (e.g., how to demonstrate proper use of bed nets).

• Use advocacy at the national level to motivate leaders and decision-makers (including national authorities, national associations representing the private sector, etc.) to support malaria control programmes actively through change and enforcement of policies, allocation of resources and public statements (e.g., national policies about subsidies of LLINs and ACTs, hospital policies that encourage health workers to speak about malaria control at routine medical visits, etc.). Involve communities and key stakeholders in all advocacy efforts.

• Focus also on sub-national levels to improve communication and coordination among the health system, local government, private sector and community members (e.g., by creating malaria control task forces, such as alliances so that local oil companies and other stakeholders from the private sector expand their programmes beyond areas of operation, etc.).

Objectives and results• Develop communication and monitoring plans that work from common objectives and clearly state

actions and behaviours the participants will undertake as a result of the communication strategies and the social transformation process.

• Use research to feed the planning process and to provide evidence of results to modify the C4D strategy on a continuing basis.

• Monitor results of C4D activities at several levels—track indicators for family and community support for pregnant women and mothers of young children, actions taken by leaders and decision-makers, performance of frontline workers and results of partnerships, as well as the end result: increases in ITN use and prompt care for malaria symptoms (see also Table 4. Shifts in measurement of outcomes and impact, in Chapter 5).

Figure 4 shows how a C4D strategy works at each programme level to improve outcomes. To simplify the link between C4D and programme activities, think about your programme in the three levels shown in that figure, which are highlighted with separate colors. Each level has its own objectives, as shown below. Different C4D approaches are necessary to achieve objectives for behaviour and social change at each level.

85 USAID, ‘Success story: Treated net protects vulnerable groups.’ (available at: http://www.usaid.gov/stories/malawi/ss_mwi_nets.html)

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• National and sub-national – tertiary participants (green) Objective: Advocacy, which includes development of policies and mobilization of

resources and extends to the private sector • Community and facility level – secondary participants (orange)

Objective: Social mobilization and community action, which includes building partnerships and capacity for a sustainable social transformation process

• Household and individual – primary participants (blue)Objective: Behaviour change communication

Figure 4, which establishes a relationship between participant levels and specific communication approaches, divides participants into three groups (primary, secondary and tertiary). However, different approaches for dividing participants groups should be considered on the basis of specific needs at country and community levels. Understanding local context is essential to the success of any programme.

Figure 4. Coordinating across levels to effect change

Source: Adapted from Strengthening IYCF Programmes: Programme Guidance. UNICEF, New York, forthcoming.

After the key participants groups have been identified, it is important to arrange coordination of efforts at each of the different levels listed below. For example:

Coordination at the national level. A multi-disciplinary team at the national level is essential to ensure the coordination and support necessary to plan, implement and sustain an effective communication strategy for malaria control within a broader communication strategy of UNICEF programmes , such as Maternal and Child Health (MCH). A national coordination team for MCH or Child Survival and Development might already exist. To

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focus on malaria interventions, you might need to add members to the existing team, form a task force or start a new coordinating body. Whatever the structure, team membership should include epidemiologists, malaria specialists, C4D specialists, monitoring experts and relevant stakeholders, government counterparts and implementing partners. If some aspect of the programme is contracted out to a social research or communication agency, those contractors should participate as well. Most important, community members and representatives of vulnerable populations should be given a voice early in the planning and coordination process, ideally including a permanent seat in the national coordinating body.

Coordination with Child Survival and Development. Malaria prevention and control interventions are an integral component of UNICEF’s high-impact Maternal and Child Survival interventions and part of family and community health. Integrated programming of this kind takes advantage of existing systems that have relatively high use by target groups, such as the Expanded Programme on Immunization (EPI), Integrated Management of Neonatal and Childhood Illness (IMNCI), child health days for children under five and antenatal care for pregnant women. Through IMNCI, UNICEF supports malaria treatment in the home. Some countries may have a communication strategy to accompany their Child Survival and Development programme, or communication activities might be ongoing without a national strategy. If there is a call to develop a national C4D strategy, this provides an opportunity to reconsider the role of behaviour and social change in improving Child Survival and Development practices and to integrate a comprehensive C4D strategy into the national programme.

Coordination on communication strategy can start at any point, but development of messages and materials is the last part of planning, not the first. Ideally, communication specialists should be involved in all steps of coordinating UNICEF programmes that deal with malaria, because there may be communication aspects for all of them. For example, in September 2006, the government of Rwanda led a coordinated effort to deliver LLINs to every Rwandan child between the ages of six months and five years during a week-long integrated child survival campaign centered around vaccinations. The cost-effective, integrated campaign was successful in all aspects, from financing, procurement and custom clearance through estimation needs, transportation, secure storage and crowd management during distribution. A total of 1.3 million nets were distributed to 2,000 vaccination points nationwide.86

Coordination is central to immediate and long-term success. Lack of coordination was one of the challenges identified in an assessment of the Roll Back Malaria bed net campaign conducted in 2002−03 in Ghana, Mali, Senegal, Tanzania and Uganda (see Table 1):87

The assessors found considerable confusion around…the applicability and scope of contemporary communication tools. This was underpinned by an overreliance on conventional IEC (Information, Education, Communication) approaches that tended to be led by health professionals rather than community-driven. All of the pilot countries demonstrated a lack of integrated communication planning and activities between sectors, for example, health, education, women and youth, agriculture. Malaria communications activities tended to run as stand-alone campaigns; these were often project and donor driven and were overreliant on social marketing approaches.

Chapter 3. C4D in action: Distribution campaign for insecticide-treated nets in Okavango Sub-District of Botswana

86 Roll Back Malaria, ‘A treated mosquito net for every child under 5 in Rwanda’, January 2007. (available at: http://www.rollbackmalaria.org/docs/rwanda2006.pdf)87 Shuffell, Sarah, ‘RBM communications assessment: Challenges and opportunities in Ghana, Mali, Senegal, Tanzania and Uganda’, Radio for Development, 2003

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Botswana undertook a pilot education and distribution campaign for free ITNs in Okavango, one of five malaria-endemic districts in the country, in early 2009 (see Annex I). This intervention, which was designed around C4D strategies of inclusion and participation, brought local performers to their home villages and neighboring areas to involve community members in demonstrations of ITN use at schools and community-wide meetings. The campaign emphasized training of people who distributed the ITNs, demonstrated their use in the communities and gathered follow-up data. The campaign distributed 33,000 ITNs in the Okavango Sub-District, increasing household ownership from 12.6 percent to 91 percent. After this effort’s success, the campaign was quickly extended to all five of Botswana’s malaria-endemic districts. (See also Annexes II and III for information about participatory approaches featured in an ITN intervention in Mozambique and a behaviour change malaria-control pilot project in Madagascar.)

Chapter 4. Malaria: Integrating C4D into programme planning

“A central lesson from communication in malaria control is that country, regional and cultural contexts vary and require different approaches.” —Alison Dunn88

A systematic planning process is necessary to design a strategy that is responsive to the specific needs of mothers who are responsible for their children’s health care and pregnant women. The planning phase is the time to learn about the barriers to ITN use and prompt malaria care, the characteristics of women who use traditional healing practices alone or with Western medicine, the gender issues that affect the ability of women to obtain bed nets and seek timely medical care for malaria, and socio-cultural, economic and other factors that influence their behaviour. With this more informed understanding, planners can design activities, messages and materials and use channels that are tailored to the range of participants who can build a supportive environment for malaria control practices. Planners should include not only UNICEF staff and government officials but also local advocates and community members who can become key actors in the social transformation process. (For more information about social transformation, see the C4D Webinar module and full C4D course.)

“…the main advantage that volunteers bring is that they live in the very same community that they serve, which means that they can talk to beneficiaries using the local language and with an understanding of the community context. They are fully aware of local realities and customs that might prevent the hanging and nightly use of nets by the family members and are ideally placed to identify the most vulnerable members of the community.” –International Federation of Red Cross and Red Crescent Societies89

The best way to learn about the context in which mothers make decisions about health care for themselves and their children is to engage the right participants in discussions at this stage. As previously shown, Figure 4 provides

88 Dunn, Alison, 2005.89 International Federation of Red Cross and Red Crescent Societies, April 2010.

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examples of who is generally included in primary, secondary and tertiary participant groups, from the household level to the national level. It recognizes that women make decisions about treating themselves and their infants in a larger context that includes, on a daily basis, husbands or partners and mothers and mothers-in-law, among others. Doctors, nurses, employers, even distributors of ITNs—all should have a voice in the planning process for the communication strategy to be effective. Potential special needs should be acknowledged by including and giving a voice to marginalized and vulnerable groups, such as women living with disability, nomadic communities, ethnic minorities, and others.

“At times … the situation demands for money and they [mothers-in-law] will tell you there is no money, or the money for the hospital can be used for something else, hence the choice of herbal treatment.” –Keri, participant in women’s focus group discussion, Ghana90

The planning process contains three steps: (1) assessment, (2) analysis and (3) design of communication strategy. Although this manual presents these as sequential steps, they are often done simultaneously in whole or in part. There is no automatic starting point. They also are re-examined throughout the planning process as new information becomes available to change ideas.

Assessment

Several important questions should be answered during the planning process from both existing information and results of formative research. They should be answered in a participatory way—usually through a series of workshops involving the coordination team, appropriate stakeholders and community members. For example, as part of the assessment process, the Botswana campaign identified supply (a shortage of nets) and cost (20.00 pulas, or about $3) as reasons for low coverage of ITNs and responded with a series of campaigns of education and distribution of free ITNs (see Annex I).

Assessment questions1. What behaviours to improve malaria prevention and treatment practices do you want to achieve at

each level? Why haven’t these results been achieved?2. What is needed to change local practices so that children and pregnant women preferentially use

available ITNs when supply is limited within households? 3. What kinds of policies are needed to support malaria control as well as access to adequate services

and products? What kinds of behaviours should be encouraged among policy-makers to pass and enforce such policies?

4. How could community members and other participant groups contribute to advocacy efforts?5. What resources for malaria control are already in place (e.g., mothers-led coordination group, ITN

treatment center, local health center, etc.)? 6. What information already exists about malaria control practices of different groups of women as well

as the behaviors of groups who may influence them? Does it make sense to integrate some of these traditional practices within core programmes to facilitate use of ITNs and ACTs?

7. How can we integrate local practices, terminology, traditions and beliefs within communication strategies so that people will feel engaged in the solutions being proposed?

Analysis

90 Malaria Knowledge Programme, Policy brief: Gender perspectives in malaria management’. (available at: http://www.healthlink.org.uk/PDFs/mkp_perspectives.pdf)

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“Doing qualitative research and understanding a community’s beliefs and behaviour is critical to the success and sustainability of community based malaria programmes.” −Harald K. Heggenhougen, et al.91

The analysis step should also address important questions about participants and their behaviours. These questions help identify (1) gaps in information that was not acquired during assessment and (2) meaningful common characteristics of members of the primary participant groups that allow them to be further segmented for tailored messages and materials.

Participant analysis. Based on secondary and formative research, identify key participant groups and involve them in programme-planning and system-changing activities (changes at the community, social and political systems).

Behaviour analysis. Through a process of community consultation, discuss ideas for recommended practices and whether it’s feasible to implement such practices. Use focus group discussion or direct observation and research adapted to social and cultural context as well as different levels of comfort with participation levels, and solicit additional ideas and feedback.

Use qualitative methods to assess participants’ point of view on responsibility for infant and child care, care for fevers, bed nets and family roles. Include the views of marginalized and hard-to-reach groups in the discussion.

Use quantitative methods to get information to measure change not only in the level of knowledge but also the proportion of people who hold certain attitudes (e.g., use of traditional herbs and healers rather than anti-malarial drugs) and practice key health and social behaviours.

Analysis questions1. What additional information do you need? 2. How can you segment women and key influential people into meaningful primary participant groups and make sure the practices you recommend fit their lifestyle and circumstances? 3. How can you reach these participant groups and equip them to engage in the process of behaviour and social change?

Box 5. Making sure recommended behaviour is feasible

Planners may recommend optimal behaviour without examining whether it is feasible for families and communities to do. The more the recommended behaviour fits into local lifestyles and circumstances, the more readily the people will adopt it. Take time to lay the groundwork for a process of social and political transformation that would help promote feasible behaviours. Pre-test ideas through focus group discussions with homogeneous groups (e.g., separate discussions with families that use traditional medicine sometimes or always and with those that do not, with families who have reasonable access to health care facilities and with those that are more likely to treat malaria symptoms at home, etc.). Make sure recommended practices fit the lives of people they are intended for and are not only needed but also actually wanted.

Design of communication strategy

“A communication strategy is an essential component of all malaria programmes from implementing changes in drugs policies to introducing home-based management of treatment and establishing the wider use of ITNs.”

91 Heggenhougen, Harald K., et al. ‘The behavioural and social aspects of malaria and its control: An introduction and annotated bibliography’. UNDP/World Bank/WHO/TDR, 2003. (available at: http://apps.who.int/tdr/svc/publications/tdr-research-publications/social-aspects-malaria-control)

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−Radio for Development92

A communication strategy should have clear, feasible, measurable malaria control objectives (see Table 3) that are based on dialogue with key participants and can be achieved through communication by:

• Enabling a sustainable process and environment for social transformation,• Encouraging social and behaviour change through policies and practices that support prevention and

treatment behaviours (e.g., in families and hospitals) and• Providing information and services

A process of community consultation can identify suitable strategies for malaria control for key participant groups, for example, an integrated approach that uses diverse media and channels to reach all intended participants at scale (e.g., not only the national mass media or development and distribution of posters, but also community media, interpersonal communication during door-to-door visits at homes or at the health centre, puppet shows or street theatre and the efforts of community leaders). The Botswana programme selected and trained performers from local drama groups. The performers then created an interactive entertainment that conveyed basic messages about malaria and demonstrated the correct use and benefits of ITNs in the targeted villages (see Annex I). A pilot project in Madagascar involved the community at every step, from initial planning through implementation and evaluation, and relied on local resource people to deliver messages through effective “edutainment” channels (see Annex III).

The design of an evidence-based communication strategy is key to the success of all interventions. Table 3 provides examples of programme and behaviour objectives. This is a fictitious example. The numerical target for expected results must be evaluated on a case-by-case basis early in programme and communication planning. In this example, the plan to improve national malaria control rates by reducing incidence and mortality focuses on insecticide-treated nets and prompt medical care. Every objective has a numerical goal, which makes it measurable. These measurable objectives will make it possible to track the progress of the change strategy during the years of the programme.

Table 3. Sample of programme and behaviour objectives for malaria control, based on C4D values

Programme objective: To decrease malaria-specific mortality and hospital admissions 30 percentage points in five years among children and pregnant women (to be achieved as part of a sustainable process of community empowerment and social and political transformation)Behavioural objectives:

1. From baseline, at least 30 percentage points more households that have access to ITNs/LLINs use them every night for women and children (if not available for all household members) year-round (during the rainy and dry seasons).

2. From baseline, at least 30 percentage points more mothers or other family members will be able to recognize potential symptoms of malaria and promptly seek treatment at a local health center.

3. At least 60 percent of selected field workers use four core communication skills93 learned in training when they conduct group education sessions with community members on proper use and effectiveness of ITNs as well as signs and symptoms of malaria and the important of early care-seeking behaviour.

4. At least 60 percent of women report having started a coordinating task force in their communities to

92 Radio for Development, ‘A toolkit for developing malaria communication strategies’, 2003, prepared for Roll Back Malaria.93 See http:// intranet/pd/cbsc.nsf

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provide support and resources in identifying malaria cases among children and seeking care.

5. At least 80 percent of district directors of health allocate adequate human, material and financial resources to implement district-level malaria control communication activities.

In this table, programme and behaviour objectives are somewhat different:

Programme objectives focus on the health status of children under five and pregnant women as affected by malaria incidence, morbidity and mortality.

Behavioural objectives focus on the many people whose behaviours affect child health, including pregnant women. Listen. Do not force practices. Keep in mind that behavioural and social objectives need to be achieved as part of a sustainable process of social and political transformation.

Both programme and behavioural objectives are usually achieved by a variety of different programmatic activities, of which communication is an essential component. Meeting communication objectives contributes to achieving the overall programme goals. It is important to remember, however, that the main outcome of communication programmes is usually a health or social behaviour (or a variety of health and social behaviours that are specific to different participant groups) that support the overall programme goal. For example, the behavioural objectives listed in Table 3 have the potential to be achieved by implementing the C4D approach:

• Local-level advocacy to ensure resource allocation and coordination by district directors, to create and sustain social transformation

• Supportive supervision and training in communication skills for community health workers and health workers, to make sure they use appropriate messaging in training sessions that should be designed to empower the community

• Strengthening of mother support groups (e.g., mothers in Tigray, Ethiopia, who coordinated identification and treatment of malaria),94 to empower individuals to participate in such groups

Box 6. Key messages about malaria: What every family and community has a right to know95

1. Malaria is transmitted through the bites of the females of one type of mosquitoes (the Anopheles). Sleeping under an insecticide-treated mosquito net is the best way to prevent mosquito bites.

2. Wherever malaria is present, children are in danger. Children with a fever should be examined immediately by a trained health worker and should receive an appropriate anti-malarial treatment as soon as possible if they are diagnosed with malaria (diagnosis should be confirmed through microscopy or with am RDT wherever possible). Artemisinin-based combination therapies are recommended by WHO for treatment of Plasmodium falciparum malaria. It is the most serious type of malaria and causes nearly all malaria deaths.

3. If a diagnosis is negative for malaria, an alternative diagnosis should be sought for the cause of fever. Care-takers should not go to a private drug peddler and take the drugs for malaria when the fever has been confirmed not to be malaria.

4. Malaria is very dangerous for pregnant women. Wherever malaria is common, pregnant women should prevent malaria by taking anti-malarial tablets recommended by a trained health worker and by sleeping under an insecticide-treated mosquito net.

5. A child suffering or recovering from malaria needs plenty of liquids and foods.

Pre-testing messages, materials and communication channels

Before you launch your communication strategy, pre-test messages, materials and communication channels to make sure you get expected results for malaria prevention and control behaviours. These include changes in 94 Kidane and Morrow, 2002.95 Adapted from Facts for Life: Malaria, April 2010.

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individual and community-level support for prompt and appropriate home-based early malaria care and ITN use by the most vulnerable groups (e.g., new social norms supporting men’s decision to leave use of nets to children and pregnant women; integration of home remedies with adequate treatment for malaria; hospital policies that would encourage health workers to discuss malaria at routine visits; development of mothers’ task forces to help identify cases of malaria).

Pre-testing is sometimes seen as an unnecessary step—a luxury that programmes with limited resources cannot afford. It is just the opposite. Pre-testing helps planners make sure that the messages and materials are appropriate and easily understood and that the communication channels chosen are the right ones to reach intended groups. For example, a net treatment project in Tanzania found that people thought of net sizes in terms of the beds the nets covered, not the nets themselves (see Box 7). This finding was important to effective communication about proper use of the nets.

Box 7. Home treatment kits: Process and lessons learned in Tanzania96

Researchers from the London School of Hygiene and Tropical Medicine worked closely with a group of women in Dar es Salaam to develop a home treatment kit for bed nets. The process involved many focus group discussions, direct observation, pre-testing and modification. The kit included a sachet of appropriately packaged and labeled insecticide, gloves and an instruction sheet. The instructions mainly used pictures, but a few words were needed to get the essential messages across. Those who were unable to understand the words or could not read asked others who could. The most difficult part of developing the instructions was describing how to vary the amount of water for nets of different sizes. One issue was that people did not describe their nets as small, medium or large, but instead related net size to the size of the bed the net covered.

From these experiences, the researchers concluded that locally appropriate packaging and instructions should be developed with careful consideration, and that packaging and instructions should be field tested before home treatment kits are made widely available.

Different communication channels will be appropriate to some groups but not others. Research can identify categories of people who are trusted by participant groups, and pre-testing of those channels of information delivery can confirm that they are effective. In Sri Lanka, public health midwives provide the link between the community and health services. In Ghana, health workers are the most credible source of information. In Bagamoyo District in Tanzania, traditional healers often treat fever and convulsions in children, and some are members of village mosquito committees.97

A study in northeast Tanzania found that mothers' general knowledge of the signs of illness in their babies reflected experience from having another child, previous clinic attendance, school attendance and traditional beliefs. When mothers recognized signs of malaria, 52 percent went for traditional treatment plus Western medical care, and when they considered the symptoms severe, almost three of every four mothers used traditional healing. Among those who took herbal/traditional treatment, 70 percent also sought treatment with anti-malarial drugs at a clinic or hospital.98

Communication tips for promoting malaria control interventions• Use non-technical language.

96 Young, Mark, ‘The role of UNICEF in scaling up ITN coverage in Africa’, Malaria Matters, 2003;11.97 Winch, P.K., et al., ‘Local terminology for febrile illness in Bagamoyo District, Tanzania and its impact on the design of a community-based malaria control programme’, Social Science and Medicine, 1996;42:1057−67, in Heggenhougen, Harald K., et al., 2003, Chapter 3.98 Ringsted, Frank, et al., ‘Early home-based recognition of anaemia via general danger signs, in young children, in a malaria endemic community in north-east Tanzania’, Malaria Journal, 2006;5:111. (available at: http://www.malariajournal.com/content/5/1/111)

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• Make sure messages are clear, concise and consistent and accurate. One Ministry of Health campaign in East Africa inadvertently showed male mosquitoes as the malaria carrier.

• Focus messages and materials for particular participant groups, even though a wider audience will be exposed to those communications.

• Identify good times and places to convey malaria control messages.• Fit communication channels to participants and messages (Box 8). • Consider non-traditional channels that may be effective in the local context (e.g., shopkeepers in rural

Kenya were trained to recognize malaria and dispense appropriate drugs).99 • Use separate materials for supportive behaviours and social practices of family and community. • Emphasize positive immediate results but recognize the constraints to the mother, such as lack of control

of household money for a child’s treatment or community preference for herbal or traditional treatment.• Portray positive social norms and gender roles for use of ITNs and seeking timely and appropriate care for

malaria. • Develop specific messages and images to appeal to a more middle-class population, if a country is

becoming more urbanized (e.g., in Botswana, images included in the Malaria Prevention Calendar feature clothes and bedroom furniture to which the middle class can relate).

Remember to stick with a few simple messages, preferably in the form of suggestions rather than commands. It’s easy to overwhelm people with too much information. Also remember to include marginalized groups—such as ethnic or religious minorities and people with disabilities—and children as key participants in all phases of planning, and listen to what they have to say.

A Roll Back Malaria study of RBM communications in six African countries found a strong preference for (1) materials in local languages (except in Tanzania, which has a national language), (2) local channels of communication and (3) messages and interpersonal communications about and delivered by “people like us”—people who share their experiences. People also wanted accurate information that is appropriate to local needs and situations (relevant, affordable, practical) and that tells them what they need to know to take appropriate actions.100

Box 8. Fitting communication channels to participants and messages

The population of the coastal town of Bagamoyo, Tanzania, is primarily Muslim. The Bagamoyo Bednet Project discovered that posters and meetings, standard message tools in other places, had little impact there. Once they learned this, they recruited the sheik in each village to teach about the benefits of regularly re-treating bed nets with insecticide during his Friday religious services. This approach had a dramatic effect: Regular re-treatment rates climbed from very low numbers to 53 percent and, in some places, to 98 percent.101

In Mali, a Roll Back Malaria campaign found that griots—West Africa’s traditional storytellers—are the most trusted and respected information sources in the community.102 This information opens the way for locally specific communication messages and channels.

A Botswana campaign provided interactive demonstrations of ITN use at village kgotlas, public meetings, usually presided over by a chief or headman, where villagers gather to discuss issues of importance to the community and make decisions by consensus. In the familiarity of that traditional setting, community members actively participated in the demonstration (see Annex II).

99 Dunn, Alison, 2005.100 Shuffell, Sarah, ‘RBM communications assessment: Challenges and opportunities in Ghana, Mali, Senegal, Tanzania and Uganda’, Radio for Development, 2003.101 Mfaume, M.S., et al., ‘Mosques against malaria’, World Health Forum, 1997;18(1):35−8.102 Shuffell, Sarah, 2003.

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Finally, reinforce messages with repetition throughout the community. People need to see and hear the same few messages many times, in different formats and through different channels, to participate in the social transformation process and ultimately adopt new behaviours.

Chapter 5. Malaria: Integrating C4D into programme monitoring and evaluation

“As communities take more responsibility for malaria control it is necessary that they are able to measure the success of their action….Key indicators include: the number of households with ITNs, the number of malaria cases treated within 24 hours of symptoms, the overall reduction of incidence and mortality of malaria, cooperation with district management and other partners, personnel and the use of funds….and the performance of the health workers in the community.” −Lulu Muhe103

Monitoring and evaluation, often referred to as ‘M&E’, are an ongoing process of data-gathering and analysis of the data you gather to determine success in meeting the objectives you and your partners defined during the planning stage. Monitoring and evaluation help programme officers:

• Highlight what is working with the different participant groups • Identify problem areas and why they are not working as planned• Correct problems before the programme ends to improve results (mid-course corrections)• Provide feedback that is essential for continuing progress—sustaining and improving gains (see Chapter 5,

‘Maintaining Change Through Social Transformation’)

Common components of M&E are a baseline survey (where you started), ongoing monitoring mechanisms and evaluation of monitoring data (where you are) and a post-intervention survey (where you ended). Together, these activities drive continuous improvement in the programme and make it possible to allocate resources where they are most needed. M&E resources and funds should be included early on in the programme’s budget. Although there is no established rule on the overall cost of M&E, a reasonable cost may be 5 to 10 percent of the programme’s overall budget.

Outcomes and impact

Ideally, monitoring mechanisms track not only the rates of ITN use, IPTp and prompt treatment of malaria cases (behaviour of primary participant groups) but also the results of C4D-based activities involving primary, secondary and tertiary participant groups to measure transformative changes across a larger social and political landscape. This is a different scope of change, and it calls for different measurements. For this reason, the C4D approach is widening the focus of M&E beyond traditional indicators of outcome and impact to include additional indicators that acknowledge individual and community empowerment, human rights and social transformation for long-term change.

Table 4 shows traditional indicators of behaviour monitoring plus the broader C4D indicators. C4D includes a well-developed M&E component, which is being completed with the help of outside experts. Further information on C4D M&E process and methods is included in the C4D Webinar module as well as five-day C4D Learning workshop.

Table 4. Shifts in measurement of outcomes and impact

Traditional indicators Plus C4D indicators• Reach of media and information • Improved service delivery and interaction of service

103 Muhe, Lulu, ‘Community involvement in rolling back malaria’, 2002. (available at:www.who.int/malaria/cmc_upload/0/000/016/247/community_involvement.pdf)

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• Increased knowledge and awareness• Improved and new skills• Increased delivery and demand for products and services• Improved service delivery (technical quality)Improved national government policies• Changes in behaviour and practices

provider and client• Changes in attitudes, social norms and power relationships• Enhances self-esteem and self-efficacy• Changes in community perceptions, engagement, empowerment• Adherence to basic human rights principles

Any programme that houses a malaria campaign should have the flexibility to respond to changing circumstances that affect local contexts, national policies and behaviours of participants and partners, such as altered malaria prevention practices, urbanization patterns, emergencies and civil unrest (see Box 9).

Box 9. Effects of civil unrest on malaria control in Madagascar104

A political crisis that began in January 2009 led to a coup d’état on 17 March 2009, complicating opportunities to collaborate on malaria control with private national or international industries. The U.S. Department of State suspended all non-life-saving government aid to Madagascar, preventing work at any level with government workers and institutions. The political crisis delayed or suspended several activities of the President’s Malaria Initiative (PMI) for fiscal year 2008. Both PMI resident advisors were ordered to leave the country for four months, and all U.S. government technical assistance to the current government, from the primary care health facility level to the central Ministry of Health, was suspended until free and fair democratic elections are held. In response, PMI reprogrammed fiscal year 2009 funds from activities that would have required working with or engaging the Government of Madagascar to activities using international and local NGOs as implementing partners. (See also Annex III for a case study of C4D in a malaria control pilot project in Madagascar.)

This means that routine monitoring needs to be a long-term commitment, built into the programme’s structure and supported by adequate resources. The ability to adapt the programme to ongoing feedback from participant groups as well as in response to M&E findings helps sustain the results of successful interventions and inform how we go about measuring how we are doing.

Answering the central question

Monitoring and evaluation answer the pivotal questions: “How are we doing?” and “How did we do?” It is important not to confuse how you are doing with what you are doing. The “what” can be a simple tally of activities, such as number of training sessions for health workers who distribute or demonstrate use of bed nets, number of contracts made by local health systems with pregnant women, number of meetings held with policy-makers. The measure that matters is the actual change that results from those training sessions, visits and meetings, for example, changes in:

• Social norms and social processes (e.g., increased social support for ITN use of most vulnerable household members, community support for prompt home-based anti-malarial treatment, participatory approach to the definition of most needed community services in support of malaria control)

• Power within different levels of society (e.g., increased number of mothers who are empowered to use scarce family funds to pay for malaria treatment and are motivated to make decisions about when to seek medical care).

• Policies and practices (e.g., government commitment to stocking public clinics and private pharmacies with adequate supplies of ACTs and effective anti-malaria drugs; IPTp treatment for pregnant women as a routine part of antenatal care, distribution of ITNs to mothers as a standard feature of immunization of young children)

104 President’s Malaria Initiative, malaria operational plan, FY10, Madagascar. (available at: http://www.fightingmalaria.gov/countries/mops/fy10/madagascar_mop-fy10.pdf)

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• Knowledge and skills (e.g., understanding that bites from female mosquitoes transmit malaria, knowing the correct way to attach and care for a bed net)

• Health and social behaviours (e.g., more pregnant women regularly sleep under a treated net and receive preventive therapy; more district directors of health allocate adequate human, material and financial resources to implement district-level malaria control communication activities)

These are the transformative changes necessary to increase ITN use among children and pregnant women and increase rates of early care-seeking behavior when malaria is suspected—the ultimate outcome behaviour—to decrease the disease’s morbidity and mortality and sustain those changes over time.

Behavioural monitoringProgrammes routinely monitor inputs and outputs such as designing and distributing communication materials and training health workers and community volunteers in counseling skills. Behavioural monitoring is part of the monitoring plan and goes a step further to track results or outcomes of C4D-based activities:

• Changes in behaviours, social norms, policies and practices, knowledge and skills that lead to lower incidence and death rates from malaria.

• Improved malaria control rates that ultimately lead to better survival, growth and overall health and well-being of children less than five years old—and therefore to better physical, mental and emotional health and well-being as those infants and young children move through adolescence and into adulthood (and to better health outcomes for pregnant women who are protected from malaria by ITNs and IPTp).

Evaluation at the end of the programme focuses on these long-term changes in behaviour and their impact on health and development goals, sometimes from a wider perspective than the programme’s objectives (Figure 5 and Table 3). Other desirable impacts, such as reduced use of the health system and associated reduced costs for families, health care facilities and employers, may not be quantified in programme goals. Behavioural monitoring , along with the focus on behavioural results, is already a well-established principle of other planning frameworks and integrated models, including UNICEF’s Behaviour Change Communication model, WHO’s Communication for Behavioural Impact (COMBI) and the P-Process framework of John Hopkins University.

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Figure 4: Monitoring C4D results

SupplyTrain

ReachInform

Behavioural Outcomes

Results of C4D activitiesChanges in

health, nutrition,

well-being

Inputs/Outputs

Partners, Stakeholders, Health providers,

Community, Families, Parents

ImpactBehavioural monitoring

Chapter 6. Maintaining change through social transformationFor malaria programmes to have a positive effect on the survival, growth, health and well-being of infants and children, improvements in malaria prevention and treatment practices must be sustained over the long term. In fact, hard-won gains in malaria control can slip away.

For example, Vietnam had great success controlling malaria during the eradication era. Then the malaria burden surged in the 1980s and early 1990s, decades during which the economy deteriorated, funding to the health system was reduced and the health infrastructure was weakened. In the early 1990s, Vietnam increased malaria funding 10-fold and undertook a comprehensive campaign to control the disease again. It featured ITNs, IRS, coordinated involvement of government and communities, and stronger case management, surveillance, public awareness campaigns and laboratory capacity. By 2003, malaria cases had dropped to 12 percent of the 1992 high of 1.3 million cases, mortality had decreased dramatically and outbreaks had stopped.105

Building in sustainability

Sustainability should be built into the Communication for Development strategy throughout the planning stage. Although conditions that affect sustainability—resources, opportunities, obstacles and constraints—vary by country, the following four elements apply everywhere and are possible everywhere:

105 Barat, Lawrence M., ‘Four malaria success stories: How malaria burden was successfully reduced in Brazil, Eritrea, India, and Vietnam’, Am J Trop Hyg., 2006;74(1):12−16.

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EVIDENCE FEEDBACK PROBLEM SOLVING SUPPORT

Creating a cycle of evidence, feedback, problem-solving and support at local levels will help maintain the high degree of participation that is needed to ensure continuing support of recommended practices for malaria prevention and treatment. Communication for Development’s continued attention to the social norms that underlie those practices is another important element in sustainability. In addition, the C4D communication strategy should include ways to help counterparts, partners and fieldworkers have productive, evidence-based dialogue, for example, by:

• Packaging data to be user-friendly, • Improving group facilitation and advocacy skills and • Disseminating information about successes.

It’s important to know well in advance that the process of gathering and analyzing information requires time and resources. M&E data are a valuable part of maintaining gains in malaria control. Participant groups and C4D specialists would then need to review results from surveys, evaluation reports and monitoring data (evidence) to analyze and discuss (feedback) and make appropriate adjustments to the programme (problem-solving). They would then use this evidence to renew resources and commitment to continue work toward the programme's goals (support). It is also important to keep track of progress achieved and challenges encountered (support - feedback- evidence) to inform programme review and amendments.

Finally, by reporting on data on behavioural outcomes and their impact on health and mortality (evidence), national programmes can celebrate successes, address weak spots (feedback and problem-solving) and advocate for resources (support) to continue supporting the social transformation process that should give voice to mothers, family members and communities on malaria and related issues that affect the health and well-being of children.

Keeping partners and participants engagedSustainability also requires (1) attention to the operation of systems (e.g., collecting and analyzing monitoring data, continued service delivery) and (2) engagement of implementing partners and secondary participants (e.g., government officials and health care providers, NGO field staff, community volunteers, local political leadership and others—and true sustainability requires government to take the lead throughout the process, not merely as an implementing partner). It is their behaviour and actions that will support the desired malaria prevention and treatment practices over time.

Participatory monitoring methods are one way for partners and participants to evaluate their own performance and see how this is affecting malaria incidence and death rates. For example, it is often difficult to keep community volunteers or support groups involved, and that, in turn, often makes it difficult to sustain recommended prevention and treatment practices. In Madagascar, women who belonged to a group or association were more likely to be dynamic volunteers than unaffiliated women. Moreover, they learned that the programme’s volunteers needed support and recognition from local authorities, heads of health centres and community members to continue their work. In fact, involving these important participants regularly in tracking their own activities (evidence), reviewing the findings (feedback), modifying their activities (problem-solving) and gaining recognition (support) may go a long way toward holding their interest and continuing their interactions with mothers and pregnant women in the community.

Making changes commonplace

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When sustainability is designed into the programme, it is possible to keep gains in malaria control and continue progress toward Roll Back Malaria and Millennium Development Goals. This could be achieved by:

• Maintaining the desired behaviours through personal and community empowerment in all programme phases, in part by ensuring a plurality of voices, including vulnerable populations and—whenever possible—children as key agents of change

• Strengthening systems—political, social, economic, support services and community, among others—through the commitment of public and private institutions and government to create system shifts that make possible a long-term process of social transformation and

• Strengthening the commitment and skills of people who support the behaviours through reinforcement and training.

Ultimately, the goal of all these activities—of every aspect of a malaria control programme designed by integrating C4D values—is to make most changes in individual and institutional behaviours and cultural and social norms commonplace, so that use of effective prevention and treatment tools becomes the expected and accepted practice rather than the exception. When this happens, the beneficial consequences in the form of positive short- and long-term outcomes for infants and children, pregnant women and mothers, communities and the health care system at large will reverberate throughout the society. This is the process that Communication for Development envisions and hopes to facilitate by integrating an approach based on human rights and social transformation within communication planning.

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Annex I. Distribution campaign for insecticide-treated nets in the Okavango Sub-District, Botswana

Botswana has made elimination of malaria a public health priority, and it is one the six Southern African Development Community countries set to achieve this goal by 2015. For now, however, malaria remains a serious problem. It is endemic in the country’s northwest region, mainly in five districts: Okavango, Chobe, Ngamiland, Boteti and Tutume. These five districts represent 32% of the population and more than 80% of malaria transmission in Botswana. A 2007 Malaria Indicator Survey in three of these districts found that only 9.4% of households have at least one ITN (WHO recommends 80% for significant reduction of malaria transmission), and only 6.5% of under-five children and 3.8% of pregnant women used an ITN. Anecdotal evidence suggests that in a few cases where nets are available to households, they are used by adult family members for protection and activities such as fishing.

Botswana organized a campaign of ITN education and distribution in one of the five endemic areas, the Okavango sub-district. Mothers and children were targeted. The first large-scale campaign in Okavango took place between February and March 2009, and Communication for Development (C4D) strategies were the driving force in the campaign. After the intervention, ITN ownership increased from 12.6% to 91%. Since 2009, the innovation has been expanded to the four other malaria-endemic districts.

The C4D strategy was developed using findings from the 2007 Malaria Indicator Survey and benefited from inputs by key community stakeholders who participated in the Triple A exercise conducted in a malaria-endemic site. (Triple A is a three-step problem-solving cycle of Assessing the problem, Analyzing its causes and initiating Actions to improve the situation. It is an iterative process that leads to regular modifications and improvements in the approaches taken.) The Triple A process enabled better tailoring of the intervention to the public health approach for malaria prevention and to communities’ needs for when and how to use ITNs.

The C4D strategy combined (1) training of key persons (distributors, supervisors, demonstrators and follow-up teams) on malaria and ITNs, (2) mass distribution of ITNs, (3) interactive demonstrations of ITN use and (4) post-distribution monitoring by the existing community structure (i.e., the community health workers). It was participatory at community level; performers did demonstrations in their own villages in local languages, and demonstrations were highly interactive. The campaign has the potential to sustain the changes by integrating all the processes (community involvement, knowledge of ITN value, distribution of free ITNs by health workers and use by children and pregnant women) into routine activities of the health care system in the five districts.

A Triple A exercise in one site (Letlhakane) revealed shortage of nets and price (20.00 pulas—about $3.00) as reasons for low coverage. In response, ITN education and free distribution campaigns were planned for all five endemic districts. The implementation strategy had several components.

Training of distributors and their supervisors. The 10-day training focused on knowledge of malaria and ITNs; functionality, proper use and care of bed nets; distribution process and logistics; roles and responsibilities of team members; data recording; interpersonal communication skills; and use of Global Positioning Systems to map out households and areas where ITNs have been distributed as the project evolves. The distribution mode was pilot-tested in one village, and modifications were made. [Tess: It would be helpful to know what the modifications were and what findings they responded to, as an example for the section on pre-testing.]

Training of community mobilizers (demonstrators). A group of 10 community-based performers, selected from local drama groups, were trained for two days on basic knowledge of malaria, including definition, causes, prevention, symptoms and detectio. The training emphasized the most vulnerable groups: children under five and pregnant women. The information was drawn from UNICEF’s Facts for Life and other, locally produced

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material. The performers developed an interactive act that portrayed basic knowledge about malaria and demonstrated the proper use and benefits of ITNs. Each village was to be covered by two performers.

Training of follow-up team. Health Education Assistants, who are community health workers and members of the Village Health Committees, were trained on interpersonal communication and how to assess proper use of bed nets using a house-to-house strategy. Their role is to assess knowledge and skills among the population and collect data on proper hanging, frequency of use and care of ITNs.

Community-based demonstrations. The demonstrations, which preceded ITN distribution, were meant to prepare communities for and sensitize them about the mass distributions. In the 33 villages covered, demonstrators performed at local primary schools and during kgotla meetings (community-wide gatherings where decisions are usually made by consensus). These presentations were: performers engaged community members in dialogue on issues related to malaria and benefits of using bed nets, and community members actively participated in the demonstration, coming forward to feel the net, hang it up and lie under it, to experience its protective nature.

Mass distribution of ITNs. This step followed soon after community demonstrations in each location. During distribution, each household was given a calendar on which peak malaria months were shaded.

Follow-up on the use of ITNs. This activity was ongoing after the end of distribution in March until June 2009 and was conducted by Health Education Assistants and members of Village Health Committees.

Participation and ownership. The participatory strategy engaged communities through the use of community-based performers who did demonstrations in their own and surrounding villages. The demonstrations were highly interactive, and the performers used local languages to disseminate messages in the different locations. As a result, community members related easily to the demonstrators, easily understood the messages and showed eagerness to practice the new behavior once bed nets were distributed.

Partnerships, local structures, services and resources. This project was funded by the Ministry of Health, Okavango Sub-District and the Clinton Foundation, which acquired the ITNs through Malaria No More and UNICEF. Local participants included traditional leaders, clinics, community health workers and Village Health Committees in each village.

A total of 33,000 ITNs—two per household—were distributed in Okavango Sub-District. After the success of this 2009 pilot effort, the project was scaled up to all five malaria-endemic districts, where 96,000 ITNs had been distributed as of July 2010, for a total of 150,000 ITNs in two years.

The next steps are (1) to ensure timely and continued provision of ITNs (when some shortages occurred, priority was given to villages known to be more affected by malaria; the Ministry of Health has been procuring bed nets with support of other organizations); and (2) to sustain the gains made by the project through the continued integration of this intervention within the health care system.

[If a link to Bostwana campaign training guide is available, include it here.]

[Tess: Do you have any estimate of when behavioral and social results from the ongoing monitoring of activities may be available? It would be great to include that estimate here.]

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Annex II. Community capacity development and malaria in Mozambique: A participatory approach

Mozambique’s malaria burden contributes significantly to high infant and under-five mortality rates and serious illness in pregnant women. Poor, rural communities tend to suffer malaria’s effects more than urban ones due to greater transmission intensity, poorer access to services and less knowledge of risks, prevention and control.

UNICEF is implementing a community capacity development (CCD) strategy in Zambzia and Gaza Provinces, guided by principles of human rights-based programming that use participatory approaches to empower communities to analyze their situation and select appropriate tools to overcome identified problems. A participatory toolkit was developed to improve knowledge about malaria, sanitation, hygiene and nutrition, and interventions were designed to improve access to malaria prevention and treatment. Where malaria is identified as a priority, support is provided to ensure access to ITNs and first-line drugs as close to home as possible. ITNs are available through social marketing at retail outlets and through targeted, subsidized delivery to children under five and pregnant women through health facilities and community councils.

Results so far. In 12 districts, 346 community councils—the key forum for community problem-solving—have been established, reaching 173,000 people. The project will extend throughout the province (population 3.5 million) by the end of 2003. Participatory processes facilitate identification of major problems faced by communities, solutions, duty bearers, their roles and responsibilities and a timeframe for action. Solutions implemented by communities include providing ITNs, renovating latrines and building bridges to improve access. Since the May 2000 launch of social marketing, ITN sales have exceeded 185,000, and 60% of community councils have chosen ITNs as their preferred method of malaria prevention. The Ministry of Health approved implementation of the community-based malaria treatment component in 2001.

After extensive flooding in southern Mozambique in 2000, the Ministry of Health, with UNICEF and NGO partners, distributed 200,000 ITNs free to flood-affected families in conjunction with a CCD/education component. Participatory approaches increased community capacity to recognize malaria symptoms, identify risk groups and correctly use and re-treat ITNs and were more effective in raising awareness of malaria and prevention than more traditional methods, such as theatre (see box). More than 250,000 people in seven districts participated in CCD activities. A survey 10 months after ITN distribution revealed high knowledge levels about malaria and excellent net retention levels: more than 97% of nets distributed were still used by the recipient families.

Lessons learned and implications

The benefits of using a participatory approach to CCD have been demonstrated in both Zambzia and Gaza provinces. Among populations that experienced the participatory processes, 93% cited ITNs as a malaria prevention method, compared with only 15% of a population that attended theatre presentations on malaria, which included a demonstration of ITNs. ITNs can form an important component of post-emergency rehabilitation activities when a comprehensive, participatory education component is included. Concerns were raised that ITNs would be sold to raise cash to purchase other valued items; however, this was not the case in Gaza, demonstrating that communities consider ITNs to be valuable, high-priority items. [Did it happen in Zambia?]

The challenge remains to expand ITN sales into poorer, rural communities. This is being addressed by making subsidized ITNs available through health facilities and community councils. As with all ITN programmes, a significantly greater challenge than selling nets is selling the insecticide re-treatment kits. Intensive and innovative marketing techniques are being developed and used to increase awareness of the insecticide and increase sales. [Note: Since this program was launched, LLINs have become more prevalent, reducing or eliminating issues surrounding re-treatment.]

Source: http://www.healthbridge.ca/malaria_matters_11_e.cfm

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Annex III. Social and behaviour change communication for the prevention of malaria in Madagascar

Background. More than 92% of Madagascar’s population lives in malaria-endemic areas. Despite progress, an estimated 81,000 children still die before their fifth birthday every year; malaria and underlying malnutrition are main causes (WHO 2007). Use of insecticide-treated nets (ITNs) can largely prevent malaria in these children, and ITN use depends on their caretakers, mostly their mothers.

A pilot project was set up in two rural communes in Sofia region: Anahidrano and Ambodimandresy (target population: 23,081). Sofia has high malaria incidence and poor health-seeking behaviour at household level. In 2006, before a distribution campaign for long-lasting ITNs (LLINs) linked to Mother and Child Health Week, 2% of households reported a malaria death in the previous 12 months, and 33.4% of children under five had a fever episode.

In 2008, UNICEF and the Ministry of Health (MoH) conducted a pilot project on behavioural change communication and community participation in Sofia region. A pre-project KAP survey found that 59% of pregnant women in Sofia believed malaria could be prevented but only 17% reported sleeping under an ITN the night before (74.2% of the women said that had had malaria during the previous 12 months). The C4D strategy, developed from this survey, uses a mix of communications channels and approaches (see Strategy and application section). The key behaviours promoted under this project were (1) the proper use of LLINs among pregnant women and children under five, (2) intermittent preventive treatment (IPT) for pregnant women and (3) early care-seeking in case of fever. Lessons learned appear below.

Participation and ownership. The project relies on community participation at every step to foster sustainability and ownership of the adopted behaviours. The triple A approach—Assessing the situation, Analyzing the problems and identifying and planning Actions to be undertaken—was very effective in developing a sense of responsibility and ownership. It engages a wide range of community groups in the process: leaders, authorities, community members and resource people in the fokontanys (administrative structure at sub-commune level). This community evaluation is conducted at the beginning of the project in each fokontany, then every two months.

Partnerships, local structures, services and resources. The project is implemented in with the NGO ASOS. It relies on the local structures of the MoH (health districts and basic health centers) and on decentralized structures such as the mayor’s office and the fokontany. They were involved from the planning phase to the community-based monitoring and evaluation (triple A meetings) phase. For implementation, the project relies on community-based village animators and folk groups.

Community participation in the behaviour change process and involvement of local health and administrative structures worked well. Although the project is led by an NGO, the decentralized government structures are thoroughly engaged in the process, and the actual behaviour change process is led by the communities themselves with trusted ‘trigger’ agents they identify. Also, a strategic communication mix using radio, group (village dialogue) and interpersonal communication (home visits) helped the project reinforce messages. Village theatre, songs, folk dances and puppeteering proved to be an engaging approach.

Strategy and application. The goal is, by the end of the project, to have communities in both communes adopt and sustain behaviours that will help reduce malaria-related maternal and child morbidity and mortality. Focus group discussions were conducted during the preparatory phase to (1) segment the target groups, (2) identify powerful and relevant messages for each target group and (3) understand which communication channels would be most effective to generate behavioural change. Materials were produced and messages identified and updated from the findings of the focus group discussions. Sensitization activities are ensured by a network of

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volunteer village animators, who work with the entire community on the three key behaviours. These people were selected by the villagers themselves, which helps to develop the community’s responsibility.

To maximize impact, the project uses a mix of interpersonal communication (home visits and village dialogue) and mass communication (local radio) to increase exposure to key messages. “Edutainment” was chosen as the most effective way of communicating messages. This approach involves the community, especially young people, and uses folk groups, puppet shows and sports events as main vehicles for communication. The project builds the capacity and competencies of local groups, village animators, puppeteers and local radios in communication techniques and malaria prevention. Village animators receive IEC materials, and local folk groups are equipped with drums, tambourines and kabaosy (Malagasy guitar), and the puppet troupes receive materials produced locally (puppets, puppet theatre). The project also set up a participatory monitoring and evaluation system with clearly defined indicators and targets for technicians, in addition to those defined by the communities.

Results. The pilot project has shown very encouraging results. The strategy has engaged the community and kept decentralized government structures engaged without leading the process. In the current fragile context of Madagascar, an approach in which the community takes the lead in the behavioural change process seems to be an effective way to bring about sustainable results. A key success factor has been having the community choose its own ‘trigger’ agent. It would seem that the pilot project strategy could be easily replicated in other countries, in particular in fragile contexts where the capacity of health system delivery is not very strong.

Baseline (Nov. 2008) February 2010

No. of households with at least two ITNs 26% 70%No. of children < 5 years and pregnant women who reported sleeping under an ITN

50% 96%

No. of pregnant women who had received the second dose of IPT 26% 49%Mother’s health-seeking behaviour at very onset of child’s fever* 21% 36%

*This remains an area for improvement.

Next steps. Final evaluation of the project is pending, with delays caused by the political crisis in Madagascar. The project plans to organize village-level ‘malaria fairs’ by end of 2010. These events will also provide an opportunity for a participatory process evaluation and reinforce the newly acquired knowledge and behaviours of the target population. As additional malaria funding becomes available, UNICEF plans to scale up this approach within the pilot regions and, once the country gains political stability, possibly to the national level as well.

The lessons learned from this pilot project will be integrated into a scaled-up approach to include other key behaviours that have high impact on reducing maternal and child mortality: hand washing at four critical moments, oral rehydration therapy, exclusive breastfeeding and neonatal care.

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Resources

The Alliance for Malaria Prevention, A toolkit for developing integrated campaigns to encourage the distribution and use of long lasting insecticide-treated nets. September 2008. (available at: http://pdf.usaid.gov/pdf_docs/PNADM837.pdf)

World Health Organization, ‘Toward health women counseling guide: Ideas from the gender and health research group’. Geneva, Report No. TDR/GEN/95.1.

Epidemiology

Akande, T.M., and Musa, I.O., ‘Epidemiology of malaria in Africa’. African Journal of Clinical and Experimental Microbiology, 2005;6(2):107−111.

World Health Organization, ‘World Malaria Report 2009’.

Malaria control in emergency situations

Allan, Richard, and Muriuki, David, ‘Emergency malaria and dengue fever control: lessons from the tsunami in Aceh’, Humanitarian Exchange Magazine, 2005;32:19−21. (available at: http://www.odihpn.org/report.asp?id=2762)

‘Behaviour Change Communication in Emergencies: A toolkit’, UNICEF, South Asia Regional Office, Programme Communication, 2006. (available on UNICEF intranet, Communication for Development)

International Federation of Red Cross and Red Crescent Societies, ‘Beyond Africa, Malaria in Haiti: Turning tragedy into opportunity’, in ‘The winning formula to beat malaria’, in World Malaria Day report, 2nd edition, April 2010, p. 14.

Protopopoff, Natacha, et al., ‘Vector control in a malaria epidemic occurring within a complex emergency situation in Burundi: a case study’, Malaria Journal, 2007; 6:93. (available at: http://www.malariajournal.com/content/6/1/93)

Malaria control in schools

Odenyo, T., et al., ‘Malaria prevention and control among primary school children in Kenya’, Abstr Academy Health Meet. 2005;22: abstract no. 3179

Southern Africa Malaria Control, ‘Malaria control in schools: protecting children and teachers, protecting the next generation’. 2004. (available at: http://www.comminit.com/en/print/184422)

Involving communities

Nigatu, Tilahun, et al., ‘Involving communities in the fight against malaria in Ethiopia’, Amref Case Studies 2009. (available at: http://www.amref.org/silo/files/involving-communities-in-the-fight-against-malaria-in-ethiopia.pdf)

Planning process

‘Advocacy for Policy Change: Guidelines for developing an action plan’. Action for West Africa Region, USAID. (found in Advocacy Guidelines AWARE Brochure, pdf)

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Food and Agriculture Organization, ‘Participatory Rural Communication Appraisal (PRCA) Methodology’. (available at: http://www.fao.org/sd/CDdirect/CDan0024.htm)

‘An introduction to advocacy’, SARA Project, Academy for Educational Development, Washington, D.C., 1997 (available at: www.academyforeducationaldevelopment.org)

Parks, Will, and Lloyd, Linda, ‘Planning social mobilization and communication for dengue fever prevention and control: A step-by-step guide’, WHO Mediterranean Center for Vulnerability Reduction, Tunis, Tunisia, 2004.

Participatory Rural Appraisal (PRA) methodology. (available at: http://portals.wi.wur.nl/ppme/?Participatory_Rural_Appraisal_(PRA

Roberts, Ann, et al., ‘A toolbox for building health communication capacity,” 1995. Academy for Educational Development, Washington, D.C. (available in Adobe PDF at www.globalhealthcommunication.org)

‘Towards better programming: A manual on communication for water supply and environmental sanitation programmes’, UNICEF Technical Guidelines Series, 1999 (available on the UNICEF intranet, WASH, General advocacy and communication publications) (including message and materials development)

How to design and conduct formative research, monitoring and evaluation

Bertrand, Jane. 2008. P-Process. Paper presented at the American Public Health Association (APHA) 136th Annual Meeting and Expo, October 25-29, in San Diego, CA.

Hosein, E., Parks W. and Schiavo R., 'Communication-for-Behavioral-Impact: An integrated model for health and social change'. In Emerging Theories in Health Promotion Practice and Research: Strategies for Improving Public Health, edited by R. J. Di Clemente, R. A. Crosby and M. C. Kegler, 535-550.San Francisco: Jossey-Bass, 2009.

Parks, Will, ‘Essentials for Excellence: Researching, monitoring and evaluating strategic communication for behaviour and social change’, UNICEF Pacific office, Fiji, 2008. (available on the UNICEF intranet and at: http://www.unicef.org/cbsc/files/Essentials_for_excellence.pdf)

Roll Back Malaria, Building capacity in monitoring and evaluation Roll Back Malaria in Africa: A conceptual framework for the Roll Back Malaria Partnership. January 2005. (available at: http://rbm.who.int/partnership/wg/wg_monitoring/docs/merg_ConceptualFramework.pdf)

Shordt, Kathleen, ‘Action monitoring for effectiveness’, IRC International Water and Sanitation Centre, Technical Paper No. 35, Delft, The Netherlands (available at: www.irc.nl/products)

Training in interpersonal communication skills

Building Interpersonal Communication (IPC) Skills: Training Community Mobilizers in Polio Eradication in Uttar Pradesh. UNICEF India, June 2006. (UNICEF Intranet, C4D site)

Core Communication Skills for Frontline Workers and Service Providers. UNICEF NYHQ March 2011. http://intranet/pd/cbsc.nsf/Site%20Pages/Page01-‘Training modules on essential communication skills for front line workers’, UNICEF Bangladesh (draft available on UNICEF intranet, C4D site)

Vella, Jane, and Uccellani, Valerie, ‘Learning to listen to mothers’. Academy for Educational Development, Washington, D.C. (available at: www.globalhealthcommunication.org)

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References

The Abuja Declaration: The African Summit on Roll Back Malaria, held in Abuja, Nigeria, 25 April 2000. (available at: http://www.rollbackmalaria.org/docs/abuja_declaration.pdf)

Agu, A.P., and Nwojiji, J.O., ‘Childhood malaria: Mothers' perception and treatment seeking behaviour in a community in Ebonyi State, South East Nigeria’, Journal of Community Medicine and Primary Health Care, 2005;17(1):45−50.Ahorlu, Collins K., et al., ‘Malaria-related beliefs and behaviour in southern Ghana: implications for treatment, prevention and control’, Tropical Medicine & International Health, 1997; 2(5):488−98.

The Alliance for Malaria Prevention, A toolkit for developing integrated campaigns to encourage the distribution and use of long lasting insecticide-treated nets. September 2008. (available at: http://pdf.usaid.gov/pdf_docs/PNADM837.pdf)Barat, Lawrence M., ‘Four malaria success stories: How malaria burden was successfully reduced in Brazil, Eritrea, India, and Vietnam’, Am J Trop Hyg., 2006;74(1):12−16.

Bean, J., ‘Can we roll back malaria?’ The Health Exchange, December 2001. [cited in Dunn, Alison, 2005.]

Beiersmann, Claudia, et al., ‘Malaria in rural Burkina Faso: local illness concepts, patterns of traditional treatment and influence on health-seeking behaviour’, Malaria Journal, 2007;6:106.

Dunn, Alison, ‘Participatory communication in malaria control: Why does it matter?’ Findings, 2005;4:1-6.

Fogg, C., et al., ‘Adherence to a six-dose regimen of artemether-lumefantrine for treatment of uncomplicated Plasmodium falciparum malaria in Uganda’, American Journal of Tropical Medicine and Hygiene, 2004;71(5):525−30.

Heggenhougen, Harald K., et al., ‘The behavioural and social aspects of malaria and its control: An introduction and annotated bibliography’, UNDP/World Bank/WHO/TDR, cited in Dunn, Alison, 2005.

International Federation of Red Cross and Red Crescent Societies, ‘The winning formula to beat malaria’, in World Malaria Day report, 2nd edition, April 2010.

Kidane, Gebreyesus, and Morrow, Richard, ‘Teaching mothers to provide home treatment of malaria in Tigray, Ethiopia: A randomized trial’, Lancet, 2000;356:550−55.

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