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REPUBLIC OF EQUATORIAL GUINEA

NATIONAL MALARIA CONTROL PROGRAM COMMUNICATION STRATEGY

2008‐2010

MARCH 2008

Ministerio de Sanidad y Bienestar Social

TABLE OF CONTENTS

EXECUTIVE SUMMARY ........................................................................................................................................ 1 1. STRATEGIC COMMUNICATION PLAN: OVERVIEW .......................................................................................... 3

1.1 Roll Back Malaria Communication Strategy ................................................................................... 3 1.2 Strategic Elements of a Malaria Communication Strategy .............................................................. 3 1.3 Equatorial Guinea Malaria Communication Strategy ...................................................................... 4

2. SITUATION ANALYSIS ...................................................................................................................................... 5

2.1 Malaria in Equatorial Guinea .......................................................................................................... 5 3. CURRENT INITIATIVES AND PARTNERS ......................................................................................................... 11

3.1 Bioko Island Malaria Control Project (BIMCP) and Equatorial Guinea Malaria Control Initiative (EGMCI) ................................................................................................................................................ 11

3.1.1. Program Components ..................................................................................................................... 11

4. COMMUNICATION CHALLENGES .................................................................................................................. 16 5. COMMUNICATION STRATEGY ...................................................................................................................... 17

5.1 Priority Behaviors .......................................................................................................................... 18 5.2 Barriers to Behavior Change .......................................................................................................... 19 5.3 Program Activities ......................................................................................................................... 22 5.4 Future Plans ................................................................................................................................... 26

6. MONITORING AND EVALUATION ................................................................................................................. 27 ANNEXES ............................................................................................................................................................. 1

Annex A: Materials developed to date (see CD‐ROM) ......................................................................... 1 Annex B: Key Messages for Targeted Audiences .................................................................................. 3 Annex C: Detailed Implementation Plan 2008 EGMCI and BIMCP ....................................................... 7

Acronyms

ACT Artemisinin Combination Therapy ANC Antenatal Care AQ Amodiaquine AS Artesunate BCC Behavior Change Communication BIMCP Bioko Island Malaria Control Project CBO Community-Based Organization CDC U. S. Centers for Disease Control COP Chief of Party CQ Chloroquine EGMCI Equatorial Guinea Malaria Control Initiative EGRC Equatorial Guinea Red Cross GFATM Global Fund for HIV/AIDS, Tuberculosis and Malaria IEC Information, Education, Communication IMCI Integrated Management of Childhood Illness IPTp Intermittent Preventive Treatment of malaria in pregnancy IRS Indoor Residual Spraying ISCIII Instituto de Salud Carlos III (Spanish Cooperation) ITN Insecticide-Treated Net LLIN Long-Lasting Insecticide-treated Net LQAS Lot Quality Assurance Sampling M&E Monitoring and Evaluation MCDI Medical Care Development International MICS Multiple Indicator Cluster Survey (UNICEF) MICT Ministry of Information, Culture and Tourism MIP Malaria in Pregnancy MOHSW Ministry of Health and Social Welfare NGO Non-Governmental Organization NMCP National Malaria Control Program (MOHSW) RBM Roll Back Malaria (WHO) RDT Rapid Diagnostic Test SP Sulfadoxine-Pyrimethamine WHO World Health Organization

National Malaria Control Program Communications Strategy 2008 – 2010

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EXECUTIVE SUMMARY

Malaria is endemic in Equatorial Guinea, and is the principal cause of morbidity and mortality, with a disproportionate impact on pregnant women and young children. The National Malaria Control Program of the Ministry of Health and Social Welfare of Equatorial Guinea is implementing an ambitious, comprehensive strategy with the goal of drastically reducing the transmission of malaria throughout the country. The program components include semi-annual indoor residual spraying (IRS), distribution of long-lasting insecticide-treated nets (LLINs), diagnosis and treatment of cases with artemisinin-based combination therapy (ACT), intermittent preventive treatment for pregnant women (IPT), behavior change communications (BCC), and a rigorous monitoring and evaluation system that includes vector surveillance, strengthening of the national health information system, and annual parasitemia surveys. The BCC component of the program seeks to support all malaria intervention areas by promoting key desired behaviors: increased early care-seeking and adherence to correct treatment, increased use of IPT, increased household acceptance of IRS, and increased consistent use of LLINs. In order to achieve the program’s behavioral objectives, a comprehensive communication strategy that harmonizes messages and employs multiple communication channels was developed through a consultative workshop with the participation of key members of the EG MOHSW and its partners in malaria control. The strategy elaborated in this document is based on a review of accumulated quantitative and qualitative research findings and experience to date. The strategy forms an integrated set of communication interventions that combine interpersonal communication and mass media channels to reach all relevant levels of society, from the household/individual level, to service providers, to leaders/policymakers. The main approaches selected by the program are as follows: Mass Media Radio/Television: The program will use radio and television to reach the widest possible audience through spots, regular programs and coverage of special events. Print Material: Posters, billboards, banners will be used to raise the level of awareness of the general public and policy makers about the integrated program components and impact of interventions. Pamphlets, flipcharts, and counseling cards will support inter-personal communication activities to reinforce messages, provide more detailed information, and serve as a reminder for positive behaviors. Events: Two types of events will be used as part of the communication strategy: (1) large scale special events such as World Malaria Day, sporting events, national holidays, launches for IRS and


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ITN campaigns, and (2) community fairs which include a mix of entertainment and malaria education through music, contests, Q&A, and theater group performances. Interpersonal Communication Community Outreach by the IRS Advance Team: The role of the IEC Advance Team is to encourage families and communities to support IRS by allowing their households to be sprayed as well as to reinforce messages about the importance of IRS as a complementary intervention to case management and LLITNs, not a replacement. The teams make pre-spraying visits to communities and accompany the sprayers door-to-door. Community Outreach by the LLIN Distribution Team: A system of use of community Consejeras and Red Cross volunteers was used in the past and will be utilized for future campaigns both for initial distribution and education on the importance of LLIN use as well as to promote and maintain “keep-up” of bednets. The distribution includes volunteer delivered messaging on malaria (cause, prevention and fever treatment) and health promotion. The volunteers go door-to-door and/or organize community meetings to not only pass messages, but to also ensure that LLINs are hanging correctly and are being used by the intended target group. Facility-Based Communication by Health Providers: Routine health services targeted at vulnerable populations, such as children under five and pregnant women are ideal opportunities to discuss and interact with caretakers. The program works with health personnel to improve correct diagnosis, case management, and IPT, as well as in counseling skills. Posters and pamphlets for people attending health facilities will be used to reinforce messages. Advocacy/Events To raise awareness about malaria control and to garner support for the program, advocacy activities will include a series of informational meetings with leaders and local authorities, supported by written materials, and inclusion of local authorities and opinion leaders in phases of planning, implementation and evaluation. Publicity for the program will include billboards, banners, murals, and radio and television appearances by influential individuals. Monitoring and Evaluation The program will conduct formative research with target group members during the development of messages and materials; monitor its activities throughout the implementation phase through direct supervision of activities and regular reporting; and measure changes in knowledge, attitudes and practices through periodic rapid assessment surveys and annual household surveys.


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1. STRATEGIC COMMUNICATION PLAN: OVERVIEW

Global efforts to reduce the devastating effects from malaria are well documented. The Millennium Development Goal six, target eight aims to halt and begin to reverse the incidence of malaria and other major diseases. In 1998 the World Health Organization (WHO) coordinated a global approach to fight malaria in collaboration with multilateral development partners, the private sector and community based institutions. This approach, the Roll Back Malaria (RBM) Partnership, now leads efforts to sustain delivery and use of the most effective prevention and treatment of malaria.

The RBM in the WHO Africa Region seeks to control malaria to a level where it is no longer one of the major contributors to mortality and morbidity in the region by 2030. Current targets seek to cut mortality and morbidity due to malaria in half by 2010, with further reductions over subsequent years to achieve an overall reduction of 80% by 2030.

1.1 Roll Back Malaria Communication Strategy

The RBM considers an effective communication strategy to be the cornerstone of appropriate national malaria control programs. Evidence-based communication activities contribute to the reduction of malaria deaths and suffering by improving the knowledge of and demand for effective interventions. Communication strategies should advocate for policies and resources supportive of malaria control, communicate policy changes, educate communities and health providers about home-based management, improve the quality of health care (e.g., counseling and client information), create demand for malaria services and products, improve client compliance with treatment, change household practices (e.g., ITN use and early treatment of fever in children), and involve communities in malaria control.

The strategy must be multifocal, targeting individuals, households and communities, as well as health-care facilities, policy-makers and resource providers. It must be designed to improve understanding of the behaviors and practices adopted by individuals, as well as the underlying reasons for their adoption, as a basis for reinforcing positive behaviors and modifying those that are less beneficial.

Typical obstacles impeding the successful reduction of malaria include inadequate resources allocated for malaria IEC/BCC and control activities, late access to proper treatment, poor prenatal prevention and treatment, low use of LLINs, low use of IRS, and low levels of epidemic preparedness and capacity for response. When combined with strategies for the development of appropriate skills and capacities, and the provision of an enabling environment, communication plays a central role in positive behavior change and the empowerment of individuals and communities.

1.2 Strategic Elements of a Malaria Communication Strategy

When addressing these audiences about the key components to malaria control – case management, IPTp, IRS, LLINs, behavior change communications messages should focus on:


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• the link between mosquitoes and malaria • Prevention of malaria through IRS, ITNs, and IPTp • the risk of malaria for young children and pregnant women; • how to recognize uncomplicated malaria and danger signs; • what actions to take in cases of uncomplicated malaria or those with severe malaria; • the importance of prompt and complete treatment; • where to get or purchase good-quality, approved medicines; and • where to go in case of danger signs or if there is no improvement.

The channels for these messages should be as diverse as the audiences receiving them. Examples include interpersonal communication, traditional communication channels, group and mass-media channels including participatory methods and social marketing through medicine packaging, radio spots and distribution of booklets to patent medicine dealers. Crucial to the success of a communication strategy is a complementing supply with demand creation for health services, increased access to medicines, IRS and LLINs and community ownership using different components of the communication strategy concurrently and the repetition of messages.

1.3 Equatorial Guinea Malaria Communication Strategy

Consistent with the above identified obstacles, audiences and strategies, the National Malaria Control Program (NMCP) in Equatorial Guinea has been engaged in developing strategic components of an effective and integrated communication strategy with support from the Bioko Island Malaria Control Program (BIMCP) funded by Marathon Oil and its partners including the Government of Equatorial Guinea, and the Equatorial Guinea Malaria Control Initiative (EGMCI) funded by the Global Fund for HIV/AIDS, TB and Malaria (GFATM). Heretofore, the communication elements of the program have been developed in an ad hoc manner in support of the various components as they were introduced. The current strategy document seeks to provide an integrated framework for a comprehensive communication strategy that supports the objectives of the NMCP of the MOHSW.


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2. SITUATION ANALYSIS

2.1 Malaria in Equatorial Guinea

The Roll Back Malaria Partnership (RBM) estimates that there are over 300 million acute cases of malaria worldwide each year, resulting in more than one million deaths. An estimated 90% of these deaths occur in Africa, mostly among young children under the age of five. RBM estimates that malaria kills an African child every 30 seconds, all year round. UNICEF reports in its State of the World’s Children Report (2007) that the under-five mortality rate in Equatorial Guinea (EG) was 205 per 1,000 live births in 2005. According to UNICEF, this represented a 21% increase over 1990. This places EG at the bottom ninth in the world on this critical measure of health status. It is very likely that the rising child mortality rate in Equatorial Guinea is due in part to uncontrolled malaria, which is found throughout the country at all times of the year.

Malaria is endemic in Equatorial Guinea, with a high prevalence of Plasmodium falciparum malaria; and it remains the principal cause of morbidity and mortality. The EG NMCP estimated in its Strategic Plan for 2002-2006 (May 2002) that as many as 40% of child deaths were due to malaria.

The information below on the malaria situation on Bioko Island is derived from annual household surveys undertaken by the BIMCP during the period 2004 (baseline) through 2007 and a recent monitoring survey conducted as part of an Island-wide bed net distribution campaign using Lot Quality Assurance Sampling (LQAS) methods. Planning for the 5th annual survey is currently underway and will take place in March 2008.

Mortality: Using recall data from 1999 to 2004, the under five mortality (risk of not surviving to age 5) is 163 per 1000 (95% CI 112 to 224), which is consistent with the rate derived from the 2001 MICS survey, 146 per 1,000 live births.

Morbidity: In 2004, the proportion of children under 5 years with a malaria episode in the

month prior to the survey as reported by the mother/caretaker was 18.7%. In the 2007 survey, this decreased to only 2.8%.

Parasitemia (prevalence of malaria infection, including asymptomatic cases): While the

2004 baseline survey showed that 45% of under-15 children had parasitemia, the 2007 survey found that this figure had fallen to 28% (a rate reduction of nearly 38%). Conversely, the 2007 survey found that 28% of pregnant women had parasitemia, a 55% increase over the 18% rate reported in 2005.

Anemia levels: In 2007, the BIMCP determined that 59% of children under 15 years

surveyed were anemic, compared to 75% of children with anemia at baseline. Although


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there was a decrease in anemia levels for pregnant women during this period, 72% were still found to be anemic in 2007.

Recognition of malaria: Over the past four years, accurate individual knowledge about

malaria has been increasing. In 2004, approximately 51% of those surveyed could name mosquitoes as a way to transmit malaria compared to 82% in 2007 (a 61% rate increase). Another significant increase is seen in the indicator to name fever as a malaria symptom – from 54% in 2004 to 81% in 2007 (a 50% increase in the rate).

Access to treatment: About 70% of children received anti-malarials in 2007. New treatment

guidelines introduced ACT to replace chloroquine (CQ) after the 2004 baseline survey. When mothers were asked to name the “best treatment” for malaria, CQ ranked third in 2007 whereas it had ranked first in 2004.

Treatment-seeking behavior: There has been an increase in percentage of febrile or

malarious children taken to a health facility within 24 hours from 15% in 2004 to 33% in 2007.

Treatment adherence/compliance: At baseline, about 50% of those surveyed adhered to a 3-

day treatment of CQ. According to a household survey conducted in 2006, adherence to the 3-day treatment course for ACT was determined to be 84%.

Drug resistance: Due to evidence of chloroquine resistance on the island (Molina 58%,

2003), the MOHSW and the Malaria Task Force agreed to the introduction of ACT in March 2004 at all health facilities on the island supported by the BIMCP. Further evidence (Raman, Medical Research Council 2007) showed an increase from 5% in 2004 to 54% by 2006 in the one of the two markers associated with sulphadoxine resistance. Since markers of pyrimethamine resistance already were at 100% in this population in 2007, the MOHSW (following recommendations of WHO), determined that the standard ACT malaria treatment should be artesunate (AS) and amodiaquine (AQ).

Case management: According to the UNICEF Multiple Indicator Cluster Survey (MICS)

2001, 50% of febrile or malarious children received anti-malarials whereas in 2006, BIMCP found that 70% received anti-malarials. Approximately 12% of sick children continued feeding during illness episodes (MICS 2001) whereas the BIMCP 2007 survey found 98% of sick children continued feeding during illness episodes.

Malaria and pregnancy: Results from the BIMCP 2007 survey determined that 90% of

mothers had antenatal care during her last pregnancy, which is a slight increase from 86% at baseline. Similarly, 85% of mothers received IPT during her last pregnancy in 2007, which is a slight increase from 82% in 2004. Two indicators from the BIMCP 2007 survey were found to be down from baseline: 1) mothers who reported always sleeping under a bed net


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during her last pregnancy went down to 30% from 40%; and 2) mothers who received iron supplements during her last pregnancy went down to 55% from 78%. Current guidelines for IPT in EG call for treatment using SP commencing with the second trimester.

Coverage of IRS: Self-reported IRS coverage on Bioko was 64% in 2007, compared to 86%

in 2005. This reported decrease in coverage may be partly due to expectations by households that if they received bed nets then they would not need to have their house sprayed. Although there was a 50% increase from 2004 in naming spraying (unprompted) as a way to prevent malaria, only 12% of those surveyed could name spraying unprompted in 2007.

Coverage of LLINs: Though the 2007 survey was conducted before the Island-wide LLIN

distribution campaign carried out by the BICMP in December 2007, the survey revealed that 33% of children under-15 years, and 30% of mothers had slept under a bed net (not necessarily insecticide treated) the night before the survey in 2007. Almost 70% of those surveyed named bed nets as a way to prevent malaria. According to the LQAS survey conducted during the LLIN distribution campaign, a coverage rate of over 80% of all beds or sleeping areas was achieved on Bioko by the end of December 2007.

The information below on the current malaria situation on the mainland is derived from the 2007 baseline household survey undertaken by the EGMCI.

Mortality: The EGMCI Baseline Survey used recall data from 2002 to 2007, and estimated the under five mortality (risk of not surviving to age 5) as 125 per 1000 (95% CI 88 to 167) The mortality rate for children under-5 according to the UNICEF MICS, 2001 of 153 per 1,000 live births falls within the confidence interval of the baseline survey.

Morbidity: The malaria incidence rate was reported to be 1.4 episodes per child per year for children under-5 and almost 1 (0.93) episodes per child per year.

Parasitemia (prevalence of malaria infection, including asymptomatic cases): Parasitemia

prevalence on EG’s mainland in children under 15 was 67%. For pregnant women, 43.1% were found to be parasitemic.

Anemia levels: The overall anemia rate for pregnant women was 71.2% (0% with severe

anemia, 9.6% with marked anemia, and 61.6% with mild anemia). Anemia prevalence in children under-five was 65.3% with few children having severe anemia.

Recognition of malaria: Approximately 71% of mothers surveyed knew that malaria was

transmitted by mosquitoes.


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Knowledge of means of preventing malaria: Bed nets were most commonly mentioned when asked about ways to prevent malaria; prophylaxis was mentioned by less than 1% and IRS was named by less than 3%.

Access to treatment: Virtually no respondents reported receiving free antimalarials from

health facilities. This is not unexpected as free drugs have not been available. Treatment-seeking behavior: Approximately 40% of children under-five were taken to a

health facility within 24 hours after onset of febrile symptoms.

Treatment adherence/compliance: (Information not available)

Treatment protocol Artesunate (AS) + Amodaquine (AQ) introduced as combination therapy in 2007 in selected facilities. Roll-out scheduled for 2008 to all of mainland facilities.

Case management: 86% of all malaria cases reported that they received treatment when sick

in the two weeks prior to the interview and 40% of children under-five were treated for care 24 hours after onset of symptoms. Antimalarials used to treat malaria episodes in decreasing frequency were quinine, CQ, AS as monotherapy, SP and artemether.

Malaria and pregnancy: A majority (81%) of women received some antimalarials during pregnancy. Of the 82% who received antenatal ANC care, most women sought antenatal care from MOHSW facilities, with hospitals having the largest share. Over 90% said they valued IPT and approximately half of those said because it benefited the mother and/or the fetus. However, there are generalized misconceptions about IPT including when to start and number of doses, and most are not aware that health facilities offer free IPT. Over half of pregnant women reported receiving iron supplements.

Coverage of LLINs: Based on MOHSW data from 2005, the percentage of children under-

five who slept under a LLIN the previous night was 0.4%. EGMCI began mass distribution of LLINs in areas of lower population density, starting in Centro Sur (to be followed by Wele Nsas in 2008). According to the Lot Quality Assurance Sampling (LQAS) conducted in Centro Sur following the LLIN distribution conducted there, the overall percentage participation was 98%, and the percentage coverage was 81%.

Coverage of IRS: In addition to the 2007 baseline data noted above, 181,254 structures were sprayed in Litoral Province during the first spray round. It is expected that 62% of the population of the mainland residing in the two selected provinces with more urban and densely populated areas (Litoral and Kien Tem) will be covered by two rounds of IRS spraying each year.


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2.2 Strategic Plan, National Malaria Control Program (NMCP)

In October of 2008, the MOHSW, with WHO support, published a new strategic plan for malaria control in Equatorial Guinea, covering the years 2009 to 2013. This plan highlights the adoption in 2006 of the new malaria treatment protocol based on artesunate and amodiaquine, and the channeling of substantial resources for malaria control from the Marathon Oil consortium through the BIMCP (MCDI and its implementing partners), as well planned support from Instituto de Salud Carlos III and the Social Development Fund. It additionally makes note of progress in controlling malaria achieved on Bioko, including substantial IRS coverage (79% of households) and LLIN use among children under 5 (76%), improved access to and increased use of ACT and IPT, contributing to a 64% reduction in under-5 mortality, a 49% reduction in malaria prevalence, and a >90% drop in the population of infected mosquitoes.

The 2009-2013 strategic plan calls for a 50% reduction in the incidence of malaria by 2013 from 2008 baseline levels, and a 50% reduction in the rate of malaria-related mortality among children under 5 and among pregnant women. The objectives for achieving these impacts include:

- 80% of persons with malaria will have access to diagnostic services and prompt treatment by 2010.

- At least 90% of sleeping spaces will be covered by an LLIN by the end of 2010

- At least 80% of the population, and especially pregnant women and children under 5, will sleep under an LLIN by the end of 2010

- At least 90% of health service providers will be trained in case management by the end of 2009

- At least 85% of the population will sleep in rooms protected by IRS

The 2008 strategic plan additionally specifies six IEC/BCC objectives:

- At least 80% of the population knows how malaria is transmitted

- At least 75% of the population recognizes the signs and symptoms of malaria

- Over 70% of the population uses health facilities for treatment of malaria

- At least 80% of the population knows how malaria is prevented and controlled

- Over 70% of the population continues to accept IRS as a means of controlling malaria


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- Over 80% of the population will accept using an LLIN as a means of preventing malaria

The strategic plan calls for an integrated communications plan in support of the objectives relating to knowledge and behavior change, involving community leaders, community members and civil society organizations that work in these communities. Specific activities to be carried out under the plan are formative research; production and distribution of IEC materials and messages based on such research; training of MOHSW service providers and community leaders; multimedia campaigns on malaria control; and documentation and dissemination of experiences.


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3. CURRENT INITIATIVES AND PARTNERS

3.1 Bioko Island Malaria Control Project (BIMCP) and Equatorial Guinea Malaria Control Initiative (EGMCI)

On the island of Bioko, the MOHSW has partnered with Marathon Oil Company, Noble Energy, Atlantic Methanol (AMPCO), GEPetrol, SonaGas and the Government of Equatorial Guinea to fund a five-year malaria control project from 2003-2008. The total budget for the five-year project is currently $13.58 million. The Bioko Island Malaria Control Project (BIMCP) seeks to significantly reduce malaria transmission on the Island and as a result substantially reduce mortality and morbidity. The key malaria control components promoted by the BIMCP include universal access to free indoor residual spraying (IRS), free long lasting insecticide treated bed nets (LLINs), effective case management with diagnostic confirmation and free Artemisinin Combination Therapy (ACT), free intermittent preventive treatment for pregnant women (IPT), integrated information, education and communication and behavior change communications (IEC/BCC) and comprehensive monitoring and evaluation.

As a result of the early success of the BIMCP, in 2006, the Government of Equatorial Guinea was awarded a grant to implement the Equatorial Guinea Malaria Control Initiative (EGMCI) with MCDI as the designated Principal Recipient. The goal of the EGMCI is to significantly reduce the transmission of malaria on the continental region of Equatorial Guinea and as a result to substantially reduce mortality and morbidity. EGMCI began operations on the mainland in October 2006. The Global Fund approved 12.9 million dollars for the initial two years of this five-year grant. In addition, the Marathon Foundation donated $1.0 million to support start-up activities.

3.1.1. Program Components

Vector control – IRS

The IRS component consists of the semi-annual spraying of all structures on Bioko Island (starting in 2004) and in the Provinces of Litoral (starting in 2007) and Kie Ntem (starting in 2008) on the mainland to control transmission of malaria by anopheles mosquitoes. IRS acts on indoor biting mosquito vectors after they have taken a blood meal when they seek to rest on the nearest vertical surface they can locate indoors. Insecticide thus applied to all inner walls, doors, eaves, and beams, kills the vector before it can digest the blood meal and retransmit the malaria parasite in a subsequent blood meal.

IRS was not part of the National Roll Back Malaria Strategic Plan for EG 2002-2006 (May 2002), but it has subsequently become the cornerstone of the nation’s malaria control strategy as a result of the BIMCP and its demonstrated impact. IRS was introduced to the mainland via the EGMCI as a result of the success of the BIMCP. To-date, 7 full rounds of spraying have been conducted on Bioko Island, and 1 full round of spraying has been conducted in Litoral Province of the mainland.


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A comparison of the two projects is presented below:

BIMCP EGMCI IRS conducted twice annually with high but

reportedly declining coverage rates on the island (85% in 2004 to 65% in 2007).

Demand for IRS in terms of stated willingness to have their houses sprayed in the next year remains above 85%.

Increasing resistance encountered due to confusion related to the importance of an integrated set of interventions (e.g., LLINs do not reduce the need for IRS), to adverse reactions to insecticide, and inconvenience effect.

Continued training of IRS Advance Teams on key messages on IRS for households and continuation of spraying rounds.

To date, BCC materials have been developed to increase knowledge of IRS and its benefits and promote spraying in households (fotonovela, pre/post pamphlet); Currently under development are materials to promote integrated messages which emphasize the benefits of IRS, case management, and LLINs.

Start-up of IRS activities conducted in Litoral Province on the mainland (Bata, Cogo and Mbini) in 2007 including training IRS advance teams on key messages on IRS for households

Adapted BCC materials to mainland (as appropriate) in order to: 1) increase knowledge of IRS and its benefits; and 2) promote spraying in households (fotonovela, pamphlet).

Spraying in Kie Ntem Province to commence in 2008 while continuing in Litoral Province.

Vector control – LLINs

Two major bed net distribution campaigns were carried out by the BIMCP and EGMCI with support from the Spanish and Equato-Guinean chapters of the Red Cross and in collaboration with the MOHSW and MCDI on Bioko Island and Centro Sur Province on the mainland in 2007. A similar campaign will be conducted in Wele Nzas province in 2008. The objective of each of the campaigns was to ensure that there was a LLIN provided free-of-charge for every bed or sleeping area that did not have a pre-existing net in good condition and to promote the effective use and treatment of these nets. Nets were distributed by teams of Red Cross volunteers that demonstrated the hanging of one net per household as an example to the family, and that sought to educate the households using posters, calendars and pamphlets developed for this purpose.


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BIMCP EGMCI Bed net distribution campaign to distribute

LLINs was launched in November 2007 based on a distribution method used on the mainland with community-based Red Cross volunteers.

Trained volunteers on disseminating key messages and identified potential new cadre of community-based volunteers, e.g., consejeras.

Materials developed to promote LLINs and bed net distribution campaign, e.g., pamphlet, posters, calendars, radio spots.

Keep-up campaign materials to be developed to support and ensure proper utilization of bed nets previously distributed.

LLINs were distributed in Centro Sur through community-based Red Cross volunteers; distribution planned in Wele Nzas province in mid-2008

Trained volunteers on disseminating key messages and identified potential new cadre of community-based volunteers, e.g., consejeras.

Materials developed to promote LLINs and bed net distribution campaign, e.g., pamphlet, posters, calendars, radio spots.

Keep-up campaign materials to be developed to support and ensure proper utilization of bed nets previously distributed.

Malaria Case Management

This component consists of provision of drugs and diagnostic supplies to all MOHSW health facilities based on the national treatment protocol, technical assistance and training for health providers in improved diagnosis and treatment of malaria, monitoring and evaluation (M&E) including illness case reporting from a strengthened health information system, annual parasitemia, knowledge, attitudes and practice surveys, monthly drug supply and health information system monitoring visits and semi-annual clinical supervision rounds, and monitoring of drug resistance. The focus of the component is on early care seeking with fever, appropriate diagnosis through microscopy and/or rapid diagnostic tests, compliance with and completion of treatment, and access to free drugs and diagnostic tests at MOHSW facilities for children under 15 years of age and pregnant women.

In 2005, the BIMCP worked with the NMCP to introduce a change in the prevailing malaria treatment policy by eliminating CQ as the first-line monotherapy of choice. The BIMCP and NMCP introduced ACT utilizing an Artesunate and Sulfadoxine Pyrimethamine combination treatment protocol along with enhanced microscopy in hospital labs and the use of RDTs at health centers without labs. In 2007, the MOHSW (following recommendations of WHO), determined that as of January 2008, the standard ACT malaria treatment should be artesunate (AS) and amodiaquine (AQ). The BIMCP is now developing new IEC/BCC materials that accord with the new protocol, both for providers and caregivers. A similar IEC strategy and materials will be introduced by the EGMCI in 2008 as part of a roll-out activity that is scheduled to take place in all of the mainland MOHSW health facilities by August.


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BIMCP EGMCI A new malaria treatment protocol will be

introduced utilizing AS + AQ in 2008. IEC materials to ensure proper adherence to this protocol by providers and compliance by patients are under development and will be rolled out in March / April 2008.

Proper diagnosis of malaria based on microscopy or Rapid Diagnostic Test (RDT) and treatment with ACT are available at all health facilities. ACT under the new protocol will be available free of charge to pregnant women and children under 15 years. The MOHSW recognizes that user fees such as charges for diagnostic consultation adversely affect the uptake and utilization of care at MOHSW facilities, and so efforts are underway to exempt all malaria patients from such payments. This new pricing strategy will bring EG into conformity with the Abuja Declaration to which it is a signatory.

IEC materials are designed to: 1) increase knowledge of danger signs and severity of malaria; 2) encourage prompt care-seeking practices; 3) increase adherence to treatment protocols at the household level; 4) increase skills of health providers for quality diagnosis and treatment. The materials developed to date include posters, flipcharts, and reminder cards for patients and job aids for health providers.

AS + AQ will be introduced in 2008. Roll-out is scheduled to begin in March and will be completed in all mainland MOHSW facilities by August.

Diagnostic tests and ACT will be available free-of-charge to all patients. The MOHSW recognizes that user fees such as charges for diagnostic consultation adversely affect the uptake and utilization of care at MOHSW facilities, and so efforts are underway to exempt all malaria patients from such payments. This new pricing strategy will bring EG into conformity with the Abuja Declaration to which it is a signatory.

BCC materials developed for Bioko will be adapted as appropriate to the mainland.

Malaria in Pregnancy

This component consists of strengthening ANC, provision of SP as a prophylaxis for pregnant women, training and support to health service providers, and M&E. IEC objectives include encouraging pregnant women to regularly attend ANC and receive IPT, iron, and folic acid and increasing LLIN use during pregnancy.


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The national protocol for malaria has not been officially approved; there is a Therapeutic Guide which was recently updated that represents the latest national guidelines. The NMCP in conjunction with the BIMCP/EGMCI and ISCIII is promoting three doses of Fansidar for all women during their pregnancy, which is in line with international recommendations. The first dose is given upon quickening or at 16 weeks. Subsequent doses are given at a minimum of one month intervals. A comparison of the two projects is presented below:

BIMCP EGMCI Utilization of IPT is promoted at antenatal

clinics. Due to difficulty in determining gestational

age with precision, quickening (fetal movement) is used as criteria for beginning IPT

BCC materials have been developed to: 1) encourage pregnant women to seek antenatal care; 2) accept and adhere to IPT, and 3) assist health providers to correctly provide IPT and counseling.

Utilization of IPT is promoted at antenatal clinics.

Due to difficulty in determining gestational age with precision, quickening (fetal movement) is used as criteria for beginning IPT

BCC materials have been developed to: 1) encourage pregnant women to seek antenatal care; 2) accept and adhere to IPT, and 3) assist health providers to correctly provide IPT and counseling.

3.2 Spanish Development Assistance and Malaria Control

The Spanish government supports the NMCP through the la Fundación para la Cooperación y Salud Internacional Carlos III (ISCIII), which currently implements a malaria control program covering 2008-2012. The funding is managed directly by ISCIII. The key elements of this program are:

• Implementation of an integrated malaria control program on Annobon Island

• Improving the quality of diagnosis of malaria through microscopy in MOH health facilities

• Reinforcement of the epidemiological monitoring system and malaria monitoring nationwide, including monitoring resistance to the drugs used to treat malaria

3.3 The World Health Organization (WHO)

The World Health Organization provides technical guidance in malaria control to the NMCP and to other organizations working in EG.

Unicef is the UN system responsible in communications and is present in Malabo.


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4. COMMUNICATION CHALLENGES

A table based on data gathered from the annual surveys and qualitative assessments for BIMCP, which identifies current barriers/challenges and communication initiatives to address these challenges by program component is included in section 5.2. The challenges identified by these quantitative and qualitative investigations form the basis for the development of this communication strategy.

BIMCP also recently conducted a risk analysis in 2007, which included a review of the issues/hazards faced by all program components. This analysis was carried out by the BIMCP home office and field staff as the basis for an external audit carried out by consultants from the U.S. Centers for Disease Control (CDC) and the Mentor Group. The risk assessment for case management and IPT components specifically identified the need for improved IEC/BCC.

The external audit also cited the need for a comprehensive and integrated set of IEC /BCC materials that integrate key messages for all of the program components. They recommended that the IEC package of standardized messages should include messages that inform and encourage people about the following:

1. What malaria is and who is most at risk 2. The need to reduce the risk of infection by having your house sprayed and or sleeping under

an LLIN 3. The need for pregnant women to go for IPT and added benefit of sleeping under an LLIN. 4. The need to seek prompt care at a health facility as soon as your child gets sick. 5. The new diagnostic test and the new treatment

To redress this issue, a set of integrated materials is currently under development.

Furthermore, communication initiatives have largely focused on materials development to increase knowledge of malaria and promote malaria control interventions which has been successful. In order to achieve behavioral objectives for each program component, additional activities will be incorporated utilizing interpersonal communication and mass media to reinforce key messages on preventing and managing malaria at the household level and generate demand for quality services at the service delivery level.


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5. COMMUNICATION STRATEGY

This document constitutes an important step towards the implementation of a comprehensive and integrated communications strategy developed with the input and participation of MOHSW NCMP personnel and collaborating stakeholders. One of the means for achieving impact through BCC is to combine a number of approaches to reach the maximum number of beneficiaries. The program will utilize multiple channels to increase synergy and MCDI will provide consistent, on-going IEC/BCC technical assistance for the MOHSW NMCP.

The goal of behavior change communication is to influence, involve and mobilize relevant sectors of society from the national level to the individual level, to foster positive behavior; promote and sustain individual, community, and societal behavior change. Planned social mobilization involves actions and processes to reach, influence, and involve all segments of society to create an enabling environment and effect positive behavior and social change.

The communication interventions used by the program can be categorized as mass media and interpersonal communication:

Mass Media

Mass media channels have the possibility of reaching large numbers of beneficiaries at a low to moderate cost, and are an excellent means of increasing awareness about the gravity of malaria in Equatorial Guinea, of improving knowledge about transmission, prevention, and treatment, and of modeling positive behaviors.. Mass communications channels to be used by the program include radio and television, print media such as billboards, posters, and banners, and special events.

Messages reinforce positive behavior change when they are clear, culturally and contextually relevant and endorse simple-to-do behaviors. All messages and materials are pre-tested before being reproduced and disseminated to ensure that they are culturally appropriate and understandable, and that they will reach the target populations.

While Spanish is the language of choice for mass media in EG, there is also a significant percentage of the population which speak either Bubi, Fang or pidgin. Taking this into account, the project will transmit messages in multiple languages and use community radio, in addition to national and private sector radio and television channels. The timing of radio and television messages will coincide with popular programs to increase the number of people reached. A study will be carried out to explore the literacy levels in local languages.

Interpersonal Communication

Effective interpersonal communication is key to achieving positive behavior change. In comparison with mass media communications, interpersonal activities have the advantage of allowing heads of household and caregivers to discuss their concerns and doubts about the program’s different interventions. They also provide an opportunity for communication agents to better understand


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values and obstacles to behavior change, so that individual solutions can be devised. The program will use a variety of means to communicate Key messages for malaria prevention and treatment will be reinforced through one-on-one consultations, home visits, and group sessions. IEC materials such as flipcharts and posters will be used to facilitate discussion, and pamphlets and flyers will be distributed as reminders of key messages.

5.1 Priority Behaviors

A prioritization was made of key behaviors that promote malaria prevention and control at multiple levels – household level, service delivery level and policy level. Key messages for each audience have been identified and are included in Annex C. Audiences and priority behaviors are summarized in the following table.

Audience Priority Behaviors General Public, men, husbands, other family members who support behavior change Families/Communities

Caregiver recognizes signs and symptoms of malaria and seeks immediate care Caregiver complies/adheres with appropriate treatment and/or referral Pregnant women receive IPT according to national protocol Families and communities actively support IRS by allowing their households to

be sprayed Pregnant women and children under-five sleep under a LLIN each night

Caregivers (mothers, fathers, relatives)

Caregiver recognizes signs and symptoms of malaria and seeks immediate care Caregiver complies/adheres with appropriate treatment and/or referral Pregnant women receive IPT according to national protocol Families and communities actively support IRS by allowing their households to

be sprayed Pregnant women and children under-five sleep under a LLIN each night

Pregnant women Pregnant women receive IPT according to national protocol Pregnant women and children under-five sleep under a LLIN each night

MOHSW Health care Providers

MOH facilities provide adequate care and/or referral according to national protocol

Support and implement policy guidelines compliant with new treatment and protocols

Policy makers, leaders and local authorities

Ongoing review of case management protocols is conducted to ensure that protocols and practices reflect known resistance levels with corresponding availability of effective and adequate drug supplies

Advocate for adequate resources to support, scale-up and sustain malaria case management component, including continued free treatment, IPT , IRS and LLINs


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5.2 Barriers to Behavior Change

Survey results have demonstrated several positive changes in malaria-related behavior, knowledge, and attitudes since the beginning of the program. The following table presents information on behaviors among the program’s target groups, influencing factors, and their evolution from baseline to follow-up, and describes communication activities that the program has and will undertake to promote further uptake of key behaviors.

The primary sources of information for this table are the 2004 and 2007 annual household surveys carried out on Bioko under BIMCP; when data are from other sources, they are cited.

1. Malaria Case Management Barriers/challenges (Baseline 2004)

Barriers/challenges (Survey 2007) Communication activities to address barrier/challenges

Household level: Most caregivers (85%) sought care

24 hours after onset of symptoms Many children (50%) did not

receive antimalarials (MICS, 2001) Half of caregivers (50%) did not

adhere to treatment 54% of caregivers named fever as a

malaria symptom Many caregivers treated cases at

home with inappropriate medications and doses (G. Mazia report, 2004)

Most children did not receive antihelmintics during follow-up from malaria episode (G. Mazia report, 2004)

Service delivery level: Many health care providers were

not using the recommended treatment protocol (G. Mazia report, 2004)

Many health care providers spent limited time with patients on counseling (G. Mazia report, 2004)

Most uncomplicated cases were unnecessarily treated at the hospital with unnecessary medications (G. Mazia report, 2004)

A minority of malaria patients were receiving antipyretics (G. Mazia report, 2004)

Few children were receiving micronutrients supplement (G. Mazia report, 2004)

Policy level:

Household level: Some caregivers (67%) sought care 24

hours after onset of symptoms Some children (30%) did not receive

antimalarials (survey 2006) 16% of caregivers did not adhere to

treatment (HH Survey, 2006) 81% of caregivers named fever as a

malaria symptom Some caregivers did not trust health

providers and thus went to traditional healers (L. Morales report, 2006)

Some caregivers did not know treatment medications were free (L. Morales report, 2006)

Many caregivers (81%) did not receive the reminder cards explaining drug schedule developed by MCDI (HH survey, 2006)

Service delivery level: Some health care providers were not

using the recommended treatment protocol (HH survey, 2006)

Many health care providers spent limited time with patients on counseling (HH survey, 2006)

Many malaria cases were given antibiotics (L. Morales report, 2006)

Few children were receiving micronutrients supplement (HH survey, 2006)

Policy level: Some health facilities were found to be

closed, limiting access to care (HH survey, 2006)

Need for adequate resources to

Household level: Materials developed for caregivers to

increase knowledge of danger signs, importance of prompt care-seeking, adhering to treatment, and promoting free services at health facilities

Adapt existing messages and materials for caregivers according to new treatment guidelines to encourage new treatment adherence.

Material in development to integrate messages on importance of case management, utilizing bed nets and IRS (recommended by R. Allan report, 2007).

Service delivery level: Improve interpersonal counseling skills

between provider and patient Adapt existing messages and materials

for caregivers according to new treatment guidelines to encourage new treatment adherence.

Material in development to integrate messages on importance of case management, utilizing bed nets and IRS (recommended by R. Allan report, 2007)

Policy level: Following recommendations by WHO,

the MOH determined that as of January 2008, the standard ACT malaria treatment should be artesunate and amodiaquine.

Encourage promotion of free services at health facilities

Ensure health facilities are sufficiently


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Need for adequate resources to support, scale-up and sustain malaria case management

support, scale-up and sustain malaria case management

equipped with staff to prevent closing Advocate for adequate resources to

support, scale-up and sustain malaria case management

2. Malaria and pregnancy Barriers (Baseline 2004)

Barriers (Survey 2007) Communication initiatives to address barriers

Household level: 82% of pregnant women received

IPT during her last pregnancy (baseline) although many pregnant women reported not receiving IPT or chemoprophylaxis (G. Mazia report, 2004)

Poor knowledge about dangers of malaria in pregnancy and use of IPT in pregnancy (G. Mazia report, 2004)

Some pregnant women (22%) did not receive iron supplementation (G. Mazia report, 2004)

Many pregnant women (60%) reported not sleeping under a bed net every night

Service delivery level: Many health providers were not

knowledgeable about IPT and appropriate treatment of malaria in pregnancy (G. Mazia report, 2004)

Health providers at ANC facilities had limited time for IEC and counseling about IPT (G. Mazia report, 2004)

Policy level: Need for adequate resources to

support, scale-up and sustain malaria and pregnancy component

Children under 1 year of age were not receiving routine IPT (G. Mazia report, 2004); introduced in 2006

Household level: 85% of pregnant women received IPT

during her last pregnancy Most women knew that malaria was

especially dangerous to pregnant women, but some did not know when to start IPT and number of doses to take (L. Morales report, 2006)

More than half of pregnant women (55%) reported that they did not receive iron supplementation

Misperception among pregnant women that there is a fee for IPT (L. Morales report, 2006)

Many pregnant women (70%) reported not sleeping under a bed net every night

Service delivery level: Some health providers were not

knowledgeable about IPT and appropriate treatment of malaria in pregnancy (L Morales, 2006)

Health providers at ANC facilities had limited time for IEC and counseling about IPT (L Morales, 2006)

Materials developed by MCDI distributed to health facilities was not in wide use (L Morales, 2006)

Although providers generally reported providing information on IPT, some women interviewed did not did not know when to start IPT and number of doses to take (L Morales report, 2006)

Policy level: Need for adequate resources to support,

scale-up and sustain malaria and pregnancy component

Consensus needed to start IPT after quickening (P. Kachur, 2007)

Need consensus on whether or not to emphasize IPT drugs as free (R. Charleston, 2007)

Household level Materials developed for pregnant

women to increase knowledge of dangers of malaria in pregnancy, encourage ANC visits, adhering to IPT and promote free services at ANC


Service delivery level: The Instituto de Salud Carlos III

(ISCIII) has established IPT as a priority for its malaria control program and has developed a range of training materials, job aids and IEC materials on IPT.

Promote training and use of existing materials as appropriate.

Policy level: Advocate for adequate resources to

support, scale-up and sustain malaria and pregnancy component

Advocate that women receive IPT dose at every antenatal care visit after quickening, but not to exceed once per month (see recent WHO guidance and experience of Malawi and Zambia, under recommendation by P. Kachur, 2007).

Promote free services at health facilities

3. Vector control – IRS Barriers (Baseline 2004) Barriers (Survey 2007) Communication initiatives to address


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barriers Household level: Perceived inconvenience of using

IRS, e.g., families need to clean the floor after spraying before children and pets enter the home (G. Mazia report, 2004)

Families perceived that nuisance mosquitoes are not being killed by IRS (G. Mazia report, 2004)

Lack of knowledge about benefits of IRS and importance of preventing malaria (G. Mazia report, 2004)

A majority (92%) did not mention spraying (unprompted) as a way to prevent malaria

Concerns about safety and effects of chemicals in IRS (G. Mazia report, 2004)

Service delivery level: Providers at understaffed facilities

had little time for counseling on benefits and appropriate use of IRS as part of comprehensive strategy to prevent malaria (G. Mazia report, 2004)

Insufficient time provided for interpersonal communications during IRS visit (G. Mazia report, 2004)

Policy level: 2002-2007 National Malaria

Control Plan did not include IRS as an intervention

Ensure adequate resources to support, scale-up and sustain vector control – IRS

Household level: Increased refusal rates as some believe

that bed nets replace IRS (R. Allan report, 2007) and IRS may be seen as something that “poor people” need (L Morales report, 2006)

Concerns about safety and effects of chemicals on family members and animals (L Morales report 2006)

Many (86%) did not mention spraying (unprompted) as a way to prevent malaria

Service delivery level: Providers at understaffed facilities had

little time for counseling on benefits and appropriate use of IRS as part of comprehensive strategy to prevent malaria

IRS delivery method needs to be improved, e.g., by reinforcing the communication skills of the sprayer and IRS advance team (L Morales report 2006)

Policy level: National Health Plan now includes IRS

as an intervention Some resistance to IRS encountered by

gatekeepers such as military and police (L Morales report, 2006)

Ensure adequate resources to support, scale-up and sustain vector control - IRS

Household level: Materials developed for household to

explain the purpose of IRS, what to do before and after visit by sprayer, and benefits and safety of IRS.


Service delivery level: Train health providers on IEC and

importance of IRS Train IRS advance team on IEC and

how to use materials on IRS, case management and LLINs with household members (via interpersonal communication)

Work with and engage community-based groups such as women’s group to provide entry into households for IRS


Policy level: Advocate for adequate resources to

support, scale-up and sustain vector control - IRS

4. Vector control – LLINs Barriers (Baseline 2004)

Barriers (Survey 2007) Communication initiatives to address barriers

Household level: Lack of knowledge about benefits

of ITNs and importance of preventing malaria (G. Mazia report, 2004)

Household level: 65% named (unprompted) bed nets as a

way to prevent malaria A coverage rate of over 80% was

achieved through a bed net distribution

Household level: Bed net campaigns conducted to

promote proper utilization of LLINs Materials developed to inform

households on benefits of LLINs and


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56% named (unprompted) bed nets as a way to prevent malaria

Inappropriate use of ITNs, e.g., few children under 5 and pregnant women are sleeping under the ITN every night (G. Mazia report, 2004)

6% of children slept under an ITN the night before the survey

Most bed nets are not impregnated (G. Mazia report, 2004) – no longer an issues with LLINs

Lack of access to ITNs and re-treatment services (G. Mazia report, 2004) – no longer an issues with LLINs

Concerns about safety and effects of chemicals in ITNs (G. Mazia report, 2004)

Service delivery level: Providers at understaffed facilities

had little time for counseling on benefits and appropriate use of ITNs as part of comprehensive strategy to prevent malaria (G. Mazia report, 2004)

Policy level: Promote bed net campaign

distribution to communities (G Mazia report, 2004)

Ensure adequate resources to support, scale-up and sustain vector control - LLINs

campaign (LQAS 2007) Households need to maintain and keep

up LLINs Some places for sleeping are not

permanent, e.g., kitchen and LLINs are placed in corridor, dining room and aisle and not bedroom

30% of children slept under an ITN the night before the survey

Some did not use bed nets as their house had been sprayed, e.g., were not aware of benefit of other intervention such as LLINs (R Allan’s report, 2007)

Service delivery level: Providers at understaffed facilities had

little time for counseling on benefits and appropriate use of ITNs as part of comprehensive strategy to prevent malaria

Policy level: Promote for LLIN distribution to

caregivers of children discharged from health facility/hospital after malaria episode

Ensure adequate resources to support, scale-up and sustain vector control - LLINs

appropriate use of LLINs especially for children under five and pregnant women

Adapt or create new materials to encourage maintenance and keep-up of LLINs


Service delivery level: Train health providers on IEC and

interpersonal communication counseling to promote use of LLINs


Policy level: Advocate for LLINs to be distributed to

children who are discharged from health facility after malaria episode

Advocate for adequate resources to support, scale-up and sustain vector control - LLINs

5.3 Program Activities

Component Behavior Activity Case Management

Caregiver recognizes signs and symptoms of malaria and seeks immediate care

Caregiver complies/adheres with appropriate treatment and/or referral

Families and communities recognize that malaria is a serious illness which can be cured and prevented


Support and implement policy guidelines compliant with new treatment and protocols Ongoing review of case management protocols is conducted

to ensure that protocols and practices reflect known

Radio/Television Printed Material IRS Advance Team Counseling by Health Providers Community Events Advocacy Strategy


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resistance levels with corresponding availability of effective and adequate drug supplies

Advocate for adequate resources to support, scale-up and sustain malaria case management component, including continued free treatment, IPT, IRS, and LLINs

Malaria in Pregnancy

Pregnant women receive IPT according to national protocol MOH facilities provide adequate care and/or referral

according to national protocol Support and implement policy guidelines compliant with new

treatment and protocols Ongoing review of case management protocols is conducted

to ensure that protocols and practices reflect known resistance levels with corresponding availability of effective and adequate drug supplies


Radio/Television Printed Material IRS Advance Team Counseling by Health Providers Community Events Advocacy Strategy

Vector Control -ITN

Pregnant women and children under-five sleep under a LLIN each night


Radio/Television Printed Material Community Events Campaign of LLIN Distribution Advocacy Strategy

Vector Control-IRS

Families and communities actively support IRS by allowing their households to be sprayed


Radio/Television Printed Material IRS Advance Team Community Events Advocacy Strategy

Radio/Television

Equatorial Guinea has two radio and television stations: the national station and the private station-ASONGA. There are also three rural stations on the mainland, affiliated with the national station. Radio represents an important channel for communication of malaria messages, as a large proportion of the population has access to radio and listens regularly. The program will utilize all of the channels to reach the widest possible audience through spots, regular programs and announcements for special events or activities. Radio spots will promote the benefits of key behaviors, while more lengthy radio programs provide a forum for discussion of issues and concerns. The program will aim to attract the widest possible audience by producing shows that are not only educational but entertaining as well. Radio productions will promote all intervention areas, and where appropriate will stress the importance of combining different preventive and care-seeking behaviors to maximize protection from malaria. Spots will be produced in Spanish and local languages, to ensure maximum understanding and appreciation by the population.


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Television has a more limited audience in Equatorial Guinea, and therefore will be used sparingly, to publicize special events and to obtain periodic press coverage of project activities.

Printed Material

A comprehensive set of print material will support the various activities planned by the program. Signage such as posters, billboards, murals and banners will be used to raise awareness among the general public, opinion leaders and policy makers about the integrated program components and impact of interventions. Billboards will be placed in key locations of the capital to serve as a constant reminder of the program’s presence. The project logo will be placed prominently with the objective of gaining recognition and visibility for the interventions. Pamphlets, flyers, and posters will be used to reinforce messages, provide more detailed information, and serve as a reminder for positive behaviors. All will be designed with a harmonized set of images and colors to make materials from the project recognizable as a cohesive set.

Interpersonal Communication by IRS Advance Team

The role of the Advance Team is to encourage families and communities to support IRS by allowing their households to be sprayed, as well as to provide information about other components of the malaria program. The teams make pre-spraying visits to communities and during spraying campaigns accompany the sprayers to encourage families and communities to comply with pre- and post-spraying protocols. On Bioko, they also reinforce messages about the importance of IRS as a complementary intervention to case management and LLINs, not a replacement. The team uses megaphones and vehicle loud speakers to announce the arrival of the spray team and printed material as well as fotonovelas and pamphlets to provide additional information and encourage reluctant households. A team of 12 advance agents are working on Bioko and 24 are working on the mainland. They are specially trained to advise the community about the spraying activities, and will undergo refresher training to improve their ability to address resistance from heads of household. Assuaging concerns about the safety of the insecticide, about the effectiveness of IRS in killing malaria-transmitting mosquitoes, and helping residents to accept the inconvenience of twice-yearly spraying are key responsibilities of the Advance Teams. Radio spots and programs are also used to announce spray schedules and encourage participation in spray campaigns.

Counseling by Health Providers

Health providers represent another important channel for communication with the program’s priority target groups. They are respected and trusted by community members and they generally have a good understanding of the socio-economic and cultural context of the community members with whom they interact. Routine services for children and pregnant women are ideal opportunities to interact with the program’s priority target groups. These contacts are cost-effective opportunities to counsel individuals and to provide drugs and services. The program will train health providers at all public health centers and hospitals in effective interpersonal communication and counseling skills, including the use of print materials and job aids designed to facilitate malaria diagnosis,


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encourage adherence to treatment, promote preventive behaviors, and counsel the use of IPT. Posters and pamphlets at health facilities will be used to reinforce messages.

Community Events

Two types of events will be used as part of the communication strategy: special events (World Malaria Day, sporting events, national holidays, launches for IRS and LLIN campaigns) and community fairs that include music, contests, theater performances, educational talks, and press coverage. The malaria program will seek to augment its presence through participation in special events, and through the organization of launch ceremonies to mark the start of activities such as the expansion of IRS activities to Kie Ntem province on the mainland, the LLIN distribution campaign in Wele Nzas province, and the official launch of the new drug treatment protocol. Ongoing community events such as traveling fairs or theater performances will be held to increase the reach of malaria messages to rural populations who may have limited access to mass media, and to increase the number of sources from which the population receives malaria messages.

Campaign of LLIN Distribution

A system of use of community Consejeras and Red Cross volunteers was used in the past and will be utilized for future campaigns both for initial distribution and education on the importance of LLIN use as well as to promote and maintain “keep-up” of bed nets. The distribution includes volunteer delivered messaging on malaria (cause, prevention and fever treatment) and health promotion. The volunteers will go door-to-door and/or organize community meetings to not only pass messages, but to also ensure that LLINs are hanging correctly and are being used by the intended target group. The “Keep-Up” portion of the campaign will emphasis the importance correct care of LLINs to maximize the duration of their effectiveness (including washing and drying instructions, repair of holes, etc.), and will remind caretakers of the importance of continuing to sleep under LLINs every night, throughout the year.

Advocacy Strategy

Advocacy is an important tool for raising awareness, ensuring visibility and garnering political support for program activities. As the country’s number one cause of sickness and death, malaria control needs to remain a top priority for the health and economic development of Equatorial Guinea. The BIMCP has demonstrated significant achievements since its start in 2003 in terms of infection levels and child mortality, and this success has been leveraged to extend activities to the EGMCI project on the mainland. Publicity for the program will include the use of signage such as billboards, banners, and posters, special events, and appearances/interviews with influential individuals. Informational meetings with leaders and local authorities will be conducted to improve their understanding and support of the program, and to leverage their influence on their respective services/communities for malaria control objectives.


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5.4 Future Plans

A detailed implementation plan for 2008 is included in Annex C. The program will focus on the key areas previously discussed but several other areas of focus will be studied in 2008 in order to develop cogent strategies for future implementation. These include working more directly with communities, schools and the informal health sector.

Community level interventions are one of the best ways of reaching the most vulnerable and marginalized individuals and allow for specific messaging related to perceived barriers. Community members who are familiar with the population and the context are able to tailor messages and confront different barriers; ranging from geographical (limited physical access to health facilities) to information (lack of knowledge about prevention) to misinformation (cost and efficacy of treatment). Delivery of messages may need to vary from community to community, but it should be kept in mind that the underlying messages should all be consistent and direct.

Schools provide a venue for reaching children and their families. Information shared with children is taken back to the household where it will often be discussed so that not only is the child receiving the messages, but these are being shared at home with parents and siblings. Schools can also establish early, positive behaviors and understanding of risks. If children are told early and repeatedly about, for example, the importance of LLINs for malaria prevention, this message will remain with them as they grow and have their own families.

Equatorial Guinea has a strong tradition of the use of traditional healers. They are influential members of the community who in some cases are the first sources of health-related advice and care. They can have an influence on care seeking and treatment, as well as community compliance with IRS and LLIN use.

Inhabitants of certain villages do not have ready access to a hospital or health center. Health posts staffed by community health workers are in varying states of function throughout the country, with greater coverage in the mainland region. The MOHSW has plans to strengthen the primary health care system by rehabilitating health posts staffed by community health workers. Efforts should be made to extend coverage with malaria diagnosis, treatment and counseling through this network, to ensure greater access to malaria care and information for inhabitants of rural villages. At the same time, these community health workers should receiving training in counseling for malaria prevention, treatment adherence, and patient follow-up.


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6. MONITORING AND EVALUATION

The program will measure the priority behaviors outlined in Section 5. Communication Strategy, as well as monitor process indicators throughout the implementation phase.

Sources of data for monitoring and evaluation include:

Annual surveys (fundamental instrument used) and follow-up surveys Formative/qualitative research; focus groups, key informant interviews, Doer/Non-doer

analysis, etc. Supervision/Monitoring visits for direct observation, exit interviews, and inventory checklist LQAS IEC Monitoring

Key Behavior Indicators (Outcome) Method of Measure % of women who reported sleeping under an LLIN during their last pregnancy

Annual Survey

% of children under-five who slept under an LLIN the previous night

Annual Survey; post-distribution LQAS

% of children under five with malaria who receive an effective anti-malarial within 24 hours of onset

Annual Survey

% of women who reported receiving 2 or more doses of IPT during their last pregnancy

Annual Survey

% of Caregivers who recognize signs and symptoms of malaria

Annual Survey

% of respondents who reported having their house sprayed in the last year

Annual Survey

Knowledge and Attitude Indicators (Output) % of respondents who know malaria is transmitted by mosquitoes

Annual Survey

% of respondents who name LLINs or IRS as effective means of preventing malaria

Annual Survey

% of respondents who know malaria diagnosis and treatment are free for pregnant women and children under 15 in public health centers and hospitals

Annual Survey

Process Indicators # of health personnel trained in effective diagnosis, treatment and counseling

Training participant registers

# of IEC agents trained in communication for malaria control

Training participant registers

# of community outreach activities conducted Activity reports


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# of radio spots and programs produced and # of broadcasts

Activity Reports

# of advocacy events held Activity Reports # of IEC materials produced and disseminated Activity Reports % of respondents who heard/saw a malaria message during the last month

Annual Survey and LQAS IEC Monitoring


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ANNEXES

Annex A: Materials developed to date (see CD-ROM) 1. Malaria case management

ACT reminder cards for caregiver (inserts with medication) ACT poster for health providers Malaria flipchart for health providers Pediatric pamphlet for caregivers Laboratory Counseling Guide Comic strip, “Esperanza no espera” Radio spots and programs for general public Provider-patient communication workbook Free diagnosis/treatment flyer Free treatment banners Antimalarial side effects job aid for providers (Draft)

2. Malaria and pregnancy

IPT posters for general public and pregnant women IPT pamphlets for pregnant women Free IPT flyer for pregnant women IPT radio spots and programs for general public and pregnant women IPT stickers for health workers and pregnant women IPT algorithm job aid for health providers IPT administration job aid for health providers Free IPT banners

3. Vector control – IRS Pamphlet for households Fotonovela for households Radio spots and programs for general public Safety posters for sprayers

4. Vector control – LLINs

Posters for general public Calendars for general public Mini-poster/flyer on LLIN use and care Radio spots and programs for general public


2

5. Integrated materials Pamphlet for community leaders (Draft) Cards for Comparison of Interventions with discussion guide Two Malaria songs Series of Billboards General malaria flyer Children’s story Malaria key messages reference for health promoters


3

Annex B: Key Messages for Targeted Audiences

1. Malaria Case Management Audience Key behaviors Key messages Caregivers (mothers, fathers, relatives, neighbors, friends)

Caregiver recognizes signs and symptoms of malaria and seeks immediate care Caregiver complies/adheres

with appropriate treatment and/or referral Families and communities

recognize that malaria is a serious illness which can be cured and prevented

Case management (first 3-5 days): Seek help from a trained provider within 48 hours of onset of fever. Increase fluids, continue feeding, and treat fever. Do not use any

other medications. Adhere to the full course of treatment, even if the patient begins to

feel better. Return to the health facility if fever does not drop after day 2, or if

the child presents any of the following signs: extreme paleness, lethargy, seizures, difficulty breathing/fast breathing, vomiting, unable to eat and drink.

Comply with referral if indicated. Keep the febrile patients sleeping under a LLIN. Return to the health facility for follow-up and additional

medications to treat anemia, intestinal parasites, update immunizations, anthropometric measures and dietary counseling.

Case management (follow-up) Increase food during the recovery period. Give the patient iron-rich foods: fish, snails, bush meat. Take as indicated the deworming treatment. Take daily iron supplements for 3 months.

Health providers (informal, formal, referral)

MOH facilities provide adequate care and/or referral according to national protocol Support and implement

policy guidelines compliant with new treatment and protocols

Case management (first 3-5 days): All fevers should be treated within 24 hours of onset. In addition to fever, the child may experience restlessness, general

weakness, or an inability to drink or breastfeed well. Other signs of malaria include body and joint pains, headaches, loss of appetite, shivering, and feeling cold.

Give the proper and full course of treatment. Do not give antibiotics or IV fluids unless the patient has signs of

pneumonia or severe dehydration.

Case management (follow-up): Return for follow-up after 3 months to examine the anemia status.

Policymakers/ Leaders (national, district, local)

Ongoing review of case management protocols is conducted to ensure that protocols and practices

Encourage health providers to provide information and services for malaria control

Promote BCC/IEC activities at community level to support care-seeking practices


4

reflect known resistance levels with corresponding availability of effective and adequate drug supplies

2. Malaria and pregnancy Audience Key behaviors Key messages Pregnant women

Pregnant women receive IPT according to national protocol Families and communities

recognize that malaria is a serious illness which can be cured and prevented

Malaria is a serious disease, especially during pregnancy. Malaria during pregnancy can cause maternal anemia, abortion,

stillbirths, premature delivery, perinatal anemia, low birth-weight infants, and, in severe cases, maternal death.

Pregnant women must receive at least 2 doses (3 tablets of SP each) after quickening, with an interval no shorter than a month.

Pregnant women must receive a daily dose of iron supplement from the first ANC visit.

All pregnant women should sleep under a LLIN to avoid mosquitoes that transmit malaria. LLINs are effective, and are safe for the mother and the unborn baby.

Families and other supporters of pregnant women (husbands, neighbors, friends)

Encourage pregnant women to: utilize IPT services recognize the importance of

IPT comply with national protocol take 3 doses of IPT (SP) after

quickening adhere to IPT (take all SP pills

as directed) adhere to iron supplementation

Support pregnant women to prevent and treat malaria in pregnancy by utilizing IPT services, recognizing importance of IPT and adhere to IPT as directed.


Health providers


Malaria is a serious disease, especially during pregnancy. Malaria during pregnancy can cause maternal anemia, abortion, stillbirths, premature delivery, perinatal anemia, low birth-weight infants, and, in severe cases, maternal death.

Fever during pregnancy is not normal. All pregnant women should get advice and proper treatment from a qualified health worker when they have fever during pregnancy.

IPT is very effective, and are safe for the mother and the unborn baby. IPT during pregnancy are recommended by MOH and WHO.



Ongoing review of case management protocols is conducted to ensure that protocols and practices reflect known resistance levels with


Promote BCC/IEC activities at community level to support malaria and pregnancy


5

corresponding availability of effective and adequate drug supplies

Advocate for adequate resources to support, scale-up and sustain malaria case management component, including continued free treatment, IPT and IRS LLINs

3. Vector control – IRS Audience Key behaviors Key messages Households/ communities

Families and communities actively support IRS by allowing their households to be sprayed


Remain at home the day of the scheduled spraying. Remove furniture from around the walls and pictures or objects from

the walls. Remove from the house or cover food and utensils. Take out your domestic animals. Make sure that all family members remain outside during spraying. Remove valuables from your home before the sprayers arrive. Wait 1-2 hours to return to your home and sweep or mop the floor

and burn or bury dead insects before children and pets enter the house.

Nuisance mosquitoes are not always killed by IRS; malaria mosquitoes are.

Malaria can be prevented in these areas by using chemicals for indoor residual spraying of houses to kill the mosquitoes that carry malaria.

IRS is a safe and cost-effective method for controlling malaria. The insecticides used for IRS are safe, and are recommended by the MOHSW and WHO.

All households should be sprayed according to a defined schedule based on the type of insecticide used

Local IRS teams have been specially trained and equipped to provide free and correct IRS services.




Promote BCC/IEC activities at community level to support IRS

4. Vector control – LLINs Audience Key behaviors Key messages


6

Households/ communities

Pregnant women and children under-five sleep under a LLIN each night


If you have a LLIN, make sure that young children and pregnant women sleep under it every night.

Malaria is a serious disease carried by mosquitoes that bite at night. Mosquitoes carrying malaria can be avoided by sleeping under a LLIN.

ITNs are safe and effective, even for children and pregnant women. Pregnant women and children under 5 years should use a LLIN

every night, to prevent serious illness and complications due to malaria.

LLINs are impregnated with an insecticide that is effective against malaria-transmitting mosquitoes for 3-5 years with proper care

LLINs may be washed no more than once every 4 months, in reglar water with soap (avoid hot water, bleach, and detergents), and should be hung to dry away from direct sunlight

If the LLIN tears, it can be easily repaired by sewing up holes with a needle and thread




Promote BCC/IEC activities at community level to support LLINs


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Annex C: Detailed Implementation Plan 2008 EGMCI and BIMCP

Activity Responsible

Persons M A M J J A S O N D

IRS Advance Team Meetings with Community leaders prior to spray round

IRS Advance Team

X X X X

Meetings with community members before arrival IRS Advance Team

X X X X X X X X X X

Megaphone announcements during spraying IRS Advance Team

X X X X X X X X X X

House to house visits; priority- resistant households IRS Advance Team

X X X X X X X X X X

Purchase of materials (megaphone, vehicle loudspeaker, educational materials)

COP X

Contracting of additional IRS Advance Team Staff COP/IRS Manager

X

Training for IRS Advance team on communication skills

IEC Team X X X

Training for IRS Advance team, Supervisors, Sprayers on malaria and communication

IEC Team X

Supervision of IRS Advance Team IEC Supervisor X X X X X X X X X X

IEC Materials Review, validate, and revise materials for community and health providers

Consultant, IEC Team

X X

Contract artist for drawings COP X X Produce materials Consultant,

IEC Team X X X

Train on use of materials IEC Team X X X Training on use of flipchart in health centers Consultant X Develop calendar for 2009 with malaria messages IEC Team X Develop finalize and validate new materials for IT curtains and wall coverings and keep-up bed net campaign

Consultant, EGMCI IEC Team

X

Produce and disseminate IT curtains and wall coverings

HQ/Field X

Produce and disseminate keep-up bed net campaign materials

HQ/Field X X

Review and evaluate effectiveness of IEC materials, revise as needed

Consultant IEC Team

X

Develop new IEC materials based on need Consultant IEC Team

X X


8

Activity Responsible Persons

M A M J J A S O N D

Communication by Health Providers Finalize, validate and TOT for training module on communication for training health providers

Consultant, IEC Team

X

Implement training module on communication for training health providers

Case Mgmt Coordinators IEC Team

X X

Supervision of Health Providers MOHSW X X X X X X X X XDevelopment of monitoring plan for health provider communication

IEC Team X

Monitor effectiveness of communication by Health Providers through direct observation & exit interviews

MOHSW IEC Team

X

X

X

X

X

X

X

X

Announcement of new protocol (press conference, lunch, speakers)

MOHSW IEC Team

X

Radio/Television Review previously developed spots and develop additional spots as needed

IEC Team X X X

Evaluate the options of subcontracting the MICT or contracting a radio coordinator

Lucho X

Seek authorization (National Radio) and contract (Asonga) for a weekly malaria program and spots

MICT or coordinator

X

Develop technical content for program IEC Team X X X X X X X X XImplement a twice weekly radio program (1 National and 1 Asonga)

MICT or coordinator

X X X X X X X X X

Provide tapes to rural radios for retransmission MICT or coordinator

X X X X X X X X X

Contract Asonga or MICT for production and distribution of a series of 4 television ads

COP X

Implement 4 TV advertisements MICT or Asonga

X X X X X X X X

Advocacy Annual meeting with government authorities COP MOHSW X Presentation to Parliament COP MOHSW X Community leader meetings (Delegados) IEC Team X X X Development of presentation materials IEC Team X Meeting with military leaders IEC Team X Meetings with Religious Leaders IEC Team X X

Public Events Contract with MICT for mobile health fairs COP X Design guideline of steps IEC Team X Define content and specific messages each quarter and train teams in content

IEC Team X X X


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M A M J J A S O N D

Traveling fairs 10 per month- mainland and Bioko implemented on 3 month rotations

MICT X X X X X X

Monitor events IEC Team X X X X X X Evaluate impact of fairs IEC Team X Special events (Malaria Day April 25, Soccer June 13, Independence Day Nov 12)

X X X

Organize committee MOHSW X X X Designate Event Coordinator COP X X X Coordinate with other institutions Event

Coordinator X X X

Develop plan of activities and budget Event Coordinator

X X X

Implement COP X X X Opening for Spraying in Kie Ntem IEC Team/

COP X

Opening for Bed Net Distribution IEC Team/ COP

X

LLIN Distribution Campaign EGMCI Coordination with Red Cross/Ministry for Promotion of Women

Case Mgmt Coordinator

X X

Pre-testing and adaptation of materials by JHU CCP IEC Team X Training of volunteers/consejeras IEC Team X Supervision of volunteers/consejeras IEC Team

Case Mgmt Coordinator

X X

Evaluation of campaign IEC Team, Case Mgmt Coordinator

X

Other IEC Activities Development of monitoring system of IEC Consultant X Monitoring of IEC IEC Supervisor X X X X X X X XPurchase of additional equipment/supplies (computer)

COP X X

Development of policy regarding provision of snacks and gifts for participants in project activities

COP X

Bi annual meeting: project management/ MOHSW and IEC staff for review and validation of activities

COP X X

Qualitative investigation on behavior change

Consultant X X

Conduct a study of the various options for increasing community presence (Min of Promotion of Women, Red Cross, MICT, FERS)

Consultant X


10


M A M J J A S O N D

Develop a strategy for working with schools; including draft materials, training curriculum

Consultant X

Develop strategy for working with Traditional Healers

IEC Team X

Exchange visits between staff of BIMCP and EGMCI

IEC Team X X X X

Exchange visit to other malaria project

IEC Team X

Provide on-going TA in BCC (from HQ and in-country)

Consultant

X X X X X X X X X X

Provide short-term training on BCC/IEC for NMCP personnel

JHUCCP or other training

X X X X

IEC Team consists of MOHSW Bioko, MOHSW Mainland, and EGMCI and BIMCP staff IEC Supervisors are BIMCP and EGMCI staff JHUCCP = Johns Hopkins University Center for Communications Programs NMCP = National Malaria Control Program MICT = Ministry of Information, Culture and Tourism MINSABS = MOHSW COP = Chief of Party

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