ssdi eop report v5 jan 24-2017 - k4health · usaid united states agency for international...

Support for Service Delivery Integration -

Communication

Final Program Report January, 2017

1SSDI-Communication Final Program Report

Table of Contents

Table of Contents ........................................................................................ 2

Acknowledgements ...................................................................................... 4

Acronyms .................................................................................................... 5

Executive Summary ...................................................................................... 6

Project Overview ......................................................................................... 9Program Design and Approach .......................................................................... 10Mass Media and Print Materials ......................................................................... 12Radio-Based Initiatives ...................................................................................... 13

Radio Serial Drama ......................................................................................................................... 13Reality Radio ................................................................................................................................... 16

National Dialogues ........................................................................................... 17Music4Life ....................................................................................................... 18Transformative Tools ......................................................................................... 18

Family Health Booklet ..................................................................................................................... 18Community Health Worker Flipchart .............................................................................................. 19DREAMS Toolkit ............................................................................................................................. 20Marriage Counseling Guide and Newlyweds Booklet .................................................................... 21Malaria Comic Book ........................................................................................................................ 22

District Health Promotion Campaigns ................................................................. 22Community Media ............................................................................................. 23Community Mobilization .................................................................................... 23

Capacity Building ...................................................................................... 26Health Education Section .................................................................................. 26

Policy Documents ........................................................................................................................... 26Knowledge Management ............................................................................................................... 26Monitoring and Coordination ......................................................................................................... 26Training in Leadership in Strategic Health Communication ........................................................... 27

University of Malawi .......................................................................................... 27Capacity Building of College Lecturers .......................................................................................... 27Internship Program ......................................................................................................................... 27Guest Lectures ................................................................................................................................ 27Audiovisual Studio .......................................................................................................................... 28

Master’s Program in Health Behavior Change Communication .............................. 28

Research, Monitoring, and Evaluation ......................................................... 30

Sustainability ............................................................................................ 31Community Mobilization .................................................................................... 31Capacity Strengthening ..................................................................................... 32Moyo ndi Mpamba ............................................................................................ 32Dissemination ................................................................................................... 32


Challenges ................................................................................................ 33

Recommendations ..................................................................................... 34

Conclusion ................................................................................................ 34

Appendices ............................................................................................... 36Compiled Monitoring Data on Program Reach ..................................................... 36Evaluation: Summary of Findings from the SSDI-Communication Endline Survey .... 39

Overview ......................................................................................................................................... 39Methodology .................................................................................................................................. 39Key Findings ................................................................................................................................... 39Conclusions ..................................................................................................................................... 41

References ....................................................................................................... 42


Acknowledgements The Johns Hopkins Center for Communication Programs (CCP) would like to thank all individuals and institutions that played a role in the design, implementation, and evaluation of the Support for Service Delivery Integration (SSDI)-Communication project (2011-2016) in Malawi. First, we would like to express our thanks and gratitude to the American people through the United States Agency for International Development (USAID), for the financial and technical assistance that made this project possible.

We also appreciate greatly the leadership and guidance that the Government of Malawi through the Ministry of Health provided throughout the life of the project to facilitate smooth implementation as well as consistent focus on the country’s priorities. We acknowledge the inputs of the following individuals at the Ministry of Health; the Secretary for Health, Chief of Health Services, former Director of SWAP, Deputy Director of SWAP, Director of Planning and Policy Development, the Director of Preventive Health Services, Deputy Directors for Preventive Health Services (Health Education Services and National Malaria Control Program), Director for the Reproductive Health Directorate, Heads of Nutrition and HIV and AIDS, Zonal Health Supervisors and their staff, District Health Officers in the 15 SSDI districts and their staff at facility and community level; and all other government officials that participated in the design and implementation of this project.

We also acknowledge the efforts of various stakeholders at national, zonal and district level. Special mention to the following; our consortium partners (Save the Children International, Youth Net and Counseling [YONECO], Creative Centre for Community Mobilization [CRECCOM], Story Workshop Educational Trust [SWET], Applied Development Communications and Training Services [ADECOTS], Mercantile International, Ecumenical Counseling Centre [ECC], and Galaxy Media); SSDI-Services and SSDI-Systems; community mobilization sub-grantees in 13 SSDI districts; University of Malawi, Chancellor College; and Community Action Groups and all community volunteers. Finally, we also extend our thanks to the CCP staff in Malawi and Baltimore for dedicating their time and energies to make this project happen.

The significant achievements outlined in this report and imprinted in the minds of all of us that worked on this project are a reflection of the hard work and inputs of everyone, from the Secretary for Health based at Capital Hill in Lilongwe to a Community Health Volunteer in a remote village in Malawi. As we close this project, we wish the Ministry of Health and all stakeholders well as you continue to work hard to promote good health and wellbeing amongst Malawians.

Moyo ndi Mpamba, Usamalireni! (Life is precious, take care of it!)

Zikomo kwambiri (thank you).


Acronyms ADECOTS Applied Development Communications and Training Services AGYW Adolescent Girls and Young Women AIDS Acquired Immune Deficiency Syndrome ANC Antenatal Care CAC Community Action Cycle CAG Community Action Group CCP Johns Hopkins Center for Communication Programs CM Community Mobilization CRECCOM Creative Centre for Community Mobilization DREAMS Determined, Resilient, Empowered, AIDS-free, Mentored and Safe ECC Ecumenical Counseling Centre EHP Essential Health Package FP Family planning HES Health Education Section HIV Human Immunodeficiency Virus LLIN Long-lasting insecticide-treated net MNCH Maternal and child health MOH Ministry of Health NGO Non-governmental organization NMCP National Malaria Control Programme ORS Oral rehydration solution SBCC Social and behavior change communication SCI Save the Children International SMS Short Message Service (text message) SSDI Support for Service Delivery Integration SWET Story Workshop Educational Trust TfD Theatre for Development USAID United States Agency for International Development WASH Water, sanitation, and hygiene YONECO Youth Net and Counseling


Executive Summary The Support for Service Delivery Integration (SSDI)-Communication project was a five year (2011-2016) USAID-funded social and behavior change communication (SBCC) project that worked with the Ministry of Health (MOH) and other stakeholders in Malawi to promote normative and behavior change in several health areas: maternal, neonatal and child health (MNCH); family planning (FP); malaria; HIV and AIDS; nutrition; and water sanitation and hygiene (WASH). The project’s vision was that by the end of 2016, families in Malawi would be better able to advocate for their own health, practice positive health behaviors, including timely use of essential health package (EHP) services, and would be engaging with a responsive health care system. Coordinated SBCC systems would be in place within national, district and community level structures accompanied by broad stakeholder commitment, leveraged funding and sustained institutional leadership. Implementation of project activities was guided by a research based SBCC strategy, which was developed in collaboration with the MOH and other key stakeholders in Malawi. The strategy was based on the social ecological framework, which posits that individual, household, social network, community and national factors affect the health and wellbeing of individuals and families by influencing directly or indirectly those individuals’ and families’ ability or propensity to act. SSDI-Communication used the life stages approach to segment key audiences and this enabled health communication to focus on what was most relevant to people at various points in their lives. Four key life stages were identified in the SBCC Strategy as follows: young married couples; parents of under five children; parents of older children; and adolescents. The challenge with SSDI-Communication’s multiple health topics and audiences was how to ensure proper coordination of campaign activities amongst various partners and consistent harmonization of messages for the four life stages throughout the implementation period. To address this potential challenge, SSDI-Communication and the MOH used formative research to develop a creative unifying concept that energized all partners and facilitated effective coordination and harmonization of all SBCC activities and messages. The unifying platform, Moyo ndi Mpamba, Usamalireni (life is precious, take care of it), was a three-year multi-level multimedia campaign. The brand name resonated with Malawian culture and values. Its literal translation, ‘life is capital/investment’, was likened to business capital which must be handled with care to ensure that that the investment/ business prospers. This brand united the following materials and activities that integrated health messages from six priority EHP areas:

• Radio based initiatives: Radio spots, national radio dialogue sessions to promote discussions on issues that affect people’s health and wellbeing, and three radio programs (one radio serial drama, and two “reality radio” programs).

• Transformative tools: A Family Health Booklet, a flipchart for Community Health Workers/Volunteers, a participatory toolkit for adolescent girls and young women to


prevent HIV, a booklet for couples who are about to get married or who are newly married, and a comic book for children that promoted both malaria prevention and literacy.

• District Health Promotion Roadshows held at trading centers and market places, which used interactive entertainment education approach to promote positive health behaviors, utilization of health services and encourage dialogue and discussions on priority health issues.

• Music4Life Initiative: Using the power and reach of music in Malawi, the project worked with musical artists to produce and perform songs that incorporated health messages. Music festivals were held at regional and national level, and a music album and all star video were produced and distributed to radio and TV stations in Malawi.

• Other supporting materials: Billboards, posters, leaflets. The project also implemented capacity building activities to strengthen the capacity of national, district and community level actors to design, implement and coordinate SBCC interventions. SSDI-Communication made significant gains in promoting normative and behavior change around the six health topics, and in strengthening capacity of national, district and community level actors to design, implement, and coordinate SBCC activities. The Moyo ndi Mpamba brand has become very popular and is widely recognized across the country. The SSDI endline survey (2016) carried out in 19 districts in Malawi reports that 89% of men and 78% of women have heard of Moyo ndi Mpamba. An SSDI Activity Performance Evaluation conducted by Dev Tech on behalf of USAID Malawi in 2016 concluded that the ‘Moyo ndi Mpamba platform has value, denotes value and should be continued’. Recognizing the popularity and effect of the campaign, the MOH has adopted the brand name as the unifying platform for all activities in the National Health Communication Strategy (2015-2020) and in the Malaria Communication Strategy (2015-2020). The project’s flagship Family Health Booklet reached approximately 3 million people in 15 districts in Malawi with essential health messages. The Moyo ndi Mpamba radio program was very popular with 57 percent of men and 33 of women being exposed to the program. The SSDI Activity Performance Evaluation (2016) noted that radio was one of the most effective channels for dissemination of messages and was good value. At least 78% of men and 71% of women were also exposed to at least one Moyo ndi Mpamba campaign activity (SSDI endline survey 2016). Both the SSDI Endline Survey (2016) and the USAID’s commissioned SSDI Activity Performance Evaluation (2016) have noted that exposure to the Moyo ndi Mpamba campaign activities was positively and significantly associated with positive knowledge, attitudes, social norms and health practice. During the 2016 endline evaluation survey conducted by SSDI-Communication, significant changes were found among those exposed to the Moyo ndi Mpamba campaign in the areas of WASH, malaria, fertility preferences, contraception use,


MNCH, HIV and AIDS, sexual behavior, and gender norms. For example, those exposed to the campaign were significantly more likely to wash their hands with both soap and water, use modern contraceptives, attend antenatal care (ANC) visits, get tested for HIV, not have concurrent sexual partners, and jointly make decisions with their spouses. An external evaluation of SSDI-Communication also found that the project spurred improvements in SBCC capacity in Malawi. The evaluation report noted that SSDI-Communication succeeded in developing an environment where evidence-based SBCC strategic planning has become the norm. This led to the development of the first ever-National Health Communication Strategy to inform planning and implementation of health communication activities in Malawi. Additionally, SSDI-Communication’s capacity strengthening of private sector firms (radio production, advertising agency, media agency) brought dividends and led to the delivery of high quality outputs by these firms. The report also noted that the project’s support to media houses helped to increase the coverage of health issues in both print and electronic media. As strongly demonstrated through the results outlined in this report, the project has been successful in achieving its objectives. It is pleasing to see that the successful Moyo ndi Mpamba brand will continue into the near future with its inclusion as a unifying platform in the National Health Communication Strategy. Several of the centerpiece communication materials developed under the project, such as the Family Health Booklet, can also be easily adapted to integrate new topics and to reach other audiences. By continuing with this successful Moyo ndi Mpamba approach, these achievements made by the project and its partners can be sustained and expanded to ensure healthy individuals, families and communities in Malawi.


Project Overview The Support for Service Delivery Integration (SSDI)-Communication was a five-year (2011-2016) social and behavior change communication (SBCC) project funded by the United States Agency for International Development (USAID). The Johns Hopkins Center for Communication Programs (CCP) implemented the project in partnership with Save the Children International (SCI) and several local organizations such as CRECCOM, YONECO, Story Workshop, Galaxy Media and the University of Malawi. An important feature of this project was that it was one among three allied projects that collectively formed USAID’s Support for Service Delivery Integration (SSDI) program. The other two projects focused on service delivery (SSDI-Services), and policy and systems strengthening (SSDI-Systems). SSDI-Services was an important collaborator as SSDI-Communication behavior change strategies and SSDI-Services mobilization strategies were built on one another. The geographic focus of SSDI-Communication was two- fold:

• Nationwide coverage, particularly through mass media, campaigns, and capacity building; and,

• Minimal direct implementation and support to community mobilization (CM) sub-grantees in 15 districts: Mangochi, Machinga, Balaka, Zomba, Mulanje, Phalombe, Nkhotakota Nsanje, Chikhwawa, Kasungu, Dowa, Salima, Lilongwe (urban and rural), Chitipa and Karonga.

The goal of all three Cooperative Agreements that made up USAID’s SSDI program, including SSDI-Communication was to contribute to progress in three critical areas:

• Reducing fertility and population growth, which are essential for attaining broad based economic growth;

• Lowering the risk of HIV & AIDS to mitigate the enormous impact on human resources and productivity; and

• Lowering maternal and infant and under-five mortality rates. Four project-specific objectives provided the focus for SSDI-Communication to contribute to the achievement of the overall SSDI goals:

• Strengthen national and targeted district level SBCC planning and coordination on EHP priorities applied across health and resulting synergies.

• Develop and produce evidence-based SBCC packages under a multi-level media campaign to support effective, integrated SBCC implementation through mass media and facility and community level.


• Build capacity of key national institutional partners and targeted district SSDI-Services partners for effective SBCC strategic planning and delivery through on-going technical assistance and monitoring on use of developed packaged interventions.

• Identify best practices for SBCC implementation through formative research, testing new innovative approaches and materials and operational research, where appropriate.

Program Design and Approach SSDI-Communication was based on the Social Ecological Framework, which posits that individual, household, social network, community, and national factors affect the health and wellbeing of community members by influencing, directly or indirectly, families’ and individuals’ ability or propensity to act. The project also used a life-stage approach. This enabled health communication and promotion efforts to be targeted and prioritized around what is most relevant to people at various points in their lives. Audiences were categorized in four major life stages: young married couples, parents of children under 5, parents of older children, and adolescents. This approach provided another exciting opportunity: significant changes in people’s lives, marked by pivotal events such as birth, graduation, marriage, and first employment, serve as teachable moments when people become open to adopting new behaviors or changing harmful practices. Finally, SSDI-Communication integrated messages across six health topics into unified communication vehicles selected based on audience accessibility and preference. This ensured that audiences received information on priority health issues that affected their daily lives (HIV & AIDS; FP; nutrition; maternal, neonatal and child health; malaria; and water, sanitation and hygiene) through media and materials that were appropriate for their literacy levels and media preferences. All of SSDI-Communication’s SBCC activities were developed and reviewed in close collaboration with the MOH’s Health Education Section (HES). By involving them at all stages of intervention design, review, and evaluation, SSDI-Communication strengthened the capacity of HES staff through a “learning by doing” approach and ensured a sense of deep ownership of the products and materials created by SSDI-Communication. Additionally, SSDI-Communication collaborated with HES to design the overall SBCC strategy for the project, ensuring that the key messages promoted by SSDI-Communication aligned with HES priorities.

SSDI-Communication built strong partnerships and used evidence-based and strategic approaches to create and deliver integrated SBCC packages appropriate for each life stage.


Moyo ndi Mpamba The health situation for a majority of Malawians remains poor, despite progress made on some indicators in the past decade. In response to this difficulty, the SSDI-Communication project supported the MOH in realizing its ambitious health promotion agenda by developing and running a three year multimedia, multi-level Moyo ndi Mpamba, Usamalireni (“Life is precious, take care of it”) campaign. The ultimate goal of this campaign was to promote positive health behaviors and create demand for available services across six focus health areas – HIV & AIDS; FP; nutrition; maternal, neonatal and child health; malaria; and water, sanitation and hygiene – and with audiences across the socio-ecological landscape and all targeted life stages. The development of the campaign focused on filling gaps identified through formative research in order to create a positive environment for men and women, health workers, religious and community leaders to actively discuss health problems, find ways to tackle them together and then take actions to change individual behaviors and community norms. The campaign was designed based on the socio-ecological model, with reinforcing interventions at multiple levels: individual, family, society and service level. The project further adopted the Life Stages Approach and targeted four specific age groups: young married couples, parents of children under five years, parents of older children (6 -9 years), and adolescents (10 -19 years). The campaign capitalized on significant changes in people’s lives, marked by pivotal events such as the birth of a child, transition from childhood to adulthood, marriage, and first pregnancy. The brand name, Moyo ndi Mpamba, Usamalireni (Life is precious, take care of it) resonated with Malawian culture and values. Its literal translation, “life is capital/investment” was likened to business capital, which can easily be lost if mishandled. Communication messages encouraged individuals, families and communities to treasure and safeguard life. Its messages and images were packaged to portray a healthy lifestyle, using positive images of audience representatives living out the aspirations of the people: small healthy families doing simple things to keep healthy such as sleeping under nets, going for ANC, and using modern contraceptives. The Moyo ndi Mpamba campaign formed the foundation and platform for all other SSDI-Communication activities. All capacity strengthening efforts for CM partners, government, the media, the academia and all other mass media interventions were developed within the framework of Moyo ndi Mpamba.


Mass Media and Print Materials To promote health behavior change across the six focal health areas of the Moyo ndi Mpamba campaign and increase brand recognition, SSDI-Communication produced a series of posters, leaflets, billboards, and radio spots that it disseminated on a massive scale.

Moyo ndi Mpamba took Malawi by storm, and the brand now is widely recognized. Data collected during SSDI-Communication’s endline survey in mid-2016 indicate that 89% of men and 78% of women in Malawi have heard of Moyo ndi Mpamba. The brand has been so well received that the Ministry of Health adopted Moyo ndi Mpamba as the official health promotion brand for the Government of Malawi, and included it as the brand for all health promotion activities for 2015-2020, as laid out in the National Health Communication Strategy for that time period.

Former State President, Her Excellence, Mrs. Joyce Banda receiving Moyo ndi Mpamba memorabilia during a World AIDS National Commemoration Event.


Posters on all six health areas promoted behaviors such as nightly use of long-lasting insecticide treated nets, eating from the six food groups during pregnancy, washing hands at key moments, and giving Zinc (along with oral rehydration solution) to children who have diarrhea. Over 44,000 copies of Moyo ndi Mpamba posters on all six health areas promoted healthy behaviors in health centers and other places frequented by community members including schools, market places, and agricultural development centers. Leaflets on all six health areas promoted behaviors that aligned with those of the Moyo ndi Mpamba posters. Over 600,000 Moyo ndi Mpamba leaflets reached the hands of opinion leaders, community leaders, and individuals active in health promotion in their communities. The project produced Moyo ndi Mpamba-branded radio spots on five health topics (excluding HIV) as well as a spot on brand promotion. Malawians nationwide heard these radio spots more than 8,000 times.

Radio-Based Initiatives SSDI-Communication took full advantage of the wide and enthusiastic popularity and accessibility of radio in Malawi to promote healthy behaviors and the Moyo ndi Mpamba brand. Its radio-based initiatives took three forms: a year-long radio serial drama, a reality radio magazine program, and annual “national dialogues.”

Radio Serial Drama The Moyo ndi Mpamba radio serial drama inspired behavior change on priority health issues among adolescent and adult Malawians through interactive radio programming. Engaging drama camouflaged strategic health communication on malaria, MNCH, reproductive health, FP, HIV and AIDS, WASH, and nutrition. SSDI-Communication collaborated with the MOH, Malawian radio producers and broadcasters, representatives from international NGOs, and representatives from SSDI-Systems and SSDI-Services to design the program. The team made an effort to develop a story that was firmly grounded in the realities of Malawian life. To achieve this, the design team developed a map of life events that occur during an average lifespan in Malawi, created a map of the fictional village in which the drama

This poster says, "Avoid Diarrhea: Wash hands after coming from the toilet and after changing a baby's nappy.” During baseline research, SSDI-Communication found that knowledge of these two key moments for hand washing was much lower than for other key moments.


was to take place that mirrored a typical village in Malawi, and developed a calendar of events that normally take place in a community in Malawi in any given year. These tools acted as a rich, detailed, and realistic background onto which the stories could be painted, allowing the program to better reflect the daily realities of Malawian life. The drama had three main plotlines:

• A young married couple, Richi and Nasilina, struggle as Richi maintains his relationship with his old girlfriend Esmie.

• Ndaziona, a 16-year-old girl, has a terrible secret that she is hiding from her mother and two brothers.

• Mrs. Nabetha Gama, a very religious woman married to a very traditional man who strongly believes in traditional healers and superstitions.

The drama unfolded over 52 episodes, aired during 12-month period from July 2014 to June 2015. Each episode included questions for audience members, who were encouraged to respond via SMS or on Facebook.


Emily Yona lives in the Kamala village of the Phalombe district with her husband. While Mr. Yona is a traveler who cuts wood for construction companies, Emily stays at home with kids and buys tomatoes in town for sale in the village. Emily and her husband struggled with hospital bills because their two children were frequently diagnosed with malaria. Emily says the family could not understand why their children were constantly suffering from malaria. The malaria episodes often forced her to abandon trips to buy tomatoes. The couple was puzzled with the situation and did not know what to do. However, Emily recalls one Thursday night when she accidentally listened to Moyo ndi Mpamba radio drama. This marked the beginning of a quest for a solution to their problem. Her face lights up as she holds her youngest child and recalls: “It was just as if they had made the program for me. They were talking about the need to sleep under an insecticide treated mosquito net every night all year round.

There is a woman by the name of Nasilina who got sick because she did not sleep in a mosquito net and this is exactly what we were doing….I made a decision that I and my family are going to sleep under a mosquito net every night throughout the year.” She adds that the family had mosquito nets but did not see the importance of sleeping in them. The family regarded the mosquito nets as materials for decoration. However, the drama prompted Emily to change her family’s behavior and she now makes sure that every member of the family sleeps under an insecticide treated mosquito net every night all year round. Midnight visits to the hospital have stopped. “Now look...Martha plays with other kids because she is not sick. Because she’s healthy and happy, I can comfortably leave her behind when going on business errands to town. And what makes me feel even better is that there are no midnight visits to the clinic as we did before. I look forward to learning more from the drama,” concludes a huge-smiled Emily.

No More Midnight

Visits


Reality Radio SSDI-Communication produced and aired reality radio programming from 2012-2016. From 2012-2015, the program was called Chenicheni Nchiti? (“What is the reality?”) and produced in collaboration with BRIDGE II, the project under which the program was originally developed. In July 2015, the program transitioned its title from Chenicheni Nchiti? to Moyo ndi Mpamba, fully aligning it with the campaign. The program aimed to create a supportive environment in communities for the adoption of healthy behaviors, and inspire individuals and families to adopt those healthy behaviors. Episodes included the real life experiences and stories of people whose lives changed as a result of adopting healthy behaviors as well as stories of people whose lives and families had suffered the consequences of not practicing healthy behaviors. In this way, listeners found role models for change while being exposed to the consequences of making unhealthy choices, which, according to behavior change theory, would increase their perception of risk while developing their self-efficacy to take action. The show’s hosts encouraged listeners to get involved and engaged by asking them to answer a question each week through an SMS message or on the program’s Facebook page. Some people who responded were interviewed for future programs. SSDI-Communication worked with stakeholders including the MOH, the National AIDS Commission, community members, and radio production partners to map out the health issues and messages to be covered in each quarter of programming, outline program content, and communication objectives for each episode. Based on this guidance, field producers gathered stories from communities throughout SSDI implementation districts.

Text4LifeInitiativeSSDI-Communication initiated “Text4Life” in July of 2015 at the same time that it launched the Moyo ndi Mpamba reality radio program. The system allowed for radio program listeners to subscribe to the service, and receive weekly messages on the health topics. By September of 2016, more than 14,000 listeners were receiving these messages on a weekly basis. The health tips sent through the Text4Life platform were derived from the Family Health Booklet and therefore aligned with overall SSDI-Communication messaging. However, to promote consistency and repetition, the messages sent each week aligned with the topic of that week’s reality radio program.

“I felt like the program was specifically and personally

targeting me,” says Mrs. Milanzi. Mrs. Milanzi says she

was careless about sanitation and hygiene at her home

because she really did not know the link between

sanitation and hygiene and wellness in general.

However, this changed when she heard an episode of

the Moyo ndi Mpamba reality radio program that

focused on WASH, and the diseases that can be

prevented through adopting WASH behaviors.


RealityRadioforDREAMSIn its final year, SSDI-Communication developed and produced a second Moyo ndi Mpamba weekly reality radio program titled “Tiyeni Achinyamata!” (“Youth on the Go!”) that focused on HIV prevention among adolescent girls and young women. Tiyeni Achinyamata! resembled the main Moyo ndi Mpamba radio show in many aspects, but had a youthful tone. The program provided a platform for adolescent girls and young women to discuss issues that put them at risk of contracting HIV, and highlighted possible ways for reducing their risk. Apart from directly reaching out to adolescent girls and young women, the program complemented community level efforts of other partners in the country in mobilizing families, schools, male sexual partners of adolescent girls and young women, and communities in keeping girls free from HIV and safe from gender-based violence. A total of 22 episodes were aired on MBC and Zodiac Broadcasting Services, with over 6,500 SMS received from listeners. The radio program supported USAID’s overall DREAMS initiative in Malawi.

National Dialogues SSDI-Communication’s National Dialogues aimed to promote dialogue and discussion among individuals, families and communities on issues that affect people’s health and wellbeing. SSDI-Communication worked with both national and community radio stations to hold two National Dialogues in 2014 and 2016. SSDI-Communication worked with and trained 13 radio stations (both national and community stations) to incorporate dialogue topics into one of their most popular programs each week during a five-week period. The effect of this was that every radio station in the country discussed the same issue every week during the period of the dialogues. Radio stations invited their listeners to call in, send SMS, and write letters to respond to the topics discussed on the programs. The topics chosen for discussion during the National Dialogues were broad, but the questions developed to stimulate the discussions were crafted in such a way that people were able to link social and behavioral issues with health outcomes. SSDI-Communication held two rounds of National Dialogues under the broad theme of “Life Choices and Wellness.” The choice of this theme was strategic, as it highlighted the significance of daily choices, decisions, and actions on health and wellness, aligning with SSDI-Communication’s umbrella Moyo ndi Mpamba campaign. The first round of dialogues had a number of sub-themes, including:

• Cultural practices and beliefs: what is more important to uphold, our culture or our lives?

• Living our lives: what matters more, is it our life or money and material things? • The family and people's wellbeing: does the family do enough to give its members the

best life? • The community working together: communities as perpetrators of good life values.


• Disease treatment versus healthy living: taking responsibility for our own wellbeing and health.

The second dialogue focused on “the role of the family and community in promoting the health and wellness of its members.” This dialogue specifically aimed to provoke debate and discussion on the role of the community in dealing with the theft of hospital commodities, and whether it was “moral” for someone to steal hospital commodities that are meant to save peoples’ lives.

Music4Life Using the power of entertainment for health promotion, SSDI-Communication implemented a Music4Life initiative through which musical artists were engaged to produce and perform songs that incorporated health messages. Under guidance from the Music Association of Malawi, the project conducted three regional music festivals that involved song, dance, and health talks. Following the music festivals, SSDI-Communication facilitated production of an music album that featured different famous Malawian artists who are familiar at both the district and national level in Malawi. The CD was distributed to over 13 national and community radio stations, markets, and freelance DJs in rural and urban areas. The dissemination of the songs through multiple channels increased the likelihood of them being heard in different gatherings and on various radio programs. The project also facilitated the production of an all-stars music video that engaged famous artists in the production of a Moyo ndi Mpamba theme song that was distributed to top TV stations in Malawi (MBC TV, Zodiak TV, and Times TV).

Transformative Tools SSDI-Communication created and distributed three Transformative Tools – print materials that include integrated health information on six health topics – to communities: The Family Health Booklet, the Community Health Worker Flipchart, the DREAMS Toolkit, and the Newlyweds Booklet. These tools served as the foundation for the direct delivery of SBCC to families, individuals and communities in SSDI focus districts.

Family Health Booklet The Family Health Booklet is an easy-to-read, integrated health promotion material, which connects families to individual-level actions, community-based initiatives and clinical services. This pictorial booklet provides essential information on health to families to empower them to prevent illnesses and promote healthy behaviors. It helps families keep track of household-level behaviors (long-lasting insecticide treated net [LLIN] acquisition and use, hand washing with soap, etc.) and clinic-based behaviors (immunizations, HIV testing, FP, child checkups

SSDI-Communication’s radio-based initiatives had a profound impact on their audiences. Cumulatively, the three initiatives prompted listeners to send over 25,000 SMS. SSDI-Communication’s endline survey found that 57% of men and 33% of women had heard one of the Moyo ndi Mpamba radio programs.


and weigh-ins, etc.). Households refer to the booklet for information on how to prevent and treat illnesses. The booklet communicates on these topics mostly in Chichewa, though a few copies provided information in the languages of Tumbuka, Kyangonde, and Yao. SSDI-Communication, in collaboration with the HES and other partners identified priority health behaviors to include in the booklet. The team reviewed key research findings in order to identify existing gaps and barriers in household-level health behaviors. They also conducted consultative meetings with community members to seek their input and to understand their health information needs. The feedback was used to refine the contents of the booklet. Community members involved in CM activities distributed the booklets to households in their catchment areas, and then followed up with them after a time to learn how they were using the booklet. During these visits, the community mobilizers paid special attention to households with pregnant women, malnourished children and those with many or frequent pregnancies, and provided tailored counseling to those households using the Family Health Booklet as a guide.

Community Health Worker Flipchart The Community Health Worker Flipchart is an integrated SBCC support material that contains cue cards and corresponding content on SSDI-Communication’s six focal health areas that aligned with the messages included in the Family Health Booklet. The flipchart is simple and easy to use, even for low-literate audiences. SSDI-Communication developed the flipchart in close collaboration with the MOH for community volunteers to use as a reference during community and household outreach activities.

The Family Health Booklet quickly became a trusted household reference for health. People of all ages received the booklet and expressed their appreciation for it. They enjoy the richness in its content as well as its pleasing pictorial presentation. Despite the low literacy level of most rural Malawians, the booklet proved to be an effective way of reaching households with key health messages. Between 2014 and 2016, nearly 676,000 copies of the booklet reached families in 13 districts, reaching over three million people with health messages.


The flipchart not only included key health messages, it also provided guidance on interpersonal communication and counseling directed toward community volunteers. During household visits, community volunteers followed a procedure outlined in the flipchart to ensure a comprehensive counseling visit:

ü Greet the client and conduct introductions. ü Establish the life stages of the household’s family members by asking if there is a

child in the household, the age of the child, the use of FP methods, etc. ü Tell the household contact about specific health topics they could discuss during the

meeting basing on the life stage of the particular household. ü Agree on a topic to discuss with the household contact and turn to the appropriate

card in the flipchart. ü Ask the client to describe the picture(s) on the chosen card and relate it to the

selected health topic, and ask probing questions to learn the client’s level of knowledge as well as their beliefs and attitudes. Answers to probing questions are then answered by the key messages on the cue card.

ü After the discussion, the volunteer and the contact person agreed on day of their next meeting when another card would be selected and discussed.

DREAMS Toolkit In support of the DREAMS Initiative in Malawi, SSDI-Communication adapted other evidence-based manuals for participatory group sessions from Malawi and surrounding countries to produce a toolkit for adolescent girls and young women (AGYW) in Malawi. The toolkit, “My DREAMS, My Choice!”, is a participatory toolkit for both in- and out-of-school girls. It provides a safe and fun opportunity for AGYW to understand their bodies as they transition from childhood to adulthood; gain skills knowledge and self-efficacy to live productive lives, free from HIV; develop social support networks and recognize safe spaces in their communities; feel empowered to speak for themselves and recognize the role they play in society and in shaping their future; help girls examine how gender norms and social roles operate and impact on their lives; and empower AGYW to access key health and other social services. The toolkit uses Participatory Learning Approaches (PLA) and is participant centered, with content delivered through discussions, games, lectures, songs, demonstrations and role plays. SSDI-Communication developed this toolkit in its final year, and did not have an opportunity to roll it out. The project only trained Trainers of Trainers drawn from various

Over 12,000 Community Health Worker Flipcharts reached communities in Malawi in 13 districts. SSDI-Communication oriented over 8,000 community health workers and volunteers on how to use it to support families to adopt healthy behaviors. Anecdotal reports indicate that the Flipchart has filled a gap in basic health information at a literacy level appropriate for audiences in rural areas.


DREAMS implementing partners who will consequently train more facilitators on how to use the toolkit in their respective organizations.

Marriage Counseling Guide and Newlyweds Booklet To better deliver health messages to newlyweds, SSDI-Communication engaged ecumenical marriage counselors to be champions of the Moyo ndi Mpamba (Life is precious) campaign by promoting health as a necessity for strong families during marriage counseling sessions with newlyweds. SSDI-Communication chose to include this approach in its overall strategy because a situation analysis revealed that religious marriage counseling sessions touched upon health issues, but that the sessions were not fully capitalizing on the unique opportunity to deliver targeted health messages to newly married couples. SSDI-Communication worked with the MOH and faith leaders to develop a booklet for young married couples (the Takunyadirani [“We Celebrate You”] booklet) containing messages on priority health topics especially relevant to couples who are about to be married or who are newly married: MNCH, nutrition, FP, malaria in pregnancy, and HIV & AIDS. The project also developed a training for religious marriage counselors, and conducted trainings in six districts. Trained counselors reached out to young married couples through counseling sessions, small-group church meetings, door-to-door visits, marriage outreach sessions, mock weddings, and sermons. The Takunyadirani booklet served as a guide for counseling sessions.

SSDI-Communication trained over 1,450 marriage counselors in six districts, and distributed 14,000 Takunyadirani booklets to as many newlywed couples, representing over 90% coverage of all marriages that occurred in the catchment areas of trained counselors; these couples also benefitted from counseling sessions. Anecdotal reports from couples indicate an uptake in HIV testing before marriage, male participation in FP-related decision-making, and better knowledge of danger signs during pregnancy.

The Takunyadirani Booklet.


Malaria Comic Book SSDI-Communication responded to a call from the National Malaria Control Program (NMCP) to contribute towards malaria prevention and control by adapting a malaria-focused comic book (originally developed by Novartis) for use in schools. The comic book tells the story of Chimwemwe, a primary school girl who suffers from malaria and is absent from school, cannot play and loses her appetite. She receives an anti-malaria drug (Artemether Lumefantrine) at a health center, completes the dosage, is healed, and her life goes back to normal. To reinforce what students have read, the book also contains other activities that include a quiz, a game and a role-play scenario.

District Health Promotion Campaigns SSDI-Communication partnered with District Health Offices and other stakeholders in the 15 SSDI focal districts to implement health promotion campaigns as a part of the Moyo ndi Mpamba platform. The district health promotion campaigns, commonly referred to as roadshows, used an interactive entertainment education approach to promote positive health behaviors, the utilization of health services, and encourage dialogue and discussion on priority health issues. To ensure high turnout, the events were held at locations such as trading centers and marketplaces. The campaigns were people-centred and optimized audience participation through quizzes, health talks, drama and dance performances by groups from the local communities as well as special performances by some of Malawi’s popular musicians such as Skeffa Chimoto, Lulu and Katelele Ching’oma. Attendees received Moyo ndi Mpamba-branded t-shirts and zitenje. At all venues, local traditional leaders and district health office representatives made remarks, reinforcing campaign health messages and encouraging communities to practice healthy behaviours and seek help from health centers in their locality. In order to maximize the impact of the campaigns, SSDI-Communication worked with service delivery partners such as Malawi Blood Transfusion Services, Banja La Mtsogolo, and Family

SSDI-Communication printed 27,050 copies of the comic book in English and Chichewa and distributed these to 2,337 schools and reading centers in 16 districts of the country. In addition to increasing knowledge levels, the malaria comic book stimulated prevention and control behaviors among pupils (e.g. sleeping under a net, cutting down grass, removing stagnant water, early attendance to the clinic upon onset of fever, and completing the dosage of the anti- malarial drug). Apart from the health benefits, the comic book has promoted reading culture amongst school going children, and supplements reading materials in schools.


Planning Association of Malawi who offered their services, including HIV testing and counselling and FP during the campaigns.

Community Media SSDI-Communication worked with the Creative Centre for Community Mobilisation (CRECCOM) and Youth Net and Counseling (YONECO) to conduct Theater for Development (TfF) activities in six districts of Malawi (Karonga, Chitipa, Zomba, Machinga, Chikwawa and Nsanje). These TfD activities aimed at sensitizing, motivating and mobilizing communities to take action to address barriers to good health in their communities. More than 36 drama groups were trained in the six districts on the TfD process. The drama groups reached more than 208,189 people with performances on different health topics and mobilized communities for action. For example, drama groups spurred the construction of toilets and the creation of new local by-laws to prevent the misuse of insecticide-treated bed nets.

Community Mobilization SSDI-Communication worked with SSDI-Services to provide capacity strengthening support to Community Action Groups (CAGs), comprised of community health volunteers, as they implemented the stages of the Community Action Cycle (CAC). Under the supportive supervision of SSDI-Communication and SSDI-Services, CAGs worked with communities to identify health problems and their root causes, prioritize health problems for action, and work together to develop solutions to those problems. CAG members received training on priority health messages and conducted household visits to engage community members on health topics in their homes. In addition, Health Surveillance Assistants (HSAs) and other volunteers conducted community meetings on health issues that included drama performances, songs, poems, and other health education activities. CAGs worked diligently to achieve community-level change. They lobbied with local NGOs, community leaders, parliament members, and their District Health Offices for support to mobilize resources they needed to improve their communities. These included boreholes and shallow wells for safe water, bicycle ambulances to ease transport to a health facility during emergencies, and iron sheets to improve the roofs of shelters and clinics.

A total of 86 district health campaigns attracted approximately 101,085 attendees. At the campaigns, 1,878 people accessed FP services, and 1,143 people (Men 537; Women 377) accessed HIV testing and counseling services. Additionally, 120 units of blood were donated and collected.


Community Mobilization is a process that strengthens the capacity of communities to plan, carry out, and evaluate activities in a participatory and sustainable way to improve their health and overall wellbeing. Using the Community Action Cycle (below), CM empowers communities to take a leading role in determining problems to be addressed, identifying the root causes of those problems, and coming up with lasting solutions, thereby building a collective problem solving mechanism for sustainable change.

The Community Action Cycle for Community

Mobilization

SSDI-Communication supported the establishment of 557 CAGs, with a membership of 8,000 CAG members, and provided them with 356 technical supportive supervisory visits. CAGs reached 2,357,470 people at community meetings through drama performances, poems, songs and with integrated messages on six health topics, and 678,924 households with health messages delivered with the support of the Family Health Booklet and Community Health Workers’ Flipchart. Over 50 Traditional Authorities and 557 Group Village Headmen engaged in CM using the CAC with the support of SSDI-Communication.


nickname of “The Magic CAG” because they have achieved so many victories for the development of their community. Since its establishment in October of 2013, the Namakwati CAG:

• Facilitated the construction of 43 pit latrines with hand washing facilities. • Successfully lobbied the company Total Land Care to install two boreholes and to support

the protection of four shallow wells. • Successfully lobbied the organization Concern World Wide to provide a bicycle ambulance

to carry pregnant mothers due for delivery and other patients to the nearest health facility. Since acquiring this bicycle ambulance, maternal and newborn deaths have gone down in the community.

• Revitalized the community’s HIV & AIDS support group with an aim to promote testing, positive living, and care and support for people living with HIV.

• Formed the Mwana Wa Thanzi women’s nutrition group to facilitate nutritional activities in the community. Childhood malnutrition has been reduced in the catchment area since the establishment of the group.

• Formed the Namakwati Girls Alert Action Forum, which provides a space for girls to discuss sexual and reproductive health and other issues. FP method use has increased and school drop out has decreased among girls in Namakwati since the creation of the Forum.

• …. Among many other achievements.

The Magic CAG Before, community members in Namakwati “…never thought people from the village could do anything to improve their health or bring development to their localities,” says Chairman Yusuf Kambwiri. Located 65km from Nkhotakota the district hospital, the Namakwati community now has the skills to take action to improve their health. The Namakwati CAG has gained the


Capacity Building

Health Education Section The goal of the SSDI-Communication project was to support the Government of Malawi to improve the health and wellbeing of Malawians. A significant part of achieving this goal involved capacity strengthening of key national institutional partners in designing and implementing effective SBCC interventions. The HES is recognized as the hub and lead in health promotion and SBCC within the MOH, which made HES an obvious and essential partner for SSDI-Communication and a key audience for capacity strengthening initiatives. SSDI-Communication implemented a series of tailored capacity strengthening activities to support the HES’s efforts to improve the health and wellbeing of Malawians through high-quality health promotion and SBCC activities. To determine the HES’s capacity gaps and needs, the project first conducted a capacity assessment. Based on this assessment, staff implemented a comprehensive series of capacity strengthening activities in partnership with the HES.

Policy Documents SSDI-Communication supported the HES in the development of three national policy documents to support strategic and coordinated health promotion and SBCC: the Health Promotion Policy (launched in 2014), the National Malaria Communication Strategy (launched in 2016), and the National Health Communication Strategy (launched in 2016). These two documents articulate and clarify HES guidance on health promotion and health-focused SBCC in Malawi.

Knowledge Management The HES also received significant support from SSDI-Communication to strengthen its knowledge management activities. SSDI-Communication supported HES in refurbishing its physical resource center, provided new equipment such as computers and a scanner for cataloguing and accessing health promotion and education materials electronically, and provided training for staff on the use of new resource center equipment. The project also supported the HES in the creation and maintenance of an online hub for health promotion: www.healthpromotion.gov.mw.

Monitoring and Coordination SSDI-Communication also supported the HES to strengthen its monitoring and coordination activities. After identifying a gap in district activity reporting, the project supported the creation of a new reporting form for District Health Promotion Officers, designed to ensure the capture of health promotion activities. SSDI-Communication also supported the refurbishment of HES’s conference facilities and facilitated quarterly Essential Health Package Health Promotion Technical Working Group meetings, as well as monthly coordination meetings for HES staff.


Training in Leadership in Strategic Health Communication SSDI-Communication provided an opportunity for training in Leadership in Strategic Health Communication. The training, implemented around the world by CCP since 1998, is considered to be one of the best trainings in health communication in the world. A total of 17 District Health Promotion Officers and five HES officers participated in the training.

University of Malawi SSDI-Communication worked with the University of Malawi to strengthen the capacity of lecturers and students in SBCC through a combination of learning and practical opportunities, as well as direct capacity strengthening in SBCC instruction.

Capacity Building of College Lecturers Chancellor College lecturers attended and participated in Leadership in Strategic Health Communication trainings alongside HES and District Health Promotion Officers. A total of four lecturers from the Language and Communication Skills Department participated in this training.

Internship Program SSDI-Communication and Chancellor College worked together to select undergraduate students to participate in internships with partner organizations. These opportunities to observe and participate in SBCC activities strengthened the capacity of students and cultivated their interest in health communication. A total of seven interns were recruited in two consecutive years, and each of them spending a month in the program.

Guest Lectures To increase interest in SBCC and provide students with access to experts in the field, SSDI-Communication delivered a total of four guest lectures at Chancellor College. The guest lectures targeted post-graduate and undergraduate students, lecturers, researchers and other members. The lectures covered a range of topics related to SBCC and relevant to SSDI-Communication and health promotion in Malawi:

• July 2013: “The Effects of Social Behavior Change Communication Interventions: Evidence from around the Globe,” Dr. Carol Underwood of Johns Hopkins University.

• November 2013: “Social and Behavior Change Communication: Why It Matters in Public Health,” Thomas Ofem, former Senior Advisor for SBCC at SSDI-Communication.

The HES has shown strong and responsive leadership in health communication and has greatly grown its capacity to lead Malawi in the area of social and behavior change communication and health promotion.


• February 2014: “Umbrella Platform Campaigns for Good Health and Wellbeing,” Dr. Alinafe Kasiya, former Deputy Chief of Party and current Chief of Party for SSDI-Communication.

• July 2015: “The Power of Reality Radio Programming for Social and Behavior Change,” Triza Hara, Deputy Chief of Party for SSDI-Communication.

Audiovisual Studio With support from USAID, SSDI-Communication procured and handed over audiovisual equipment to Chancellor College for the creation of a fully equipped audiovisual studio. The equipment was procured to aid teaching of communication studies in recognition of the need for better-trained communication experts who can work in health communication to ensure development and implementation of high quality programs. The studio equipment, worth approximately $17,500 (MK 7 million), included state of the art video cameras, microphones, digital mixers, recorders and studio monitors.

Master’s Program in Health Behavior Change Communication SSDI-Communication collaborated with faculty at the University of Malawi, Polytechnic College in Blantyre, Malawi, to support the establishment of a Master’s program in Health Behavior Change Communication, as well as the development of the curriculum for the degree. SSDI-Communication participated in a curriculum review meeting for the Masters program that was held in Liwonde in 2014. The Chief of Party and the SBCC Advisor attended the meeting. In July 2016, SSDI-Communication facilitated one of the sessions for the program that was focused on sharing lessons and experiences from the Moyo ndi Mpamba, Usamalireni Campaign.

“My classroom interaction with students has shown that the [guest] lecture brought practical relevance to what is learned in the classroom. During interactions with my students in an Introduction to Communication Studies as well as an Intercultural Communication class, some of my students referred to models and theories that were presented in the guests lectures. One student, Kenneth, mentioned the socio-ecological model as an example of a model that is applicable, and referred to SBCC as an area of application. Another student, Miracle, was interested to know how intercultural communication can be understood in the context of the development of SBCC materials. Furthermore, there is a keen interest shown by about four students who are developing their research proposals to venture into the area of health communication.”

Mrs. Rachel Chimbwete Phiri, Lecturer and Head of the Language

and Communication Skills Department at Chancellor College


Media4Life SSDI-Communication and the HES launched the Media4Life initiative to deepen the relationship between the health and media sectors in Malawi in order to advance public health in Malawi. The partnership built active, sustainable, and mutually beneficial synergy in the promotion of positive behavior change among the Malawi population, as well as increasing coverage, awareness, and advocacy on health related issues among the public. The initiative provided a platform for media owners, senior media professionals, and public health practitioners to 1) discuss health and wellbeing issues relevant to Malawians, 2) foster a sense of commitment among participating journalists to feature health issues on their media platform, and 3) build capacity for health-related reporting. To achieve these goals, the initiative implemented a series of activities. Media for Life Conferences gathered key media and public health stakeholders, and provided them with a space to examine the status of health in Malawi and the relationship between the media and health sectors. Two of these conferences allowed participants to explore opportunities for sustained and committed cooperation. Journalist Trainings empowered 91 journalists with knowledge in the six priority health areas that were the focus of SSDI-Communication. These trainings aimed to promote high-quality health reporting and to improve the coverage of health issues in the local media. Media Cafes generated discourse and dialogue around health topics and motivated health reporting. Six media cafes implemented by the project also allowed the MOH to cultivate positive relationships with members of the media. Journalist Fellowships supported the travel of selected journalists to districts to cover health-related issues. Two journalists from four big media houses were awarded fellowships. Equipment support provided media houses with essential equipment needed to enhance their capacity to cover health issues. SSDI-Communication provided equipment worth $5,000 to four media houses.


Research, Monitoring, and Evaluation SSDI-Communication conducted a variety of research, monitoring, and evaluation activities throughout its implementation period. At the beginning of the project, SSDI-Communication conducted a baseline survey in the 15 SSDI focus districts. The survey was quantitative, and measured levels of predictors of positive health practices (such as knowledge, self-efficacy, risk perceptions, social normative perceptions) as well as self-reported practice of healthy behaviors. The results of this baseline survey served as comparison measures that, at the end of the project, contrasted the data collected during the endline survey to demonstrate where SSDI-Communication achieved behavioral and normative change, and where it did not. They survey also examined access to communication platforms and media, and preferences for receiving information about health. To accompany the quantitative data collected during the baseline survey, SSDI-Communication also conducted a qualitative formative research study. The study results provided insight into Malawian men’s and women’s perceptions of “health,” what factors enable and support positive health practices and what factors are considered barriers to good health practices and good health outcomes. Those that participated in this research were also asked about the role of malaria as a threat to health, their perceptions regarding health care facilities and their preferences regarding sources of information. Both the baseline survey and formative research provided vital insights that informed the design and implementation of the Moyo ndi Mpamba concept, brand, and campaign; the key messages included in SBCC materials and packages; the design of individual SBCC materials, packages, and platforms; and finally the implementation and dissemination of SBCC materials and messages. Throughout the implementation of activities, SSDI-Communication conducted a variety of monitoring activities. Among other things, to routinely monitor activities, staff ensured that radio airwaves were monitored in order to determine how many times Moyo ndi Mpamba radio spots and radio programs aired; trips to the districts confirmed that posters, billboards,

The Media4Life initiative has resulted in the signing of memoranda of understanding between the Ministry of Health and 4 major media organizations (The Nation Publications, Malawi Broadcasting Corporation, Times Group and Zodiak Broadcasting Services) to guide a partnership for high-quality health reporting. Health stories are receiving increased coverage in all participating media houses, including 14 community radio stations. The Media4Life initiative also facilitated the formation of a national network of health reporters.


and leaflets were in place and disseminated; supportive supervision visits to CAGs provided opportunities to learn how many CM activities were ongoing; and collaboration with SSDI-Services allowed staff to track how many Family Health Booklets and Community Health Worker Flipcharts were disseminated. Additionally, SMS received during the airing of the Moyo ndi Mpamba radio serial drama as well as the Moyo ndi Mpamba reality radio program served as vital monitoring and feedback data. These messages provided valuable insight into how audiences received the programs, and how future episodes could be adjusted to better meet their needs. During the final few months of implementation of activities in June and July of 2016, SSDI-Communication gathered data for an endline survey. The survey methodology mirrored the baseline survey in order to collect information that could be compared to the data collected in 2012. The results of this survey, summarized an appendix of this report, demonstrate the changes in predictors of health behaviors, as well as any change in the performance of healthy behaviors themselves. Statistical analysis also demonstrates which changes of these are significant, and whether or not they can be attributed to exposure to SSDI-Communication’s activities. This endline evaluation demonstrated that SSDI-Communication did indeed have a significant positive impact on the knowledge, attitudes, and behaviors of Malawians. In addition to evaluation activities conducted internally by the project, USAID commissioned an external evaluation, which was implemented by DevTech. The purpose of the external evaluation was “to determine the effectiveness of the SSDI-Communication’s multilevel approach to promote normative behavior change and health-seeking practices.” The external evaluation team used a combination of qualitative and quantitative methods to answer its evaluation questions. The data collected during external evaluation indicated overall that SSDI-Communication’s SBCC, CM, and capacity strengthening activities were evidence-based, strategically designed, and effective.

Sustainability Efforts toward the sustainability of project activities was inherent to their implementation. SSDI-Communication’s efforts in the areas of CM, capacity strengthening, national-level SBCC, and documentation all contributed towards the sustainability and continuation of health promotion by and for communities in Malawi.

Community Mobilization Through the creation and ongoing capacity strengthening of CAGs, SSDI-Communication ensured that participating communities had the tools they needed to create the change they want and need, and to promote healthy behaviors. Additionally, print materials developed by SSDI-Communication and left behind in communities (the Family Health Booklet, Community


Health Worker Flipchart, and booklet for newlyweds) ensures that CAGs will have the health information they need to continue their activities effectively.

Capacity Strengthening HES leadership and staff formed a vital part of the SSDI-Communication team. They worked alongside SSDI-Communication staff to design and review project activities throughout the lifespan of the project. This “learning by doing” and empowerment of HES to implement SBCC has left a legacy and foundation which will support their future activities as well as future capacity strengthening activities for the HES. Additionally, the establishment of the HES virtual and physical resource centers, refurbishment of the HES boardroom, and establishment of the HES recording studio have provided the HES with the tools they need to carry SSDI-Communication’s work forward. SSDI-Communication’s work to encourage the growth of SBCC-focused educational opportunities for Malawians at the University of Malawi is another essential element of ensuring the sustainability of its activities. The establishment of a Master’s degree in Health Behavior Change Communication, as well as the delivery of various guest lectures focused on SBCC, have spurred increased interest in the field among students and lecturers, and a better understanding of key concepts. Students and lecturers that participated in these activities will serve as allies and resources for future and ongoing SBCC efforts throughout the country. The capacity strengthening of journalists also contributes to the sustainability of SSDI-Communication’s work, as increased coverage of health issues in the media is essential to ensuring that adequate funding is provided for health promotion and health service delivery.

Moyo ndi Mpamba Moyo ndi Mpamba is now the national health promotion brand for Malawi. It has not only been adopted by the MOH to be the brand for all health communication and promotion through 2020, it is also incredibly popular among the public who have internalized the campaign’s message and made it their own. The brand will continue on as the public face of SBCC activities implemented by the Health Communication 4 Life project, and may also be adopted by other health promotion and development projects throughout the country in the future.

Dissemination To ensure that the materials and knowledge created and collected by SSDI-Communication are documented and shared with the public, the project has created an online toolkit. The toolkit includes overview information about project activities, as well as SBCC materials, strategies, reports, research and evaluation results, fact sheets, and other resources. The toolkit can be found at https://www.k4health.org/toolkits/ssdi-communication-toolkit.


Additionally, the results of the project’s evaluation will be used to develop various manuscripts for submission to academic journals, to ensure that the project’s lessons learned are available to those who design, implement, and evaluate SBCC programs. The project will also write a manuscript that focuses solely on the use of formative research for the creation of the Moyo ndi Mpamba campaign, in order to contribute to the knowledge base on the design of integrated SBCC programs.

Challenges SSDI did face challenges to implementation across the years, many of them simply inherent to working in Malawi and in a complex environment with many stakeholders and projects with whom to coordinate. The challenges that impacted the project in a significant way include:

• Funding: Funding for the project was reduced at critical periods of the project, which impacted the scope and intensity of implementation. At times, project implementation had to be scaled back to meet the funding realities.

• Delay in Reaching Agreement: When SSDI began, there were ongoing discussions between USAID and MOH on how/whether to waive research fees (for IRB clearance). SSDI was prohibited from paying fees, but the GOM would not approve research without fees. Research could not go on without IRB clearance, and the design of the SBCC strategy was dependent on formative research. This process led to a significant delay in implementing the baseline research and developing an SBCC strategy.

• Economic and Natural Disasters: Between 2011 and 2012, Malawi experienced fuel shortage, which disrupted travel plans by project teams to the implementation districts. In addition, over the course of the project Malawi faced flooding and food shortage, all of which affected SSDI’s ability to implement.

• Clarity of Project Roles: There was some ambiguity in the division of scope of work for CM between the two cooperative agreements, SSDI-Services and SSDI-Communication, which led to inefficiencies in implementation.

• Challenges Faced by the HES: The HES, a major partner, stakeholder, and collaborator, faces challenges that by extension affected SSDI. These include inadequate funding for the HES, poor collaboration between HES and the vertical MOH programs that receive SBCC funding, and staffing. On staffing, several key staff positions have remained unfilled, and there has been staff turnover in both Lilongwe and the districts. To date, there has been insufficient political will to address these challenges.

• Availability of Services to Meet Demand: SSDI’s role was to increase demand for and use of services, but Malawi still suffers from a lack of service coverage to meet that increased demand. In addition, service providers were sometimes not able to leave their posts to attend training, which made coordination between services and communication more challenging.


Recommendations The successes and challenges of SSDI lead to a set of recommendations for communication and demand generation initiatives going forward in Malawi.

• Integrate health messaging under one umbrella: Integrated SBCC ensures that families have access to all essential information on priority health topics through platforms that reflect their lived experience, which does not silo health concerns. This model should be continued, and the lessons learned on integrated SBCC in Malawi should be disseminated globally.

• Build on Moyo ndi Mpamba: Future SBCC programming in Malawi should be encouraged to continue with the Moyo ndi Mpamba brand. It is a well-recognized and appreciated concept and serves as an existing umbrella for health messaging.

• Recognize CM as a communication function: Consider redesigning future programming to place the responsibility for CM with SBCC programs to ensure that communication, from the national level to the community and household level, is consistent and integrated.

• Be realistic and pragmatic in working with government: In planning for partnership, capacity building, and coordination with the MOH, set realistic expectations for all parties. That work together should include an increased emphasis on advocacy with government for funding for health promotion/HES.

• Strengthen the Capacity of the SBCC Community in Malawi: Continue to build a cadre of SBCC professionals with SBCC strategic planning skills through programs such as the Leadership in Strategic Health Communication Course.

Conclusion SSDI-Communication has left a mark on Malawi that will endure for years or even decades. The Moyo ndi Mpamba campaign, brand, and concept has entered the consciousness of Malawians, who have internalized the message that “life is precious” and that we all need to take care of it. The project’s comprehensive array of SBCC platforms and activities, accompanied by capacity strengthening efforts with key partners, has laid a solid foundation for the success of future integrated SBCC initiatives implemented by both USAID-funded implementing partners and the MOH. Evaluation study results – both internal and external – show that SSDI-Communication’s activities across SBCC, capacity strengthening, and CM were effective and well-accepted by all audiences. The Moyo ndi Mpamba campaign positively impacted knowledge, attitudes, and behaviors that will improve the health of communities in Malawi.


The total estimated amount for the project was US $24 million. However, the total amount obligated by USAID for this activity as of 31st December 2016 was US $17,378,622.06 - 72% of the estimated total funding required. There were no cost overruns during implementation, and despite the significantly reduced budget, the project was still able to make significant accomplishments that have been outlined in this report. Overall, SSDI-Communication implemented SBCC activities that reached approximately 13 million people through various communication channels outlined in this report. According to the SSDI evaluation report (2016), 71% of women and 78% of men in the SSDI districts were exposed to Moyo ndi Mpamba messages. The SSDI Activity Performance Report (2016) points out that Moyo ndi Mpamba platform was appreciated and understood by 82.1% of women and men. Both evaluations also noted that there were improvements in knowledge, efficacy and practices as a result of the project’s interventions. At the national level, significant progress was also made in developing evidence-based SBCC strategic planning and capacity. This strong performance of the project suggests that this was a financial investment well made by USAID.


Appendices

Compiled Monitoring Data on Program Reach Output Indicators Description

2011-2016 Target

2011-2016 Achievement

Number of meetings of a National Health Promotion Committee

The number of times that the EHP Communication Sub-technical working group meets

14 11

Number of program SBCC strategies refined and integrated

Number of topic-specific strategies, such as malaria or FP communication strategy developed

3 3

Number of community members reached with SSDI messages

Number of people that have seen or heard SSDI messaged

10,621,050 13,396,997

Number of Moyo ndi Mpamba reality program aired

Number of program produced and aired

147 89

Number of radio spots produced

Number of spots produced

20 22

Number of radio spots aired

Malaria 4,500 6,096

WASH 1,050 1,517

MNCH 1,050 2,183

FP 1,050 2,299

Nutrition in Pregnancy 1,500 1,513

Complimentary feeding 1,500 848

ORS and Zinc 135 135

DREAMS Radio program promotion

150 150

Number of print materials, t-shirts, zitenje produced and distributed.

Family Health Booklet 508,500 684,039

Malaria Comic book 25,000 26,120

Community Health Worker Flipchart

10,000 11,383

LAM leaflets 15,000 15,242


Output Indicators Description

2011-2016 Target


ORS and ZINC leaflet 20,000 22,982

LARC leaflet 20,000 20,142

Malaria flyers on fishing 240,000 240,000

Cholera leaflets 150,000 141,215

MNCH posters 6,000 6,276

FP Poster 6,000 5,786

Complimentary feeding Poster

6,000 5,439

Nutrition in pregnancy Poster

10,000 10,609

Implant – FP Poster 6,000 5,651

WASH big poster 6,000 5,188

Malaria RTD poster 1,500 1,490

Promoting role of Chiefs in discouraging use of LLIN for fishing poster

2,000 1,996

Discouraging use of LLIN for fishing (targeting fishermen) poster

2,000 1,996

LLIN Family poster (Don’t sell nets)

2,000 1,996

LLIN Family poster (Don’t use net for fishing)

2,000 1,996

Proper use of LLIN – Fisherman poster

2,000 1,996

Moyo ndi Mpamba T-shirts

15,000 15,307

Number of road shows conducted promoting Moyo ndi Mpamba campaign

Number of roadshows 30 86

Number of Malawians successfully completing an SBCC fellows

Number of SBCC fellows recruited in the program completing a

5 4


Output Indicators Description

2011-2016 Target


program one year training and mentorship program.

Number of guest lectures conducted

Number of lectures 16 5

Number of Technical support visits conducted to CM sub grantees

Number of visits 180 157


Evaluation: Summary of Findings from the SSDI-Communication Endline Survey

Overview Moya Ndi Mpamba (MNM) was widely accessible to Malawian men and women of reproductive ages as reflected in the findings. Moreover, exposure to the campaign was positively and significantly associated with positive knowledge, attitudes, social norms and health practices. While this association was not universal, it was more often true than not. As noted above, changes between baseline and endline were largely, although not universally, positive. These findings point to the predominantly positive effects of exposure to MNM media programming and other activities. Methodology This study relied on a stratified random sampling design, weighted by population, with 15 intervention and four control districts. The sample was stratified by district, enumeration areas and sex. The total sample comprised of 2,205 respondents; 981 men and 1,224 women.

Key Findings

ExposuretoMoyoNdiMpamba• Seventy-eight percent of men and 71% of women were exposed to at least one Moyo

ndi Mpamba campaign activity. • Men were exposed to significantly more campaign activities than women. • More people in general were exposed to the radio program than the community or

face-to-face activities.

WASH• Nearly 70% of all exposed respondents reported that they wash their hands using soap

and water at endline compared to 57% during the baseline. (The percent of non-exposed respondents who reported behavior was slightly lower than the overall rate at baseline.) Additionally, there was a considerable decrease in those who reported only using water (41% at baseline and 28% at endline).

• Compared to non-exposed participants, exposed participants were significantly more likely to report washing their hands with soap and water and less likely to report using water only.

Malaria• At endline, under-five children living in households exposed to the program were more

likely (92%) than those who were not exposed (84%) to sleep under a bed net the night prior to the survey.

• Of mothers who reported sleeping under a bed net, 91% at endline compared to 83% at baseline reported using an insecticide-treated net.


FertilityPreferencesandContraception• Exposure to the campaign was associated with greater likelihood of currently using any

form or a modern form of contraception for both men and women • 45% of the population who were not currently pregnant or trying to get pregnant

reported currently using modern contraception. • Exposure to a FP message from at least one activity from the campaign was associated

with increased FP intention among both men and women. • Among current non-users of contraception, 81% of men and 69% of women intend to

use contraception in the future. • Women who were exposed to at least one campaign activity were significantly more

likely to desire fewer children.

MaternalandChildHealth• Among women with a child ≤5 years old, 98% reported receiving ANC during their

pregnancy. • The mean number of ANC visits varied by Moyo ndi Mpamba participation or

exposure: while non-participants reported an average of 3.1 visits, Moyo ndi Mpamba participants reported an average of 3.4 ANC visits, a statistically significant difference.

• Program participants were significantly more likely to use any bed net as well as more likely to use LLINs every night during their most recent pregnancy.

• Compared to baseline, a larger percentage of women at endline reported giving birth with the aide of a trained medical attendant, and that a physician or clinical officer attended their birth. There were no differences by program participation.

HIV&AIDS• 35% of all respondents indicated that they had talked to at least one other person

about HIV/AIDs topics compared with 44% at baseline. While endline rates were lower, exposure to the program was positively and significantly associated with such conversations.

• Just below 90% of women and 82% of men sampled reported being tested for HIV compared to two-thirds at baseline.

• Exposure to the program was significantly and positively associated with HIV testing (women: 79% unexposed vs. 93% exposed; men: 72% unexposed vs. 85% exposed).

SexualBehavior• 21% of the total sample reported having more than one sexual partner in the past 12

months • Exposure to at least one campaign activity was associated with significantly reduced

likelihood of having more than one sexual partner in the past 12 months. • Overall, 14% of respondents reported using a condom at last sex. • Exposure was not significantly associated with condom use at last sex.


• Women who were exposed to Moyo ndi Mpamba were significantly more likely to perceive that some/most of their peers would approve of their consistent condom use. There was no significant effect of exposure among men.

GenderNorms• Exposure was associated with significantly higher gender equitable beliefs among both

men and women. • Program participants (both men and women) were more likely than non-participants to

report greater levels of joint decision-making.

Conclusions The findings reported herein point to the popularity and accessibility of the Moyo ndi Mpamba campaign. Given the clear associations between program exposure and positive outcomes, it is important to continue to use the Moyo ndi Mpamba platform to convey health-related knowledge and positive attitudes, encourage social normative change and create an enabling environment for positive health practices. To improve program exposure, the findings suggest that it will be important to (1) increase radio ownership and access to radio programming and (2) expand CM. Under SSDI, Malawi has made important strides in creating an enabling environment to sustain positive health practices and support positive behavior change. By continuing the successful Moyo ndi Mpamba approach, these achievements can be sustained and furthered, ushering in a healthier future for the children, women and men of Malawi. See full report for the complete details on the results of the evaluation of the SSDI-Communication project.


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