Posts or Comments 19 September 2021

Monthly Archive for "August 2014"



Communication &Treatment Bill Brieger | 27 Aug 2014

Documenting SBCC’s Important Role in Malaria Case Management

Community health worker Cheikh Tandian in southern Senegal during routine sweeps of villages with RDTs and ACTs. Photo by Ian Hennessee

Are there examples of effective social and behavior change communication (SBCC) for malaria case management that can be shared with other countries looking to improve their programming?

After examining research, policy documents and program evaluations from Ethiopia, Rwanda, Senegal and Zambia to determine whether effective SBCC activities have been used to improve malaria case management, I haven’t come across many strong examples. Program reports don’t tend to mention SBCC program evaluation. Reports that do mention it are difficult to find credible because the indicators used don’t address the real determinants of behavior.

Behavioral researchers have spent decades trying to illustrate just how insufficient it is to measure only knowledge. Attitudinal factors like perceived risk, self-efficacy and cultural norms are important behavioral determinants conspicuously missing from reports on malaria case management program design and evaluation.

Here’s an example of an attitudinal indicator related to malaria case management: Proportion of health care service providers that believe new diagnosis and treatment guidelines (test before you treat) are effective. I found a carefully designed study (a cluster-randomized controlled trial) assessing community health workers ability to diagnose and treat children. After a brief training, health workers evaluated over a thousand children with fever and accurately treated them based on disease classification 94%-100% of the time. Of note in this study: facility-based health workers (nurses or doctors) in two districts of the Southern Province of Zambia were less likely to follow guidelines or honor the results of rapid diagnostic tests than community health workers.

MalariaCare recently conducted a series of interviews revealing the same pattern. A 2014 systematic review on malaria in pregnancy found health care provider reliance on clinical diagnosis and poor adherence to treatment policy is a consistent problem. Perhaps doctors feel their considerable experience enables them to diagnose patients accurately without policy-mandated tests? Do community health workers adhere to a policy more tightly because they have a limited number of tasks and take pride in fastidiously carrying them out? The point is that the most educated individuals in an entire country – or those most likely to have accurate, timely information – can be outperformed by individuals with little or no formal education when exposed to the exact same set of government guidelines.

The difference is attitude.

Are programs targeting the attitudinal barriers behind adherence to malaria test results? Are evaluators measuring changes in these key attitudes? You can’t measure impact if you didn’t actually change behavior and people don’t change the way they act unless their decision-making process – in all of its beautiful human complexity – is acknowledged and addressed.

The Roll Back Malaria Partnership (RBM) has an SBCC community of practice made up of public health professionals working to promote a more rigorous, evidence-based approach to malaria SBCC program design and evaluation. One of the group’s products, the Malaria Behavior Change Communication Indicator Reference Guide, was developed to help Ministries of Health, donor agencies and implementing partners design and measure levels of behavior change related to malaria prevention and case management. The guide contains a list of indicators that go beyond knowledge and awareness into important behavioral determinants like attitudes. The guide has been available since February 2014 and this month the group is happy to announce its publication in Portuguese (it is also available in French and English).

The answer to the question posed by this desk review is that there is a lot of great work being done in malaria case management but it is being in done in a way that makes it difficult for others to follow. This new tool was developed to ensure SBCC programming is designed in such a way that its impact can be measured and replicated.

Agriculture &Economics &Occupation Bill Brieger | 26 Aug 2014

Malarious Occupations

Often the focus of malaria case management and malaria prevention is on children under five years of age and pregnant women. Adults generally can be at higher risk for getting malaria because of their occupations, as was seen in two recent publications.

The Asian Scientist reporting on Bangladesh explained that “Slash-and-burn farmers … are exposed to a higher risk of malaria infection.”  The report notes that not only are woodcutters and jhum (slash-and-burn) cultivators at increased risk of being infected by malaria and but they are also endangering their families.

The researchers at the Centre for Vaccine Sciences and the Centre for Population, Urbanisation and Climate Change of the icddr,b, in collaboration with the Johns Hopkins Malaria Research Institute, Baltimore, reported that “jhum cultivators and people living with them had 1.6 times higher odds of being infected with malaria than non-jhum cultivators.”

The study also appeared in the American Journal of tropical Medicine and Hygiene where the authors observed that “Possible mechanisms cited in the study for the observed higher malaria incidence among jhum cultivators include increased exposure to mosquitoes, sleeping away from home unprotected by bed nets and lack of access to health services.”

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Wild cat Gold mining in Burkina Faso also exposes miners to malaria.

Gold mining is another ‘vulnerable occupation, according to a study in Venezuela. Daniel Pardo of BBC News posted photographs that show how mining creates water-filled pits as breeding sites and also the substandard living quarters of the miners where mosquitoes have easy access to victims.

According to the BBC, “Venezuela used to be a world leader in managing malaria, but is now the only country in Latin America where incidence of the disease is increasing. Around 75,000 people were infected last year, and according to government figures, 60% of cases were in Sifontes, a tiny region of the country where gold mining – where workers drill for gold in mosquito-friendly standing water – is booming, and healthcare is scarce. “

These two experiences challenge our ideas of focusing control on only certain groups who are perceived as vulnerable. If we are to eliminate malaria, we need to identify all at risk populations, especially those in rural and hard to reach areas like miners and farmers.

This situation also tells us that much of the occupational risk of malaria is created by humans who overlook health costs in the economic calculations about their work. Clearly we cannot eliminate malaria without collaboration among the health and economic sectors in an effort to promote the overall welfare of populations.