Category Archives: Communication

Ebola and the Irony of Bush Meat

The deadly Ebola epidemic of 2013-15 in West Africa was suspected of having started when a child in a remote village of Guinea came in contact with infected bats. After that initial episode NONE of the thousands of subsequent cases were traced to zoonotic causes, and yet the health authorities and the media put high level focus on the need to avoid bush meat – whether bats, monkeys, antelope or others – as a prime way to avoid the disease.

dos-and-donts-ebola-poster-final-07jul14_amhNew evidence is emerging that in fact it the evolving relationship between the virus and humans that allowed the disease to spread so widely. within the animal kingdon, humans, not bush meat where the major spreaders of Ebola.

Now two conflicting reports have surfaced about efforts to curb the consumption of bush meat.  First, a research team based in Rivers State, Nigeria, one of the places where Ebola reached, conducted a study that tracked the average number of carcases recorded in each market before and after the Ebola virus spread in Nigeria in June 2014. They reported that …

“The markets were surveyed twice a month between March and September 2014. Our survey found a statistically significant fall in trade for all the main traded types of animals. These included antelopes, monkeys, genets, mongooses, rodents, porcupines, birds, crocodiles, turtles and snakes. In particular, the trade in monkeys and fruit bats almost disappeared. Trade in turtles, crocodiles and other cold-blooded species was less affected.”

The group concluded that bush meat, though culturally valued, was “not as important as previously thought for rural people in west Africa.”

83ebb85e-bc1e-11e3-_562888c-getty-imagesThe second report, published a few days later, was posted in the Nigerian newspaper, Vanguard, and echos earlier stories.  ”

“Some bush meat sellers in some major markets in Lagos have said the business is booming again barely two years after the country was declared Ebola Virus Disease free. Some of the bush meat sellers told newsmen on Saturday that they were fully back to their business.”

Behavior change is not a simple process, especially when it comes to culturally rooted practices. Had better hygiene practices been possible by health workers and the public, it is possible that Ebola would have remained isolated. We should worry more about guaranteeing health workers the skills and equipment needed for infection prevention that the sales of bush meat.

An Ideation Model: Attitudes, Beliefs and Practices Relevant to Malaria Prevention and Treatment in Madagascar and Liberia

Stella Babalola, Nan Lewicky, Grace Awantang, Michael Toso, Hannah Koenker, Arsene Ratsimbasoa, Monique Vololona of the Johns Hopkins Center for Communication Programs and the Division for Malaria Control, Madagascar Presented findings on how local perceptions help predict uptake of malaria interventions at the 143rd American Public Health Association Annual Meeting, October 31 – November 4, 2015, in Chicago. Their presentation on Liberia and Madagascar is summarized below.

While Liberia has an average malaria parasitemia prevalence of 28%, malaria is considerable less common in Madagascar and varies by region and altitude. This difference provides an interesting opportunity to observe similarities and contrasts in community perceptions of the disease.

Slide6Theoretical basis of the research is based on the Ideation model which has been described as follows and as seen in the attached figures:

  • “New ways of thinking and the diffusion of those ways of thinking by means of exposure to mass media and social interactions in local, culturally homogeneous communities” – Kincaid, 2000
  • “views and ideas that people hold individually” – van de Kaa 1996

Slide7The ideation model has successfully predicted current use of a contraceptive method as well as accessing childhood immunization. The team took up the challenge to learn whether this model would be applicable to malaria interventions.

Malaria-related ideation was proposed to consist of: Malaria knowledge (cause, symptom, prevention); Perceived susceptibility to malaria; Perceived severity of malaria; Perceived self-efficacy to prevent malaria; and Social interactions about malaria. These may lead to uptake of malaria interventions.

Slide10Items for measuring bed net ideation could include – knowing where to procure a bed net, Willingness to pay for bed net, Having a positive attitudes towards bed net (derived from ten attitudinal statements), Perceived response-efficacy of bed nets, Perceived self-efficacy for procuring and using bed nets, Participation in household decisions about bed nets, Descriptive norm about bed net use and Social interactions about bed net use.

Percent of female caregivers that slept under an ITN on the night before survey increased by level (score) of bed net ideation as seen in the graph. Results (odds ratio) of logistic regression of sleeping under an ITN on bed net ideation and other covariates showed a similar trend.

Slide15Intermittent Preventive Treatment of Malaria in Pregnancy ideation measures included the following:

  • Knows name of the drug for malaria prevention during pregnancy
  • Knows the timing of first dose of IPTp
  • Has positive attitudes towards ANC and IPTp (derived from four attitudinal statements)
  • Perceived response-efficacy of IPTp
  • Woman participates in decisions about own health
  • Social interactions about malaria and pregnancy
  • Descriptive norm about ANC visits

Slide21The percent of women who took at least two doses of IPTp during their most recent pregnancy also increased by level of IPTp ideation Likewise the results (odds ratio) of logistic regression of obtaining at least two doses of IPTp on IPTp ideation and other covariates were highest among those with highest levels of ideation.

Items for measuring case management ideation included –

  • Perceived response efficacy of malaria diagnostic test
  • Perceived self-efficacy for detecting uncomplicated malaria
  • Perceived self-efficacy for detecting severe malaria
  • Descriptive norm about prompt treatment of malaria in children
  • Social interactions about malaria treatment
  • Participation in household decisions about child health
  • Positive attitudes towards appropriate malaria treatment

Slide27Again the percent of children sick with fever in past two weeks who received prompt ACT treatment by caregiver’s increased with increasing level of treatment ideation. As before the results (odds ratio) of logistic regression of prompt ACT treatment on caregiver’s treatment ideation and other covariates shows highest levels of ideation were associated with greated treatment seeking.

The team concluded that the same ideation model with demonstrated validity for family planning, child immunization, WASH and other health behaviors is relevant for malaria prevention and treatment. Strategically designed messages and interventions addressing ideational variables can help foster adoption of health-protective malaria prevention and treatment behaviors.

The authors acknowledge The US President’s Malaria Initiative (PMI) for technical guidance on the implementation of the surveys and The Ministry of Health and Social Welfare in Liberia and the Ministry of Health in Madagascar for their collaboration on the surveys.

Case Management of Malaria: A Review and Qualitative Assessment of Social and Behavior Change Communication Strategies in Four Countries

Kamden Hoffmann1 and Michael Toso2 presented a poster today at the 143rd annual meeting of the American Public Health Association in Chicago. Their findings are posted below.

report coverIntroduction. With the introduction and growing availability of combination therapy and rapid diagnostic tests, case management of malaria has evolved and expanded in scope. Social and behavior change communication (SBCC) activities have been developed to influence prompt care seeking behavior, adherence to test results, and completion of full treatment regimens. This review describes SBCC programming, and the extent to which it has been evaluated for impact, in Zambia, Ethiopia, Rwanda, and Senegal.

Objectives. The purpose of this review is to identify promising SBCC practices related to case management at both community and service provider levels in the four focus countries: Zambia, Ethiopia, Rwanda and Senegal. Essential for any large-scale communication strategy is a form of impact assessment. Impact assessments aim to answer the question, “Did the communication strategy achieve the specified objectives?” Impact assessments look at the difference that the strategy made in the overall program environment. The indicators can vary depending on the approach and channels used in the strategy.

An example of an impact indicator for malaria case management could be: the proportion of children under five years old with fever in the last two weeks for whom treatment was sought. Typical data sources include:

  • Population-based household surveys, such as the Demographic and Health Survey, the Malaria Indicator Survey, or the Multiple Indicator Cluster Survey.
  • Sub-national household surveys, particularly in areas where malaria communication activities were targeted.

Countries Picture1

Methods. An initial review was undertaken, consisting of a thorough PubMed search for articles related to malaria case management that mentioned SBCC, in the four countries. Malaria case management country-level documents, project reports and related SBCC materials were also collected. Implementing partner reports were gathered from each country related to SBCC and/or malaria case management. A comprehensive list of search terms were used for all four countries.

Qualitative analysis consisted of Key Informant Interviews (KIIs) with members of NMCP SBCC/BCC units within the Ministry of Health, USAID implementing partners, and President’s Malaria Initiative staff. A semi-structured questionnaire was used to gather information related to perceptions and first-hand experiences. A total of nine interviews and four written responses were collected. All interviews were recorded and transcribed. The transcribed interviews and written responses were entered into NVivo 10. An initial codebook was developed based on the semi-structured interview guide. Open and axial coding enhanced the initial codebook as themes were generated in the software.

Countries Picture2

Conclusions. The review was not able to find a substantial amount of material to show gains in the ability to measure impact of SBCC interventions in malaria case management outcomes. Several programs were able to measure changes in care-seeking behavior and uptake of ACTs; however, these types of programs need to be refined in order to measure the specific contribution of malaria SBCC interventions. Each country reviewed presented a program related to either the care group model or a model with a strong community component, and holds promise for further exploration in terms of launch points to expand the measurement of SBCC impact.

MToso IMG_0503Author Affiliations.

1 Insight Health, 710 Sutter Gate Lane, Morrisville, North Carolina 27560

2 Johns Hopkins Bloomberg School of Public Health, Center for Communication Programs, 111 Market Place Suite 310, Baltimore, MD 21202, USA

Funding for this study was provided by the US President’s Malaria Initiative.

References.

1 Kidane G, Morrow R. Teaching mothers to provide home treatment of malaria in Tigray, Ethiopia: a randomized trial. The Lancet 2000.

2 Innovation for Scale: Enhancing Ethiopia’s Health Extension Package in the Southern Nations and Nationalities People’s Region (SNNPR) Shebedino and Lanfero Woredas, October 1 2007-September 30 2012. Report of the Final Evaluation. December 2012.

3 Linn AM, Ndiaye Y, Hennessee I, et al. Reduction in symptomatic malaria prevalence through proactive community treatment in rural Senegal. Trop Med Int Health. 2015;20(11):1438-1446.

4 Landegger, J., et al. CHW Peer Support Groups for Integration of Health Service Delivery and Improved Performance: Learning from a Peer Group Model in Rwanda

5 Limange, J., et al., Evaluation: Mid-Term Evaluation of the USAID/Zambia Communications Support for Health Program, January 2013, USAID.

6 Salvation Army/Zambia (TSA), Salvation Army World Service Organization (SAWSO), and TSA Chikankata Health Services Chikankata Child Survival Project (CCSP), 2005?2010, Final Evaluation Report. December 2010.

Seasonal Malaria Chemoprevention Implementation in Senegalese Children

20151028_123042-1Dr Mamadou L Diouf and colleagues[1] from the National Malaria Control Program, Dakar Senegal and the President’s Malaria Initiative/USAID, Dakar, Senegal presented their experiences with Seasonal Malaria Chemoprevention among children aged 3-120 months in four southern regions of Senegal at the 64th Annual Meeting of the American Society of Tropical Medicine and Hygiene. Their findings are outlined below.

Malaria is major cause of disease and death in infants and children, with seasonal transmission, highest in the southern and eastern regions which are the wettest areas. SMC is administration of a complete treatment course of AQ+SP at monthly intervals to a maximum of 4 doses during the malaria transmission season to children aged between 3 and 59 months in areas of highly seasonal malaria transmission (where both drugs retain sufficient antimalarial efficacy).

Health post nurse training volunteersTarget areas for implementation are areas where more than 60% of clinical malaria cases occur within a maximum of 4 months, the clinical attack rate of malaria is greater than 0.1 attack per transmission season in the target age group, and AQ+SP remains efficacious (>90% efficacy).

Adoption of SMC in 2013 as a new intervention in malaria control policy. Four south-eastern regions eligible according to WHO criteria for SMC (Tambacounda, Kédougou, Sédhiou and Kolda) chosen

The poster presented Senegal’s experience implementing SMC and focuses particularly on process, challenges and lessons learned. Available information generated from the national SMC implementation guidelines, technical documents, field activity reports, and SMC impact evaluation survey were reviewed.

The medication distribution strategy relied on a door to door campaign strategy with community volunteers. On the first day, the volunteers, trained by health workers, administer drugs to the children under surveillance of their mothers or guardians. For the 2 remaining days, mothers administer the medication.

campaign resultsIn 2014, the SMC Campaign was conducted in the four regions for three months covering the high transmission season (August, September, October, and November). Kedougou, was the only region that conducted 2 SMC rounds as it started implementing in 2013.

The target was extended to children from 3 to 120 months (624,139 estimated in target age group). This age group extension, compared with WHO recommendations (3 to 60 months,) was based on shift of vulnerability towards the ages from 60 to 120 months shown by the epidemiologic data on malaria morbidity in Senegal.

Administrative coverage rates for the 3 passages respectively was 98.6%, 97.9% and 98.0%. Information was obtained from the SMC impact evaluation survey in the south of Senegal, 2015 July by Dr JL Ndiaye.

SMC districtsKey interventions and process began with the National and regional Steering Committees involving NMCP, health staff, donors/partners and researchers. There was development and update of tools and materials (guidelines, planning forms, data collection and analysis support. Training of staff took place at all levels and operational actors

Early field planning was held with staff at regional and district level: identification of activities, dates, estimation of household/child targets, estimation of resources needed (budgets, HR, logistics, etc.). Early delivery of drugs, tools, supports was ensured to be available at health post level at least 1 week before the 1st campaign day.

Rigorous selection of volunteers and supervisors was based on specific criteria. Develop communications activities took place at least 2 weeks before and during the campaign period focusing on SMC gains, HH census, administration by mothers for the 2 remaining days, and possible side effects.

New casesCampaign roll out included supervision of the process at the districts and health posts (organization model, administration). There was mobilization of logistics for transportation of volunteers, drugs, and materials. Day to day monitoring took place with regional debriefing to analyze data from districts, geographical progression, target coverage progression and identify issues and challenges. Daily electronic distribution of “SMC bulletin” to health staff and partners helped to disseminate information on districts performances.

Post campaign evaluation took place at all levels: workshops for sharing and validating data and information, identification of key issues, lessons learned, and formulation of recommendations to improve future campaigns. Local health agents, NMCP staffs, partners and authorities were involved.

Spontaneous pharmacovigilance system tracked and treated side effects. This consisted of distribution of yellow cards to health facilities, case notification by health agents, availability of a side effects line listing, and immediate and free-of-charge case management.

The following key challenges were faced:

  • Correct availability of drugs and tools at health posts
  • Complete coverage of all households and children
  • Completion of 2nd and 3rd doses by guardians of children
  • Availability of children and guardians during harvest period and class time
  • Comprehensive communication for population particularly in possible occurrence of side effects
  • Case management of side effects free of charge
  • Availability and promptness of data
  • Long term logistic availability

Rainy SeasonFinally there were some outstanding questions. Can we switch SMC from campaign to routine system at health post level? Can we expand SMC to other regions and with what targets? Also, can we improve formulation and taste of drugs for enhancing children’s compliance?

Financial support: This work was made possible through support provided by the United States President’s Malaria Initiative, and the U.S. Agency for International Development, under the terms of an Interagency Agreement with the Centers for Disease Control and Prevention (CDC). The opinions expressed herein are those of the authors and do not necessarily reflect the views of the U.S. Agency for International Development or the Centers for Disease Control and Prevention.

[1] Dr Mamadou L Diouf, Mr Medoune Ndiop, Dr Mady Ba, Dr Ibrahima Diallo, Dr Moustapha Cisse, Dr Seynabou Gaye, Dr Alioune Badara Gueye, Dr Mame Birame Diouf

Factors associated with the uptake of malaria prophylaxis during pregnancy among female caretakers in Madagascar

Grace N. Awantang, Stella O. Babalola, Hannah Koenker, and Nan Lewicky of the Johns Hopkins Bloomberg School of Public Health, Center for Communication Programs presented a poster today on IPTp uptake in Madagascar. Their Abstract follows:

Grace imageIntermittent preventive treatment of malaria in pregnancy (IPTp) is one of the key interventions promoted for combatting maternal mortality and malaria. In Madagascar, supply side factors such as SP availability and ANC attendance are barriers to practicing IPTp.

Less than one fifth of women (18.4%) at risk for malaria take the recommended two doses of sulfadoxine/pyrimethamine (SP) to prevent malaria during pregnancy whereas about half (49.7%) visit a health provider at least four times during pregnancy. Understanding the significant predictors of IPTp2 is crucial in order to inform interventions that can effectively promote this behavior.

Prior research has shown that both communication campaigns and individual cognitive, social and emotional factors, ideation, play a role in determining other health behaviors including malaria. We examined the correlates of IPTp2 using cross-sectional household survey data collected from female caretakers of children under five years of age.

madagascarCaregiver recall of any anti-malaria messages during the past year was used to determine their exposure to health communication.  Knowledge of IPTp, response-efficacy of IPTp, attitudes towards antenatal care (ANC), attitudes towards ANC, discussion of IPTp, and descriptive norm about ANC determined a person’s ideation score.

Of 1,589 female caretakers, over half (56.8%) were exposed to an anti-malarial message and a tenth (10.8%) mentioned SP as the drug used by pregnant women to prevent malaria.  Message exposure, IPTp ideation and education level were all significant predictors of IPTp2 uptake in multivariate analysis.

Uptake was lowest among caretakers in the Highland transmission zone where transmission is unstable and highest in the Sub-desert transmission zone. Results suggest that both individual ideation and exposure to anti-malaria behavior change communication play a significant role in IPTp uptake among women in Madagascar.

The small portion of the variation in IPTp2 uptake explained by the measured covariates suggests that programmatic efforts should address supply-side factors that hinder access to ANC and preventive treatment of malaria during pregnancy.

Leading by Example: President of Senegalese AIESEC-CESAG supports the Zero Malaria! Count Me In! campaign

Yacine Djibo, Founder & President of Speak Up Africa is helping focus International Women’s Day (March 8th) on efforts to protect women from malaria in Senegal. She is highlighting the ZeroPalucommitments of 8 strong and beautiful women, in Senegal, that are dedicated to eliminating malaria in their country. These commitments are part of an inclusive mass communication campaign that aims to launch a national movement in favor of malaria elimination in Senegal: the “Zero Malaria! Count Me In” campaign

International Women’s Day, represents an opportunity to celebrate the achievements of women all around the world. This year’s theme is “Empowering Women – Empowering Humanity: Picture it” envisions a world where each woman and girl can exercise her choices, such as participating in politics, getting an education or fighting malaria. Below is the seventh feature on women fighting malaria……

Massandjé Touré, President AIESEC-CESAG

Massandjé Touré, President AIESEC-CESAG (Centre Africain d’Etudes Supérieures en Gestion)

Massandjé Touré is the President of Senegalese AIESEC-CESAG, a youth-led network creating positive impact through personal development and shared global experiences. The AIESEC association believes that every young person deserves the chance, and tools, to fulfill their potential, this is why it provides young people, self-driven, practical, global experiences.

As part of the Zero Malaria! Count Me In campaign, Massandjé Touré, signed the Declaration of Commitment on July 10, 2014, at the National Malaria Control Program in Senegal (NMCP), alongside the NMCP Coordinator, Dr. Mady Ba.

AIESEC-CESAGTo further the commitment of AIESEC-CESAG, the students enrolled in the Sama Video, Sunu Santé (My video, Our Health) programme. This programme gives the opportunity to children, living in rural communities, to express themselves on their own health issues by writing and creating short films with the help of tutor. The first edition of this programme took place in the rural community of Fimela.

The second edition is now taking place in collaboration with Sup’Imax students, a higher education audiovisual school, AIESEC – CESAG students, Ibrahima Thiaw Junior High, PATH, the National Malaria Control Program and Speak Up Africa, in the frame of the Zero Malaria! Count Me In campaign.

Thank you Massandjé for leading by example and joining the Zero Malaria! Count Me In campaign and bringing awareness to all your fellow students, in Senegal and Africa.

*****

Headquartered in Dakar, Senegal, Speak Up Africa is a creative health communications and advocacy organization dedicated to catalyzing African leadership, enabling policy change, securing resources and inspiring individual action for the most pressing issue affecting Africa’s future: child health.

What the Press Tells Us about the Early Days of Liberia’s Ebola Outbreak

The mass media are assumed to play an important role in the national response to a crisis, and Ebola should be no exception. The first cases of the disease in Liberia appeared in March 2014 after victims crossed the border from its point of origin In Guinea. A search for Ebola-related articles from the early period, March to May, was undertaken in The Liberian Observer.

DSCN7963While to date over 1,000 articles and references on Ebola were found in The Liberian Observer, most of the news coverage has appeared from August to October. In particular there were few articles in March, a surge in April and then a tapering off in May and June, before Ebola gained more prominence in print from July onwards.

Generally the early news articles in the Observer report events and opinions surrounding Ebola rather than serve as direct avenues for behavior change communication (BCC). Articles on politics, science, religion, economics, social commentary and even cartoons focused indirectly or directly on key events in the development of the national response.

DSCN7881Because of upcoming elections politicians used the outbreak to criticize each other’s response to the problem. In the early days the economic concerns focused primarily on reduced revenues across national borders in the region. Religious leaders either tried to rally support for control through prayer and fasting or blamed the epidemic on sin.

A couple opinion pieces in April acknowledged that BCC was going on through the radio. Special events such as sporting and athletics adopted an Ebola prevention theme, and several local NGOs pledged support for community outreach and awareness creation. Senators even had a retreat to learn more about the disease so they could educate their constituents.

DSCN7922 aOn March 23rd Marday L Peters wrote in the Observer, As Deadly Virus Threatens Liberia, Where is the Outcry?” At least from the communications point of view, the situation improved in April.

A.M. Johnson, The Health Correspondent for the Observer reported about Health Promoters Network, Liberia (HPNL) on April 3rd, quite early in the outbreak. HPNL in expressing its support for Ministry of Health and Social Welfare efforts “urged everyone within our borders to adhere to those preventive measures such as do not eat animals that are found dead in the bush, and avoid contacts with fruit bats, monkeys, chimpanzees, antelopes and porcupines. Limit as much as possible direct contact with body fluids of infected persons or dead persons. Wash your hands with soap and water as frequently as possible.” HPNL called on other Liberian NGOs to join the cause of educating the public.

On April 20th, S. Vaanii Passewe, II mentioned in a commentary that, “… the airwaves were laden with the news of an outbreak of the deadly Ebola outbreak… Subsequent warnings from the Ministry of Health notably said that the populace should report suspected cases, refrain from coming into body contact with suspected Ebola patients, avoid shaking hands, do not have casual sex with strangers, etc. These weird precautionary measures heightened fear.”

Some actionable information was provided in regular news articles in April. For example in an article on April 25th The Observer talked about “Ending Ebola in Liberia, A Collective Approach Needed,” readers were told about the symptoms, the potential spread through fruit bats and the fact that there was no specific cure, but supportive care is needed.

Further study of more mass media outlets concerning Liberia’s Ebola control efforts is needed. We know that although an early start to educate the public was undertaken, a relative dearth of coverage in the Observer might also indicate a reduction in enthusiasm by the press, NGOs and government to sustain Ebola communication and action. For whatever reason, the epidemic spiked. Fortunately efforts are now back on track, but there is a long road ahead.

Communication Challenges: Malaria or Ebola

The purpose of health education of behavior change communication (BCC) is to share ideas such that all sides of the communication process learn to act in ways that better control and prevent disease and promote health.  Both community members (clients) and health workers (providers) need to change behavior is their interaction to become a health promoting dialogue.

This dialogue becomes easier when all parties share some common perceptions about the issue at hand. Both health workers and community members can usually agree that malaria often presents with high body temperature. Also both usually agree that malaria can be disruptive of daily life and even be deadly.

But there are differences. While both may agree that there are different types of malaria, the health worker may mention different species of Plasmodium such as falciparum, ovale, vivax, malariae and now even knowlesi. The community member may think of yellow malaria, heavy malaria, aching malaria, and ordinary malaria. These differences may put acceptance of interventions to control malaria into jeopardy. Fortunately, current downward trends in malaria incidence imply that our communicants have more in common than not.

Cases 20140924Along comes Ebola Viral Disease in West Africa, which has killed around 3000 people in Guinea, Liberia, Sierra Leone and Nigeria at this writing.  The disease has never been seen on that side of the continent before. It is spreading more rapidly than it even did in its previous East and Central African outbreaks.  How does one communicate with people – both community members and health workers – about a disease they have never seen before?

The following encounter reported by BBC shows the initial confusion.

Not infrequently in the last few weeks I’ve encountered people complaining of a headache or a night of intense sweating. They slide off to the hospital and reappear a day or two later with a bag full of drugs, and they laugh it off. “Oh yeah, there are so many mosquitoes at this time of year,” they say. Better it be ‘normal’ malaria than death (Ebola).

The confusion results in harmful changes in treatment seeking behavior according to the The Pacific Northwest Conference of The United Methodist Church.

Misinformation and denial are keeping sick people from getting help. Some people are hiding from government officials and medical teams because they fear that if they go into quarantine, they will never see their loved ones again. Since the early symptoms of malaria and Ebola are similar, many malaria patients are not getting treatment. This crisis jeopardizes the progress toward improving access to health care generally.

In his blog, Larry Hollen summarizes the dilemma as follows: Both diseases disproportionately affect the poor and ill-informed Because Ebola and malaria have common early symptoms, such as fever, headache and vomiting, there may be confusion about the cause of illness among both those who are ill and health care providers.

Efforts to communicate the nature and dangers of Ebola have proceeded anyway. Posters, billboards, radio spots and even local volunteers with bullhorns, armed with information from the ministries of health or NGOs remind people that Ebola can kill and that people must report to a health facility for testing and care.

This top-down approach to communication often meets skepticism and suspicion. The messages also do not match reality when people find health centers closed due to loss of staff or health workers reluctant to see febrile patients fearing that they may have Ebola, not malaria. A health education dialogue cannot take place under such circumstances.

In fact suspicion is the order of the day. Sierra Leone and Liberia have emerged not long ago from brutal civil wars that not only destroyed must health and other infrastructure but killed much of their populations and alienated those who survived. Reinforcing this suspicion and distrust are militaristic approaches in both countries to contain the poor populations most affected.

False rumors are spreading that the international donors who are slowly rallying resources to fight the disease are actually the ones who may have created and started the spread of Ebola. It is unfortunately not surprising under such circumstances that a health education team going to a remote village in Guinea were killed.

Some positive approaches to Ebola communication have been documented including the use of trusted community health workers making door-to-door visits in Sierra Leone. More effort is needed to plan a more inclusive dialogue among all parties in order to halt the Ebola epidemic. Dialogue can start from the known – like the similarities with malaria – and move into the unknown. Drugs and vaccines will not be enough, if trust and good communication are lacking.

Hearing, Seeing, Changing: Bednet Behavior

An important new article in Malaria Journal by colleagues at the Johns Hopkins University Center for Communications Programs gives confidence to health educators and behavior change practitioners that their interventions do make a difference. Using the 2010 Malaria Indicator Survey (MIS) from Zambia, they were able to comparing women’s reports of exposure to behavior change communication (BCC) messages and their use of insecticide treated nets (ITNs) the previous night.

CAM03755 smExposure to ITN messages was focused on women who “reported hearing or seeing any malaria messages in the past six months and also cited at least one specific channel: television or radio, in the newspaper, on posters or billboards, or from peer educators and drama groups.” Using two different analytic approaches, the authors found that exposure to messages was responsible for between 12-29% of net use. They concluded that the results “illustrate that BCC programmes can contribute to national programmes seeking to increase the use of ITNs inside the home.”

The recent MIS in a variety of endemic countries have taken up the task of measuring not just use of ITNs but also knowledge of the role of ITNs in preventing malaria and exposure to BCC messaging about ITNs.  Similar analysis should be performed on these data sets.

NetMark billboard aThe 2010 Nigeria MIS, for example, reported that 27.9% of women reported exposure to malaria messages in 4 weeks prior to the study. Likewise 57.9% of women had knowledge that Sleeping under mosquito net prevents malaria in pregnancy (MIP).  The 2012 MIS from Malawi reported that 25.3 women claimed exposure to malaria messages in past 4 weeks, and of those, 87.3% had knowledge that Sleeping under mosquito net prevents MIP.

A 2011 survey in Ghana found that 57.3% of women claimed exposure to malaria messages in past 4 weeks, and of those 83.7% had knowledge that Sleeping under and ITN prevents MIP. A question remains though, what was the actual nature of those media efforts to which women claim exposure?

The surveys do note the broad sources of information, e.g. radio, health workers/clinic, community activities. A review of overall national malaria strategies  and specific malaria BCC documents will certainly indicate that national programs and their partners intend to engage in a variety of BCC activities. The issue is whether, where and how those activities took place.

To give more validity to BCC outcomes, we must also encourage national malaria programs and their partners to document better their BCC activities so we can more easily attribute ITN behavior change itself to specific, funded interventions.

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.