Tropical Health Matters

Save the Children designs programs to protect children and families from malaria. An important aspect of the design process is learning about the factors that influence community members’ behaviors related to the prevention of the disease. Here we learn about behavioral factors that must be considered to design effective programs. This information is being presented at the 2021 American Society of Tropical Medicine and Hygiene Annual Meeting. See Author List below.

Understanding the drivers of malaria-related behavior helps national malaria control programs and implementing partners to plan national malaria strategies and to tailor interventions accordingly. This study examined the factors affecting adoption of malaria behaviors and those that drive or inhibit them among populations at high risk of malaria in Cote d’Ivoire.

This study was a multi-method, qualitative study with an exploratory approach using focus group discussions (FGDs), in-depth interviews (IDIs) and life stories. The study was conducted in 12 health districts across 10 health regions of Cote d’Ivoire in both urban and rural areas. FGDs and life stories were conducted with pregnant women and mothers of children under 5 and men (heads of household). IDIs were conducted with a number of stakeholders including: departmental district directors; midwives, nurses, community health workers, leaders of women’s groups, community leaders, and the local media.

The findings from this study show that incorrect knowledge about LLINs, LLIN dislike and discomfort, housing structure and size, sleeping arrangements for children under 5, and lack of LLIN recycling strategies were among the root causes for incorrect, non-use and/or inconsistent use of LLINs. In terms of ANC attendance, the main reported barriers were influence of their beliefs and norms, cost, perceived poor services provided, bad experiences from gynecological examinations, and the distance of health facilities in rural areas. Additionally, the lack of information on the benefits of SP for prevention of malaria in pregnancy and the use of traditional medicine were the main barriers for SP in pregnancy. Cost, poor services by health care providers and stock outs were the main barriers to diagnosis and treatment for children U5.  The main factor that influenced the adoption of preventive measures was free LLIN distribution through ANC viists and mass distribution campaigns.

Findings from this study are useful to inform the revision of the Social Behavior Change Communication Strategy in Cote d’Ivoire. Additionally, they can inform key messaging and the design of interventions in a context where malaria is the main cause of morbidity and mortality and children under 5 and pregnant women are the most affected.

AUTHOR LIST:

Jacob Y. Agniman1, Manasse N. Kassi1, Yssouf Ouattara1, Edouard C. Balogoun1, Serge B. Assi2, Philomène A. Beda1, Michel N’da-Ezoa3, Aristide E. Kouadio1, Joel Koffi1, Apollinaire N. Kouadio1, Paul Bouey4, Sara Canavati4, Eric Swedberg4 — 1Save the Children, Abidjan, Côte D’Ivoire, 2Le Programme Nationale de Lutte contre le Paludisme (PNLP), Abidjan, Côte D’Ivoire, 3Socio-Anthropologue de la Santé, Abidjan, Côte D’Ivoire, 4Save the Children, Washington, DC, United States

Save the Children recognizes the importance of strong health systems to deliver malaria interventions. Here they arsharing a wealth of information on these efforts at the 2021 American Society of Tropical Medicine and Hygiene Annual Meeting. Here is an abstract from one of their malaria efforts. See Author List below.

Since 2010, Cote d’Ivoire has made significant progress in the fight against malaria; however, since 2016 progress has stagnated and malaria incidence is steadily increasing. The aims of this study were to assess knowledge, attitudes and practices among heads of households, pregnant women and caretakers of children under 5 years of age (U5) and IPTp-SP compliance.

A mixed-methods study was conducted in rural and urban areas in 20 health districts of Cote d’Ivoire. A total of 1,812 households composed of 8,813 members were surveyed using a structured questionnaire. Qualitative data were gathered through twenty focus group discussions. Data triangulation was used during analysis.

Fever was the main malaria symptom reported by heads of households (38.5%) followed by headache (25.5%). Additionally, many FGD participants also reported sadness as a symptom of malaria. The primary cause of malaria was mosquito bites, followed by fatigue, the sun, and salty water, 70.7%, 15.1% and 10.9%, 3.3% respectively. The main prevention methods reported were sleeping under an ITN (60.4%), spraying the house (25.9%), taking medication (5.8%), and using a fan (7.9%). In FGDs, additional means of prevention were discussed including sanitation of the environment, personal hygiene, and stopping alcohol consumption.

The majority of women with at least one child reported having attended at least three ANC visits in their last pregnancy (85.1%). The cost of ANC was a main factor affecting attendance.  Overall, 78.2% of them received SP and of these women, 98.1% said they received it during their ANC visits. However, only 55.4% received 3 doses or more of SP and 76.79% received SP free of charge. The reasons for not taking SP were stock outs, side effects, bitter taste, and preference for injections.

Our study revealed that knowledge of prevention measures (ITNs) and causes of malaria (mosquito bites) were high and in line with the targets of the National BCC Strategy 2021-2025. However, even though the majority of pregnant women would like to take SP, they were blocked by the health system unable to provide them with the drugs and others had to pay for them. These problems within the health system are likely to contribute to the high malaria incidence in Cote d’Ivoire.

AUTHOR LIST

Edouard C. Balogoun1, Manasse Kassi1, Philomène A. Beda1, Jacob Y. Agniman1, Serge B. Assi2, Florence Kadjo-Kouadio3, Michel N’da-Ezoa4, Aristide E. Kouadio1, Joel Koffi1, Apollinaire N. Kouadio1, Paul Bouey5, Sara Canavati5, Eric Swedberg5 — 1Save the Children, Abidjan, Côte D’Ivoire, 2Le Programme Nationale de Lutte contre le Paludisme (PNLP), Abidjan, Côte D’Ivoire, 3Médecin Spécialiste de Santé, Abidjan, Côte D’Ivoire, 4Socio-Anthropologue de la Santé, Abidjan, Côte D’Ivoire, 5Save the Children, Washington, DC, United States

The TiPToP malaria in pregnancy project of Jhpiego and Unitaid has been adjusting to the COVID-19 pandemic. Their abstract below is being presented at the 2021 American Society of Tropical Medicine and Hygiene Annual Meeting and explains the use of bulk SMS to support health worker knowledge retention on antenatal care and the use of intermittent preventive treatment of malaria in pregnancy during COVID-19 in Bosso local government area of Niger State, Nigeria. See Author List below.

In light of COVID-19 travel restrictions, bulk SMS were used to support knowledge retention of health workers following an in-person training held before the pandemic. In December 2019, 72 facility health workers and 260 community health workers (CHWs) in Bosso local government area of Niger State, Nigeria participated in a 12-day training about benefits of early antenatal care (ANC) attendance, CHW referrals to ANC, and use of intermittent preventive treatment in pregnancy (IPTp) with sulphadoxine-pyrimethamine to prevent malaria.

In-person supervision visits were conducted 3 months following training, although three months later in-person supervision was no longer possible due to COVID-19 related travel restrictions. Post-training support transitioned to use of bulk SMS which were sent twice a week to each cadre for two 3-month rounds of messaging.

Knowledge tests comprised of 10 multiple choice questions linked to key ANC and IPTp guidelines were administered at 5 time points: 1) baseline; 2) post-training; 3) at in-person supervision visit 3 months after training; 4) after first round of bulk SMS (6 months post-training); and 5) after second round of bulk SMS (9 months post-training).

Average test scores for each cadre were calculated at each time point and T-tests were used to assess differences in scores. The results show that facility health workers scored an average of 53% on the pre-test followed by scores of 76%, 74%, 86%, and ending at 80% 9 months following training. CHWs started with an average score of 49% which increased to 67% post-training; subsequent average scores were 83%, 74%, and 94%.

Results were compelling with facility health worker knowledge improving from 76% immediately post-training to 80% 9 months later (p-value<0.05) and for CHWs the improvement was from 67% to 94% (p-value<0.05). These findings suggest that use of SMS can support knowledge retention of key ANC and IPTp guidelines following an in-person training. Program managers, trainers and supervisors may consider using this approach to support health workers where resources and/or movement are restricted.

AUTHOR INFORMATION:

Charity Anoke 1, Orji Bright 1, Joseph Enne 1, Bartholomew Odio 1, Christina Maly 2, Amina Zimro 3, Ibrahim Idris 3, Elizabeth Njoku 1, Oniyire Adetiloye 1, Emmanuel Dipo Otolorin 1, Elaine Roman 2  — 1Jhpiego, Abuja, Nigeria, 2Jhpiego, Baltimore, MD, United States, 3Niger State Ministry of Health, Minna, Nigeria

Cristina Enguita-Fernàndez and colleagues share findings on from a qualitative study on the acceptability of a community-based approach to IPTp delivery in 4 sub-Saharan countries in the UNITAID TiPTop project. Their poster is available at the vitrual 69^th Annual Meeting of American Society of Tropical Medicine and Hygiene.

Increasing uptake of intermittent preventive treatment of malaria in pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) is key to improving maternal health indicators in malaria endemic countries, yet current coverage rates remain low. This qualitative study is part of a project evaluating the acceptability of a community-based approach to the delivery of IPTp (C-IPTp) through community health workers (CHWs) in 4 countries: the Democratic Republic of Congo (DRC), Madagascar, Mozambique and Nigeria.

Between March 2018 and February 2020 a total of 435 in-depth interviews and 181 focus group discussions were carried out in the four country sites with pregnant women, relatives, women of reproductive age, community leaders, CHWs, and health providers. These were combined with direct observations of both community and facility based IPTp delivery.

Grounded theory guided the study design and data collection, and data were analysed following a combination of content and thematic analysis to identify barriers to IPTp uptake. Although the novel C-IPTp intervention overcomes some access barriers (such as distance from health care providers, and travel costs), the study identified important barriers, some of which cut across delivery mechanisms and others that are specific to the C-IPTp approach.

Cross-cutting barriers consisted of perceived attributes of SP that explain treatment refusal. These consisted of sensorial characteristics, including the drug’s perceived foul smell, taste and large size; experiences with adverse drug effects, such as nausea and weakness; fears of adverse pregnancy outcomes, such as miscarriages or oversized babies leading to C-sections.

Attributes originated either in individual experiences of SP intake or were socially transmitted. Barriers specific to C-IPTp were centered around concerns over trust in CHWs as adequate providers of maternal healthcare and their competence in delivering IPTp. Despite sensitization activities, misinformation could still be determining these barriers. Ensuring an improved awareness of SP effects and its use, as well as a better understanding of the intervention should lead to enhanced C-IPTp adherence

Authors and Affiliations

Cristina Enguita-Fernàndez¹, Yara Alonso¹, Wade Lusengi², Alain Mayembe², Aimée M. Rasoamananjaranahary³, Estêvão Mucavele⁴, Ogonna Nwankwo⁵, Elaine Roman⁶, Franco Pagnoni¹, Clara Menéndez¹, Khátia Munguambe^{4 – 1}ISGlobal – Barcelona Institute for Global Health, Barcelona, Spain, ²Bureau d’Étude et de Gestion de l’Information Statistique, Kinshasa, Congo, Democratic Republic of the, ³Malagasy Associates for Numerical Information and Statistical Analysis, Antananarivo, Madagascar, ⁴Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique, ⁵University of Calabar, Calabar, Nigeria, ⁶Jhpiego, affiliate of Johns Hopkins University, Baltimore, MD, United States

Courtney Emerson and co-workers address the issues of Intermittent Preventive Treatment of Malaria with Sulfadoxine Pyrimethamine and Provision of Insecticide Treated Nets in Geita, Tanzania: Provider Communication and Opportunities at the virtual 69^th Annual Meeting of American Society of Tropical Medicine and Hygiene. See their findings below.

Intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is a life-saving intervention to reduce morbidity and mortality among pregnant women and their infants. Additionally, provision and use of insecticide treated nets (ITNs) to prevent malaria is critical to improving pregnancy outcomes.

To assess implementation of malaria in pregnancy services and related health communications, we surveyed 1111 women who had delivered a live born infant in the preceding 12 months (recently pregnant women), as well as 1194 adults from randomly selected households without a recently pregnant woman in Geita Region, Tanzania in 2019. Most (88.2%) recently pregnant women reported receiving any IPTp dose; 45.5% received 3 doses. 72.3% of women received their first dose in the second trimester, as recommended by national guidelines, but only 14.4% received IPTp in the 4th month; 20.3% of women did not receive IPTp until third trimester.

There was a significant difference between ITN ownership and use among households (HH) with and without a recent pregnancy: ownership of at least one net was 95.2% vs 87.9%, respectively (p<0.0001), and use was 90% vs 77.8%, respectively (p<.0001). Despite this, few HHs had enough ITNs to cover all residents; on average, HHs had 1 ITN for every 3 rather than every 2 people, as recommended. Notably, only 21.2% and 26.2% of HH with and without a recent pregnancy had sufficient ITNS (p=0.005), despite 87.3% of recently pregnant women receiving an ITN during their last pregnancy.

Of recently pregnant women, 87% received advice on preventing malaria from a health worker. Of these, 82.7% were advised to sleep under an ITN, but only 66.4% were advised to take SP, and 52.1% to attend ANC regularly. Although uptake of any IPTp was high, there are critical messages that need to be more consistently communicated to pregnant women by ANC providers including the importance of attending ANC regularly during pregnancy. To improve outcomes among pregnant women, additional net distribution may be warranted due to the unexpectedly low access.

Authors and Affiliations

Courtney Nicole Emerson(1), Ryan Lash(1), Ruth Lemwayi(2), Melkior Assenga(2), Alen Kinyina(2), Annette Almeida(2), Samwel L. Nhiga(3), Lia Florey(4), Chonge Kitojo(5), Erik Reaves(6), Miriam Kombe(5), Peter Winch(7), Stephanie Suhowatsky(7), Mary Drake(2), Julie Gutman(1) 1.US Centers for Disease Control and Prevention, Atlanta, GA, United States, 2.Jhpiego, Dar es Salaam, United Republic of Tanzania, 3.National Malaria Control Program, Tanzania, Dar es Salaam, United Republic of Tanzania, 4.US Agency for International Development (USAID), Washington DC, DC, United States, 5.US Agency for International Development (USAID), Dar es Salaam, United Republic of Tanzania, 6.US Centers for Disease Control and Prevention, Dar es Salaam, United Republic of Tanzania, 7.Jhpiego, Baltimore, MD, United States

Recent news over this weekend included efforts at school and peer education on bednets in Ethiopia, gender inequality effects of COVID-19 and pandemics, a reduction in severe malaria in Rwanda and increased use of home based case management, and the altering of scientific reports by political appointees. Links in these summaries take one to the full story.

Effectiveness of peer-learning assisted primary school students educating the rural community on insecticide-treated nets utilization in Jimma-zone Ethiopia

Abstract: Making insecticide-treated nets (ITNs) utilization a social norm would support the global goal of malaria eradication and Ethiopian national aim of its elimination by 2030. Jimma zone is one of the endemic settings in Ethiopia. This study aimed to report effects of malaria education, delivered by students, on community behaviours; particularly ITNs. The intervention engaged students from primary schools in participatory peer education within small groups, followed by exposing parents with malaria messages aimed at influencing perceptions and practices.

Over the intervention periods, the findings showed significant improvement in exposure to and content intensity of malaria messages delivered by students. Socio-demography, access, exposures to messages, and parental perception that students were good reminders predicted ITN utilization over the intervention periods with some changing patterns. Exposing the community to malaria education through students effectively supports behaviour change, particularly ITN usage, to be more positive towards desired malaria control practices. A school-based strategy is recommended to the national effort to combat malaria.

Melinda Gates calls on Leaders to Ensure that Women, Girls are Not Left Behind in the Global Response to COVID-19

Melinda Gates has launched a paper exploring how the COVID-19 pandemic has exploited pre-existing inequalities and drastically impacted women’s lives and livelihoods. In the paper, titled “The Pandemic’s Toll on Women and Girls,” Melinda makes the case that to recover fully from this pandemic, leaders must respond to the ways that it is affecting men and women differently. She puts forward a set of specific, practical policy recommendations that governments should consider in their pandemic response—to improve health systems for women and girls, design more inclusive economic policies, gather better data, and prioritize women’s leadership.Writing in the paper, Melinda describes how previous disease outbreaks, including AIDS and Ebola, tend to exploit existing forces of inequality, particularly around gender, systemic racism, and poverty.
Melinda concludes, “This is how we can emerge from the pandemic in all of its dimensions: by recognizing that women are not just victims of a broken world; they can be architects of a better one.

Severe malaria drops by 38% in Rwanda

In its annual Malaria and Neglected Tropical Diseases Report, the Ministry of Health says that the national malaria incidence reduced from 401 cases per 1,000-person in 2017-2018 fiscal year to 200 cases per 1,000-person in 2019-2020. According to the report, 4,358 cases of severe malaria (representing a 38 per cent reduction) were reported at the health facility level compared to 7,054 in 2018-2019. The decrease in malaria deaths is attributed to home based management interventions, the free treatment of malaria for Ubudehe Categories I and II and the quality of care at health facility level.

There has also been a steady increase of proportion of children under 5 and above plus adults who are seeking care from 13 per cent to 58 per cent in 2015-2016 and 2019-2020 respectively. “This indicates that interventions such home based treatment of children and adults that contributed to early diagnosis and treatment have been successful in decreasing the number of severe cases and consequently the number of malaria deaths,” the report indicates.

Political appointees sought to alter CDC scientific reports so they don’t contradict or undermine the president

Caputo (a US presidential appointee) and his communications staff have worked to delay CDC reports that contradict President Donald Trump’s rhetoric. One publication was held back for about a month, according to Politico, for recommending against the use of hydroxychloroquine, a malaria drug touted by the White House as a potential cure for COVID-19.

The reports, written by career scientists, are known as the Morbidity and Mortality Weekly Reports, and according to Politico, are used to “inform doctors, researchers, and the general public about how Covid-19 is spreading and who is at risk.” Jennifer Kates, of the Kaiser Family Foundation’s global health work, who has relied on past reports, told Political they are “the go-to place for the public health community to get information that’s scientifically vetted.” Alexander (a presidential appointee), in this missive, said any future reports related to the coronavirus “must be read by someone outside of CDC like myself.”

Job Aids can provide valuable assistance to health workers, but it is important to evaluate if they serve the intended purpose.  With support from USAID’s Maternal and Child Survival Program, Bright Orji, Enobong Ndekhedehe, Elana Fiekowsky, Patricia Gomez, Aimee Dickerson, Reena Sethi, Bibian Udeh, Kristin Vibbert, and Robert Sellke reported at the 66th Annual Meeting of the American Society of Tropical Medicine and Hygiene on their evaluation of a Job Aid for Nigeria on the prevention of malaria in pregnancy as seen below.

Annually, nearly 7 million pregnant women in Nigeria are at risk of malaria in pregnancy (MIP). Although antenatal care is the platform for the prevention and treatment of MIP, malaria is also treated at outpatient departments.

It is known that women of reproductive age (WRA) are often treated for malaria without assessing pregnancy status, although artemisinin combination therapies are contraindicated in the first trimester of pregnancy, and many pregnant women do not receive the recommended low cost interventions.

In order to increase access to these MIP interventions, the President’s Malaria Initiative supported the Maternal and Child Survival Program and partners to develop a two-page job aid for case management of uncomplicated malaria among WRA. In collaboration with the Nigeria Malaria Elimination Program, the job aid was evaluated in Ebonyi State, a high malaria burden area, to determine providers’ perceptions of its clarity, acceptability, and utility.

A half-day workshop on use of the job aid was provided to 35 health workers (nurses – 20%; nurse-midwives – 20%; community health extension workers – 48%; and medical doctors – 12%) already trained on MIP case management, selected from 15 facilities where WRA seek care. After 3 months of use, a one-page questionnaire was administered to 34 health workers.

One-hundred percent stated that the job aid helped them to do the following: identify pregnant women among the WCBA presenting with fever; use rapid diagnostic tests to diagnose malaria; and treat uncomplicated MIP. Sixty-eight percent used the job aid to provide correct treatment for severe malaria and 88% used it while providing services all or most of the time.

The results indicated that after a half-day orientation on use of the job aid, health workers were able to use it to help them identify women who may be pregnant and provide appropriate treatment for uncomplicated MIP. They are also able to explain its use to colleagues.

It is suggested that a poster-size version could be printed and disseminated to appropriate cadres of health workers in clinics where WRA seek care for fever, as it is anticipated that providers could benefit from its use.

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of USAID or the United States Government.

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.

New 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.”

The 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.”

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 143^rd 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.

Theoretical 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

The 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.

Items 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.

Intermittent 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

The 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

Again 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.

Kamden Hoffmann^{1 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.

Introduction. 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.

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.

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.

Author 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.