social and behavior change considerations for areas
TRANSCRIPT
Socialandbehaviorchangeconsiderationsforareastransitioningfromhighandmoderatetolow,verylowandzeromalariatransmission
December2017
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AcknowledgementsHC3thanksAndrewTompsett(PMI/USAID),DonaldDickerson(PMI/USAID),LawrenceBarat(PMI/USAID),JessicaButts(PMI/CDC),ShelbyCash(PMI/CDC),BKKapella(PMI/CDC),andJimeeHwang(PMI/CDC)fortheircontributionstothisdocument.
ThisreportwasmadepossiblebythesupportoftheAmericanPeoplethroughtheUSAgencyforInternationalDevelopment(USAID)andtheU.S.President'sMalariaInitiative(PMI).TheHealthCommunicationCapacityCollaborative(HC3)isbasedatJohnsHopkinsCenterforCommunicationProgramsandsupportedbyUSAID’sBureauforGlobalHealthunderCooperativeAgreement#AID-OAA-A-12-00058.ThisdocumentwassupportedbytheOfficeofInfectiousDiseaseandPMI.ThecontentsofthisreportarethesoleresponsibilityofHC3.TheinformationprovidedinthisreportisnotofficialUSGovernmentinformationanddoesnotnecessarilyrepresenttheviewsorpositionsofUSAID,PMI,theUSGovernmentorTheJohnsHopkinsUniversity.
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TableofContents
Acknowledgements................................................................................................................2
Introduction...........................................................................................................................4
Background............................................................................................................................4
OverviewofSBCConsiderations.............................................................................................5TransitioningfromAreasofHighandModerateTransmissiontoAreasofLow,VeryLow,andZeroTransmission....................................................................................................................................7
Enhanceandoptimizevectorcontrol..................................................................................................7Enhanceandoptimizecasemanagement:testing,treatingandtracking.........................................10Increasesensitivityandspecificityofsurveillancesystemstodetect,characterizeandmonitorallcases..................................................................................................................................................12Population-wideparasiteclearanceandadditionalornewinterventions........................................12Investigateandclearindividualcases,managefociandfollowup...................................................14
StrengtheningIntegration..............................................................................................................15
RecentMalariaSBCinModerate,Low,andVeryLowAreasofTransmissionIntensity..........16CaseStudy1:Zambia.....................................................................................................................16CaseStudy2:GreaterMekongSub-Region.....................................................................................19CaseStudy3:AmazonMalariaInitiative.........................................................................................21
Conclusion.............................................................................................................................23
Bibliography..........................................................................................................................24
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IntroductionA37%reductioninmalariacasesand60%reductioninmortalityduetomalariainthepast15yearshavesavedanestimated6.2millionlivesandincreasedthelifeexpectancyamongthoseintheWorldHealthOrganization(WHO)AfricanRegionbyalmosttenyears[1].Theglobalcommunityhascalledforevengreaterprogressamongtheremaining3.2billionpeopleatriskofinfection.Tothisend,theWHOGlobalTechnicalStrategy(GTS)goalsincludereducingmalariaincidenceandmortalityratesbyatleast90%,eliminatingmalariain35countries,andpreventingre-establishmentinallmalaria-freecountries.Inareaswithhigh,moderate,low,andverylowtransmissionalike,useanduptakeofmalariainterventionsrelyheavilyoncommunityawareness,demand,andacceptanceofessentialcommoditiesandservices.WhiletheWHOhasrecentlydevelopedamalariaeliminationframeworkandhasanumberofestablishedpolicies,manuals,andrecommendations,detailedguidancedoesnotyetexistforsocialandbehaviorchange(SBC)indifferenttransmissionsettings.WhiletheRollBackMalariaStrategicFrameworkforMalariaSocialandBehaviorChangeCommunicationprovidesstandardapproaches,bestpractices,andindicators,itdoesnotdosoinmalariaeliminationcontexts.ThisdocumentdescribesthelandscapeofcurrentSBCprogramminginsuchcontextsandprovidesanumberofconsiderationsforfutureinquiryandresearch.Thisdocumentdescribeswaysinwhichprogramplannersandimplementersmighttailortheireffortstospecificmalariatransmissionstrataandsuggestsanumberofoperationalresearchquestions.ThreecasestudiesexemplifyconsiderationsraisedanddescribetheroleofSBCinstrengtheningthefightagainstmalaria:
• ThefirstcasestudyfromZambiadescribesasuccessfulinterpersonalcommunication(IPC)approachpairedwithcommunity-ownedsurveillance.
• ThesecondcasestudyfromtheGreaterMekongsub-Regiondescribesmulti-channel,cross-borderinitiatives.
• ThethirdcasestudyfromSouthAmericadescribestheAmazonMalariaInitiative’sregionalcoordination.
Thislandscapedocumentisanimportantfirststepinunderstandinghowtoscale-upandmaintaincoverageofproveninterventionsinallareasandsupportcountriestoeffectivelytransitionfromhighormoderatetolow,verylow,orzerolevelsofmalariatransmission.
BackgroundTheworldhasmadeastonishinggainsinthefighttoendmalaria.Thesegainsarenotevenlydistributed,however,andmayprovereversiblewithoutrenewedcommitmentandinnovation.AchangingepidemiologicallandscapedemandsnewglobalstrategiesandgoalsthattransitionSBCapproachesfromareasofhighormoderatetolow,verylow,orzeromalariatransmission,whilesimultaneouslypreventingreintroductioninareasthathavealreadyachievedmalariaelimination.ThefirstpillaroftheWHOGTSisensuringuniversalaccesstomalariaprevention,diagnosis,andtreatmentforallpopulationsatrisk[2].ThecornerstoneoftheGTSassumes
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adequateandsustaineddemandanduseofavailableservices.Evidencesuggestscurrentdemandanduseofmalariainterventionsisfarfromuniversal.Onlyhalfofsub-SaharanAfricansatriskofmalariasleptunderaninsecticide-treatednet(ITN)in2015.JustathirdofeligiblepregnantwomenreceivedWHOrecommendeddosesofsulphadoxine-pyrimethamine(SP)forintermittentpreventivetreatmentofmalariainpregnancy(IPTp).Only14%ofchildrenunderfivewithevidenceofrecentorcurrentPlasmodiumfalciparuminfectionandahistoryoffeverweretreatedwithanartemisinin-basedcombinationtherapy(ACT)[3].WhileitisimportanttonotethatITNuse,ACTprescription,andIPTpuptakeareheavilyinfluencedbyaccess(whichisincreasing),theimportanceofgeneratingdemandforandbuildingtrustintheselife-savingcommoditiescannotbeoverstated.Ifinterventioncoverageremainsatlevelsachievedbetween2011and2013,amoderateriseinmalariaincidencewilloccurby2030.Ontheotherhand,increasingcoverageofmultipleinterventionsto80%couldresultina40%dropinmortalityby2030comparedto2015levels[4].
OverviewofSBCConsiderationsMalariaSBCconsiderationsinthisdocumentareorganizedaccordingtothecategoriesoftransmissionintensityoutlinedbytheFrameworkforMalariaElimination(Figure1).ShiftsinSBCfocusaredescribedasatransitionfromareasofhighandmoderatetransmissiontoareasoflow,verylow,andzerotransmission.Whereapplicable,suggestionsforSBCoperationalresearchareprovided,andfollowedbyageneraldiscussionabouttheimportanceofstrengtheningintegrationacrossallinterventions.
“Servicedeliveryinmalariaisnotonlyaboutdeliveringproducts;itisalsoaboutensuringtheyareusedproperly.Communicationmethodologiesareessentialtoensuretheappropriateuseofinterventions.”-GlobalMalariaActionPlan
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TransitioningfromAreasofHighandModerateTransmissiontoAreasofLow,VeryLow,andZeroTransmission
“Thefirstpriorityforallcountrieswheretransmissionratesofmalariaarehighormoderateistoensuremaximalreductionofmorbidityandmortalitythroughsustainedprovisionofuniversalaccesstoquality-assuredandappropriatevectorcontrolmeasures,diagnosticsandantimalarialmedicines,togetherwiththeimplementationofallWHO-recommendedpreventivetherapiesthatareappropriateforthatepidemiologicalsetting.Theseactivitiesmustbebackedupbyefficientdiseasesurveillancesystems,robustentomologicalanddrugefficacysurveillance,aswellasstrongpublichealthcommunicationandbehaviouralchangeprogrammes.”-GTS2016-2030Enhanceandoptimizevectorcontrol
WhileITNsandIRSreducemosquitoes’capacitytotransmitmalaria,theyaremosteffective
whenITNuseand/orIRSacceptanceishigh.ResearchdatashowsthatexposuretomalariaSBC
canincreasenetuse,netlongevity(Box1)andIRSacceptance(Box2).
Box1:Evidence-basedITNSBC–MeasuringtheeffectofSBConITNbehaviorsAnumberofstudieshavedemonstratedthatcombiningSBCwithvector-controlprogramshadapositiveeffect
onuseofbednets[5,6,7,8].InCameroon,netusewas10-15percenthigheramongthoseexposedtomalaria
messages[7].AstudyinNigeriafoundthatSBCencouragingnetcareandrepaircansignificantlyprolongthe
lifespanofITNs[9].ThemethodsusedtodeterminetheimpactofSBConnetuseandlongevityinthesestudies
includepropensityscorematchingandintervention-controldesign.TheseexamplesdemonstratethatSBCcan
haveameasurableimpactonITNuseandlongevityandthatthemethodsofmeasuringimpactmaynotbe
prohibitivelycomplicatedorexpensive.
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Inhightransmissionandmoderatetransmissionareas,focusingonindividualbehaviorchange
isnecessarybutinsufficient.Socialchange,shiftsinbehaviorbywholecommunities,is
necessarytoestablishandmaintainacultureofnetuseandIRSacceptance–andcoverage
ratesthatbestowacommunityprotectiveeffect[14].SBCthatencouragesmaintainednetuse
shouldbeongoing,notsimplyrelegatedtoITNpromotionduringmassdistributions.
Considerationsforkeepingcoverageanduse/acceptanceofbothITNandIRShighmaychange
ascommunitiestransitiontolow,verylow,andzeromalariatransmissionintensityareas.For
example,thedurationoftimecommunitiesspendineachlevelofmalariatransmission
intensitywilllikelycontributetobehavioraldeterminantslikeriskandseverity(bothrealand
perceived).Useofbehavioraltheory,programdesign,andtheframingofmessagesabout
Box2:Evidence-basedIRSSBC–CommunityengagementTheRBMActionandInvestmenttoDefeatMalariacallsforahuman-centeredapproachtomalariaelimination
thatbeginswiththosemostaffectedbymalaria,notsimplytreatingthemasrecipientsofaid.Atkinson,
WhittakerandSmithhavepublishedanumberofarticlesoncommunityparticipationinmalariaandother
healthprogramsincludinglessonslearnedfromasystematicreviewofcommunityparticipationininfectious
diseasecontrolprograms[10,11].Theyarguethatthemostcompellingreasonstoengagewithcommunities
willbetheneedtoaddressdecliningperceptionsofrisk.Theauthorsalsoadvisenottoclaimmalariaisthe
mostpressinghealthconcern,asthiswillnotlikelybethecase,butrathertoincludemessagingaboutthe
benefitsandpositiveeffectsmalariareductionhashadoncommunitiesandtodemonstratewhatcanbedone
tosustainthis.Theseauthorsdescribecommunityengagementonaslidingscalebeginningwithcommunity
non-complianceorrejection,ontopassiveacceptance,moderateparticipation,andfinallyactivecommunity
participationandcommunityownership.Atkinsonandcolleaguesdescribethosewithactiveparticipationand
ownershipas“competentcommunities[11].”
TheWHO’sAFrameworkforMalariaEliminationarticulatesthefollowingobjectivesofcommunity
participation:
• Encouragingappropriatehealth-seekingbehavior
• Strengtheningcommunityaccesstomalariatesting,treatmentandreporting
• Promotingacceptanceandappropriateuseofvectorcontroltools
• Empoweringcommunitiestostrengthenself-monitoringanddecision-makingaboutmalaria
• Buildingcommunityandlocalpoliticalsupportforeliminatingmalaria
• Increasingactivecommunityparticipationineliminationactivities,includingasurveillancesystem
linkedtodistrictandothersystemsuptonationallevel.
PromisingPractice:Horizontalparticipatorypracticestostimulatecommunitycontributions[12].The“openspace”approach,ameansofengagingwithcommunitiestodeterminetheirwillingnesstocontributeto
malariareductionefforts,wasemployedintheRuhuhasectorofRwanda.Workshopswereheldtolearnfrom
andcollectcommunityfeedback.Theoutcomesofthisactivityweremutuallyagreeduponactionstoreduce
malariaandplanningforfutureactivities.Thisapproachwasappliedamongcommunitiesthathadseenrecent
reductionsinmalaria(from60%to20%).Usedaspartofanintegratedmalariaeliminationstrategy,the“open
space”workshopsyieldedtwolocalsolutions:theestablishmentofarewardssystemandmalariaclubs.A
subsequentCommunityMalariaActionTeamsinterventionwasconducted.Attheendof2014theseteams
reportedareductionofpresumedmalariacases,attributinggainstoincreasesinuseandacceptanceofIRS
sprayingandcommunity-basedhealthinsurancemembership[13].Localhealthdataindicatedamalaria
burdenreductionof15.5%.Ahouseholdsurveyconducted6monthsaftertheinterventionfoundanincrease
inIRSacceptancefrom94.5%to98.7%,anda47%increaseinpromptcareseekingforfever.
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malariaseverityinareaswherehighmalariatransmissionhasexistedfordecadesshouldlook
verydifferentthanSBCinareaswheremalariahasrecentlybeeneliminatedorre-introduced.
SBCconsiderationsfortransitioningtolow,verylowandzerotransmission:Theimpactof
ITNsandIRSistemporary,andgainsmaybequicklyreversedifuseoracceptancefalls.Froman
SBCstandpoint,themereadoptionandscaleupofbehavioralpracticeisnotenough:
acceptanceofIRSsprayinganduseofITNsmustbemaintainedathighlevels.Whilebehavior
maintenancetheoryisnotyetcommonlyusedtoinformmalariaSBCprogramming,itsfocuson
theroleofmotives,self-regulation,resources,habits,andenvironmentalandsocialinfluences
[15]mayproveusefulwhereITNsandIRShavebeenimplementedforanumberofyears.
EstablishingorreinforcingITNuseinmobile,migrant,andvulnerablepopulationsduringthe
transitionfromhighandmoderatetolow,verylow,andzeromalariatransmissionwillrequire
newmeasurementtoolsandapproaches.Establishedsocialnormsinfixedorsedentary
communitiesmayfunctiondifferentlythaninsmaller,moremobile,moreheterogeneous
groups.Inadditiontousingroutinehealthfacilitydatacollection,theprocessofassessing
behavioral,environmental,andsocialinfluencesamongthosewhoengageinriskybehavior
(notusingITNs,forexample)mayrequirenewsurveysandsamplingtechniques(explored
furtherinthepopulation-wideparasiteclearanceandadditionalnewinterventionssection).Informationgleanedfromthesenewtechniquesmayuncoverbehavioralinfluencesthatdiffer
fromthosecommonamongsedentarygroups.
OperationalResearchQuestions:1. AlmostallstandardmalariaSBCindicatorsmeasureindividualbehaviorchange.Even
thosethatmeasuresocialnormsareenumeratedatthehouseholdlevel.Wouldthe
developmentofanindicatorthatmeasuresacceptableITNandIRSattitudesandbehaviorsatthecommunitylevelprovetobeamoremeaningfulwayofdeterminingif
socialnormshaveactuallybeenestablished?
Box3:Evidence-basedVectorControlSBC–Community-ownedvectorcontrolinthePhilippinesAprograminitiatedinthecommunityofSimbalaninthePhilippinesexemplifiesthekindofcommunity
ownershipthatwilleliminatemalariainthefaceofshrinkingresources[16].Themountainousareahasbeen
relativelyfreeofmalariaforquitesometime,withasinglepocketofstabletransmission.AcombinationofITN
distribution,IRScoverage,anduseofRDTsreducedmalariasignificantly.Theseapproachesareconsidered
successfulbecauseofcommunityownership.Communityactioncommitteesonmalariawereestablishedwith
thehelpoflocalofficials,healthworkers,teachers,andcommunity-basedgroupsthatplannedand
coordinatedmalariaactivities.Thesecommitteesoversawananti-malariabrigadeofvolunteerswhohelped
implementvectorcontrolatmonthlyintervals.Thesebrigadesassistedinhealthpromotion,ITNsurveys,
diagnostictestingandinsomeinstanceshelpedwithIRS.Asmall-scalepublic-privatepartnershipwithlocal
motorbike-taxiassociationswasestablishedtoprovidetransportation,usuallyforfree,insupportofmalaria
control.Thisincludedtransportforpatientsandmovementofbloodslidesandreports.House-to-housevisits
werecarriedoutby“personalsellers”,individualstrainedbyaprovincialhealthofficerwhopromoteduse,care
andrepairofITNsintheircommunities.Finally,educationonmalariatransmissionandvectorcontrolwas
incorporatedintoschoollessons.Acommunityactioncommitteedevelopedtheirownvisionstatement,which
includedthegoalofself-sufficiency–independentofexternalresources.Widespreadcommunity-driven
malariapreventionandcontrolthatmimicstheSimbalancommunitymotivationandenthusiasmwillbean
importantelementofmalariaeliminationinLatinAmerica,SSA,andAsia.
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2. CurrentITNandIRSSBCeffortsareofteninformedbybehaviorchangetheorythat
focusesonadoptionofnewbehaviors.WouldthedevelopmentofprogramsdesignedwithbehaviormaintenancetheoryprovetobemoreeffectiveinareaswhereITNand
IRSusehavealreadybeenestablished?
3. Monitoringshiftsinhumanattitudes,perceptions,andbehaviorswillremainimportant
ascountriestransitiontomoderateandlowtransmissionstrategies.Caninteractive
voiceresponse(IVR)andshortmessageservice(SMS)beusedtoquicklyandinexpensivelydetermineshiftsintheseimportantbehavioralantecedents?
Enhanceandoptimizecasemanagement:testing,treatingandtracking
ThecornerstoneofmalariacasemanagementSBCisincreasingtheproportionofthosewho
seekcareforfeverquickly,particularlypregnantwomenandchildrenunderfive.Program
implementerswhohaveusedthepositivedevianceapproach(Box4)havefoundthat
leveraginglocalvoicesandmodelingbehaviorcanhavepositiveimpactonpromptcareseeking
inhightransmissionareas.
SBCconsiderationsfortransitioningtolow,verylowandzerotransmission:Whileraising
awarenessaboutthebroadspectrumofcausesoffeverisimportantinareasofalltransmission
intensity,itisevenmoreimportantamongcommunitiestransitioningfromhighandmoderate
tolow,verylowandzerotransmissionintensitytoavoidconfusionandconcernaboutthe
increasingnumberoffeverstestingnegativeformalaria[18].Establishingtrustintestresultsis
equallyimportantamongcommunitymembersandserviceprovidersalike.Serviceprovider
SBCactivitiesshouldencourageadherencetonationalmalariacasemanagementguidelinesin
theeventofanegativetestresult,andensureadequatecounselingforfebrilepatientswhodo
notreceivetreatmentformalariawhenpresentedwithanegativeRDT.Thiswillavoidpatient
dissatisfactionandpreventerosionoftrustbetweenpatientsandproviders.TheU.S.
President’sMalariaInitiative(PMI)guidancerecommends“diagnostictestingbecloselylinked
withSBCactivitiesthatfocusonchangingtheexpectationsandpracticesofpatientsand
caregivers[19].”
Ascommunitiesexperiencefewerandfewercasesofmalaria,itmaybemoreeffectiveto
maintainlevelsofperceivedseveritythanperceivedrisk,asriskwill,infact,decreasebut
decreasednaturalimmunitywillmakeimportedcasesmoresevere.
Box4:Evidence-basedCaseManagementSBC-PositiveDevianceIntheGreaterMekongSub-Region,the“positivedeviance”approachwassuccessfullyusedtoincrease
knowledgeaboutmalariaandincreasepromptcareseekingforfever.Theapproachidentifiespeoplewhoare
alreadydemonstratingpositivebehaviorsandturnsthese“positivedeviants”intorolemodelsfortherestof
thecommunity.Thisapproachreliesonrealisticmodelingofbehaviorsbyindividualsthatcommunitymembers
considertobesimilartothemselves.Theapproachhasbeenusedtoimprovebehaviorsinavarietyofcontexts
andpopulationgroups,includingmobileandmigrantworkers[17].
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Epidemiologicalchangesinmalariatransmissionwillalsoshiftdemographicimportancefrom
pregnantwomenandchildrenunderfivetoincludeadultsandmenasallagesandbothsexes
loseacquiredimmunity.SBCinterventionswillneedtofocusincreasinglyonnewparasite
reservoirs(adolescentsandadults)tocontrolseasonaloutbreaksandepidemics[20].The
AmazonMalariaInitiativecasestudy(page25)includestoolsandmaterialsdevelopedforSBC
inCentralandSouthAmerica,whereadultmobileandmigrantpopulations,suchasminers,are
atargetaudience.
Seasonalmalariachemoprevention(SMC)involvestheoccasionaladministrationofafull
treatmentcourseofantimalarialmedicinetochildreninareasofhighlyseasonaltransmission
duringseason(s)ofhigherprecipitation.InareaswhereSMCisimplemented,communitySBC
interventionshavefocusedonraisingawarenessofthesafetyandefficacyofmedicinesand
encouragedcommunityacceptancetomaximizeprotectionandminimizedrugresistance(Box
5).PMIhasidentifiedcommunityhealthworkersasparticularlywellplacedtoidentify
householdswitheligiblechildrenasakeygroupofSBCagents.Reinforcingtrustbetween
communityhealthworkersandserviceprovidersandthosetheyservewillensuredosesgiven
forlaterconsumptionarecompleted.
Whererecommended,SBCshouldbepairedwithIPTpinterventionstoincreaseuptakeatthe
communitylevel.IPTpdeliveryatthecommunitylevelhasbeenpiloted[23]andisinthe
processofbeingscaledupinseveralSub-SaharanAfricancountries.SBCinterventionsshould
encourageANCattendanceinallareas,butparticularlythosewhereIPTpisbeingdeliveredat
thecommunitylevel.IncreaseddeliveryofIPTpshouldnotcomeatthecostoflowerANC
attendance.Agrowingbodyofevidencesuggeststhatserviceproviderattitudes,biases,and
behaviorsareakeydeterminantofIPTpuptake,implyingthatSBCinterventionsthatinclude
supportivesupervisionorparticipatorylearningapproachesmayincreaseserviceprovider
adherencetoIPTpguidelines(seeSBCCforMalariainPregnancy:StrategyDevelopment
GuidanceImplementationKit).The2016WHOrecommendationsonantenatalcarefora
positivepregnancyexperiencerecommendparticipatorylearningactioncycleswithwomen’s
groupstoencourageregularANCcontactsandaddressquestionsorconcernstheymighthave
aswell.
Box5:SBCforSMC:TheACCESS-SMCinitiativerolledoutSMCacrosssevencountriesintheSahelregion
between2015-2017.Knowledge,attitudeandpracticesurveysconductedintheGambia,Guinea,Maliand
NigerfoundhighcommunityacceptabilityofSMC.ExpressedintenttoacceptSMCinthefuturewasalmost
universal.Barrierstoacceptabilityincludedthetasteofthemedicineandconfusionwithotherhealth
campaigns,whileperceivedtreatmentefficacywasoftenlistedasafacilitatortoacceptability.Communication
channelsusedtoreachcommunitymembersandencourageacceptanceincludeddoor-to-doorvisits,
communitydialogues,andradioprogramming.Thosesurveyedoverwhelminglypreferrednurses,doctors,and
communityhealthworkersasmessageagents[21].
TheWHOSeasonalMalariaChemopreventionwithsulfadoxine–pyrimethamineplusamodiaquineinchildren:afieldguideprovidesdirectiononadvocacyforcommunityandsocialmobilizationandbehaviorchange
communication:“DeliveringkeymessagesaboutSMCshouldreducetheriskofmisunderstandingandanynegativeperceptionsaboutthestrategy.Communitymemberscanbeinvolvedinadvocacyforcommunityandsocialmobilization.”Acompletelistofpointstoemphasizeareincludedintheguidance[22].
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Increasesensitivityandspecificityofsurveillancesystemstodetect,characterizeandmonitorallcases
ComponentBoftheFrameworkforMalariaEliminationinvolvestestingallindividualswith
suspectedmalaria.Attimes,malariacasedetectionandreportingwillinvolvetheassentand
participationofasymptomaticcommunitymembers.Thisrepresentsanecessaryshiftin
messagingatthecommunitylevel,requiringattentionfromSBCprogramsandpractitioners.As
areastransitiontotreatindividualswithmalariawhoareasymptomatic,SBCactivitiesmust
substituteemphasizingexclusivetest-before-treatmessagingwithcallstoactionthat
encouragetrustofhealthworkersandtheirnewtreatmentregimens.
Activecasedetection*willbeemployedinlow,verylowandzerotransmissionareas.
Communitiesusedtoactivitiespromotingcareseekingandtestingforfevermaynowneed
messagingtoraiseawarenessandknowledgeaboutwhytestingandtreatmentisnecessaryin
theabsenceoffever.Thissensitizationshouldtakeplacebeforeroll-outandcontinueuntil
activecasedetectionactivitiescease.Asactivecasedetectionishighlyfocalized,traininghealth
workerstoeffectivelycommunicatewithsurroundingfamilies,neighbors,andcommunity
membersisimportant.Ascountriesbegintousepreventivetreatmentmoreselectively,among
smallertargetgroups,ensuringserviceprovidersareequippedasagentsofbehaviorchangeis
increasinglyimportantaswell.Patientcounselingmayreplacemuchoftheworkformerlydone
bycommunityhealthworkersatthecommunitylevelinzerotransmissionareas.
Population-wideparasiteclearanceandadditionalornewinterventions
ApplyinglessonslearnedfromotherinfectiousdiseasesandhumanmovementAshiftinhowweconceptualizethoseatriskofmalariawillrequirechangesnotonlyin
demographicfocus,buttheapplicationoflessonslearnedaboutinfectiousdiseasesandhuman
movementincludinghowtolocate,trackandinfluencebehaviorsofmobilepopulations.Smith
*Detectionbyhealthworkersofmalariacasesatcommunityandhouseholdlevels,sometimesinpopulation
groupsthatareconsideredhighrisk.Activecasedetectioncanconsistofscreeningforfeverfollowedby
parasitologicalexaminationofallfebrilepatientsorasparasitologicalexaminationofthetargetpopulation
withoutpriorscreeningforfever.
LessonsLearned:AsmalariacasesdecreasedinSwaziland,theNMCPconductedyearlyknowledgeattitudes
andpracticessurveystodeterminewhichcommunicationchannelstoprioritize.Basedonthesesurveys,the
NMCPisabletoadjustmessagesandcampaignsfromyear-to-year.ThecurrentSBCstrategyincludesactivities
toencourageuseofchemoprophylaxiswhentravelingtoareasofmalariatransmission[24].
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andWhittakerdescribethreewaysmalariaSBCpractitionersandNMCPprogramplanners
mightre-conceptualizeandrespondtomobilepopulations[25].
First,mobilepopulationsarenotasdifficulttoaccessaspreviouslyimaginedandtherisktheir
travelposesisoftenmisunderstood.Second,regardlessofhowdifficultitmaybetoreacha
particulargroup,workingwitheachpopulationasparticipantagentsintheirownhealthis
moresuccessfulthantreatingthemasrecipientsofoutsideinterventions.Andfinally,a
necessaryshiftinfocusfrommobilepopulationsasdemographicgroups,tomobilityasa
systemisimportant.Thecasestudyoncross-borderSBCinterventionsintheGMSillustrates
thefirstpointinatangibleway(page21).
Thelessonaboutaccessibilitycanbeunderstoodbyexaminingruralfarmsandplantationsin
ThailandandCambodiathatattractmigrantworkers.Theseareasarenotisolated,but
accessibleandconnectedtoroadsandeasilytracedtransportationroutes[23].Itwouldbea
mistaketoassumethatbecausemigrantsaremobile,andmovebetweenruralareasthatare
difficulttotravelto,thattheycannotbeeffectivelyreachedwithSBC.Ratherthanfocusingon
thedemographicandgeographicdifficulties,plannerscanexaminepointsofinterconnection:
wheremigrantsmove,wheretheycongregate,andwhocomesintocontactwiththemmost
often.MigrantsintheGMStravelandstayfordifferentperiodsoftimeandwithvarying
frequency.Reachingthosewhohavechangedresidencepermanently,whotravelperiodically
orseasonally,whotravelforashortterm,orthosewhotravelroutinely,ispossible,butmay
requiredifferentapproaches.Thisrequiresre-thinkingpreviousassumptionsaboutriskandthe
timing,frequency,speedanddurationofhumanmobilitybetweenmalariatransmissionzones.
OnesuchexampleisastudyofmalariatransmissionbetweenmainlandZanzibarandmainland
Tanzania.
Usingcellphonerecordstomeasurethenumberoftravelersanddurationoftheirstays,
researchersdeterminedthatthemajorityoftrafficfromZanzibarwastolowtransmissionareas
onthemainland.Mosttravelersreturnedwithinaweek.Thistravelpatternwasnotfoundto
poseasignificanttransmissionthreat[26].Whileitwouldbeeasytoassumetravelbetween
transmissionzoneswouldfacilitateimportedcasesofmalaria,itisn’tthetravelitselfthatis
important,butspecificorigins,destinations,andrespectivetransmissionlevels,malaria
receptivity,andvulnerability.Thishasbeenclarifiedusingresearchonhowdifferentdata
pointscanbeusedtotrackhumanmovementtodevelopmalariaeliminationstrategies.
Aclearerpictureofwhereand
whenhumanpopulation
movementcausesimportedcases
ofmalariaispioneeredbyPindolia
andcolleagues[27].Theirwork,
supportedbyotherresearch[28],
suggestsSBCpractitionersshould
focuseffortsonpotentiallyinfected
individualsorgroupsmovingfrom
Guyantetal.HumanPopulationMovementRiskIndex
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lowtransmission,highreceptivityareastohightransmissionareasandback,aswellasthose
movingpermanentlyfromhightolowtransmissionareas.Thesetravelersposeagreater
concernforeliminationthaninfectedtravelersmovingtohightransmission,highreceptivity
areasorlowtransmission,lowreceptivityareas.Datacollectiontoolsusefulindetermining
groupsamongmobilepopulationsthatposethegreatestriskincludeindicesofvulnerability,
exposure,andaccess[29].ThisdatawillhelpSBCpractitionerscomparemalariavulnerability
amonggroupsandprioritizeeffortsandresourcesaccordingly[16].
Finally,justasmanyHIVprogramsworkthroughsocialnetworksandpeereducators,and
involvethosetheyareattemptingtoreach,malariaeliminationeffortsshouldworkwiththose
whoengageinhigh-riskbehaviorstoinfluenceandrecruitindividualsintheirsocialnetworks,
focusingnotondemographicgroupsbutonhigh-risksituations[30,31,32].
SBCconsiderationsfortransitioningtolow,verylowandzerotransmission:SBCpractitionersshouldshiftfrommeasuringfixedgeographicallyanddemographicallydefinedpopulationsto
examiningmobilityasasystem,andlookingforwaysofreachingandinteractingwithpeoplein
thatsystemwhosharerisk-takingbehavior.Evidencesuggeststhatencouragingthemtotake
anactiveroleintheirownwell-beingwillyieldpositiveresults.Monitoringhumanmovement,
anddeterminingwhateffectthedirectionofthatmovementwillhaveondifferentareas,will
involveunderstandinganduseofmalariavulnerabilityandreceptivityindexes.Thiswill
necessitateuseofroutinedata,collectedwithgreaterfrequency.
TheGreater-MekongSub-Regioncasestudy(page21)describesSBCinterventionssuchasnet
lendingprograms,trainingnon-registeredmedicinevendors,andIPCwithtravelersatmultiple
pointsonknowntraderoutes.Programsdesignedforlowandverylowareasofmalaria
transmissionshouldbuildonlessonslearnedinthisregion.
OperationalResearchQuestions:1. Inareastransitioningfromhighandmoderatetransmissiontolow,verylowandzero
malariatransmission,mightsnowballsampling[33],aformofrespondentdrivensampling,beusedtoobtainrepresentativesamplingofhardtoreachpopulationsanddeterminingriskfactors?
2. Timesamplingisanapproachthathasbeenusedtoreachgroupswithcommonrisk-
takingbehaviors.Thisapproachinvolvessamplingatasettimeandlocationwhererisk-
takersgather,suchasclubs,bars,marketstalls,orbusstops[34].Ascountriesexpand
pocketsofverylow,low,andzeromalariatransmission,couldtimesamplingbeusedtoreachgroupswithcommonmalariariskbehaviors?
Investigateandclearindividualcases,managefociandfollowup
ComponentDoftheFrameworktoEliminateMalariainvolvescloseinvestigationofeverysingle
malariacase,andthedevelopmentofasystemtofollowupwitheachcase.Riskofre-
establishmentofmalariacanbedefinedasthecombinedeffectofanarea’sreceptivityand
15
vulnerability,whichinturnarefunctionsofecological,climatic,socio-demographic,
epidemiological,entomological,andhealthsystemfactors[1].Receptivityandvulnerability
mustbothbepresentforre-establishmenttooccur.Ifeitheroneortheotherisconsidered
zero,re-establishmentisnotpossible.Useofroutinedataathealthfacilities,traveler
movement,andsurveillancedataaboutallmalariacaseswillbecomeincreasinglyimportantfor
programplanners,particularlyatinlowertransmissionintensityareas.
Channelselectionandprioritizationwillbecomeincreasinglyimportant.Asvectorsofthe
parasitedecreaserapidly,masscommunicationchannelslikeradioandTVwillbecomelessand
lessrelevantaswillwide-spreaduseofhealthworkerstocommunicatewithcommunities
aboutmalaria.
Pointsofentry,includingcountryborders,willbecomeincreasinglyimportantfocalpointsof
malariacommunication.FromanSBCstandpoint,coordinatingwithneighboringcountrieswill
alsobecomeincreasinglyimportant.Thiscanbeaccomplishedthroughparticipationinregional
strategydevelopmentandsharingofbestpracticesthroughSBCcommunitiesofpractice,such
astheRollBackMalariaSocialandBehaviorChangeCommunicationWorkingGroup.
StrengtheningIntegrationThecaseburdenofmalariastrainspublicandprivatehealthsystems.Inhightransmission
settings,malariacomprises50%ofhospitalvisitsandadmissions,andcanaccountfor40%of
publichealthspending,timeandresourcesatpeaktimes[33].However,inareasoflowand
verylowtransmission,evenasmalariacasespersistatlowerfrequency,SBCeffortstoaddress
themmayhavetobepairedwithothercompetingillnesses.Reportedcasesofmalariawill
becomethemostimportantindicatorofprogresstowardseliminationandserviceproviderswill
becomethechiefmeansofcommunicatingwithpatientsaboutmalaria.Asthishappens,itwill
beincreasinglyimportanttoprioritizemessagesandpromotemalaria,emphasizingactionsto
avoidmorethanonediseaseorillness.Infact,theWHOrecommendstakingadvantageof
opportunitiestocommunicateaboutmultiplevector-bornediseases(thosecurrentlyposinga
riskaswellasmalaria)whenpossible.Inareaswhereothervectorbornediseasesarepresentit
maybepossibletopackageSBCmessagingandmaterialsinawaythatprovidesasetof
behaviorsfamiliescantaketoavoidmultipleillnesses.
WhiletightintegrationbetweenNMCPandmaternalandchildhealthandreproductivehealth
unitsisimportantinareasofeverytransmissionintensity,asmalariabudgetsareadjusted,so
toowillthenumberofthoseemployedbythegovernmenttofocusexclusivelyonthedisease.
ItwillbecomeincreasinglyimportantforSBCofficialstoworkwithmultipleMOHunits.Inroads
witheducationandtourismministriesandprivatesectorcompaniesmayprovebeneficialas
well.
Thefirstsectionofthisdocumenthasreviewedmalariainterventions,categorizedbyWHO-
definedmalariatransmissionlevels,discussingSBCrecommendationsforeach.Inthenext
section,threecasestudiesillustrateSBCactivitiesindifferentpre-eliminationcontexts.Each
16
casestudyhighlightschallengesandpromisingpractices,eachpreparedwiththeinputofthe
responsibleimplementingpartners.
RecentMalariaSBCinModerate,Low,andVeryLowAreasofTransmissionIntensity
Thefollowingthreecasestudieshavebeenselectedbecausethedifferentapproachesspanthe
rangeofmalariatransmission,eachofferinguniqueinsights.TheZambiacasestudydescribesa
highlyparticipatoryinterventionthatmayproveeffectiveinhigh,moderate,andlow
transmissionsettings,makingitapragmaticchoiceforcountriesintransition.TheGreater
Mekongprovidesadetaileddescriptionofchallengesinvolvedinreachingandinfluencing
mobileandincreasinglyheterogeneousgroupsofthoseatrisk.Finally,adescriptionof
collaborationbetweenthegovernmentsofLatinAmericancountriesillustratesthedegreeof
cohesionnecessarytosustaingainsinaninterconnectedregion.
CaseStudy1:ZambiaGeneralMalariaLandscape:Asacountrywithmoderatetohighmalariatransmission,Zambia
fitstheWHOdesignationofahighburdencountry.NinetypercentofZambia’s15million
inhabitantsareatriskofmalariainfection.Locatedinaregionwithbothhighburdenand
pocketsoflowerandzerotransmission,ZambiaisasignatoryoftheElimination8(E8)regional
cross-borderinitiativeandhassetacountryeliminationgoalby2020.Whilestilllargelyfocused
onmalariacontrol,Zambia’sparasiteprevalenceandtransmissionvarieswidelythroughoutthe
country,necessitatingstrategiestailoredfordifferentregions.
SBCImplementation:ZambiaNMCP’sstrategiesandactivitiesreflecttheneedsofdifferent
transmissionintensities.SBCimplementationbytheUSAID-fundedCommunicationSupportfor
Health(CSH)projectexemplifiesanapproachwithbenefitsforareasofhighandlowmalaria
transmissionintensity.
CSHimplementedmulti-componentSBCactivitiesinZambiafrom2010-2014.Implementedby
ChemonicsInternational,ManoffGroup,andICFInternational,CSHbuilttheZambian
government’sinstitutionalcapacitytoinfluenceHIV,nutrition,maternalhealth,andmalaria
ChampionCommunitiesIntervention:Interpersonalcommunication
FormativeResearch:AssessmentofbarriersandinfluencingfactorsrelatedtoANCservicesandITNuseSBCapproach:Behavior-CenteredProgramming(BCP)&CommunityChampions
• Keyelementsincludeuseofresearchtodetermineprogramstrategy,tailoredmediamessagesto
addressspecificbarriersidentifiedbyformativeresearch,multi-channelapproach,useofmessage
pre-testing,activecommunityparticipation.
• SixstepsofBCP:1)Situationalassessment2)Behavioralanalysis3)Programdefinition4)Strategic
behavioralchangeactivities5)Communicationsplan6)M&Eplan
• Workingwithcommunitiesasagentsofbehaviorchangeincreasesthelikelihoodofownership.
17
behaviors.CSH’sBCPapproachfocusedonbringingaboutchangeattheindividual,community,
andorganizationallevels.Families,healthworkers,andcommunitymemberswereincludedin
aparticipatoryprocessthatensuredbeneficiariesofSBCplayedanactiveroleinthedesignand
testingofhealthpromotionactivities.Amonganumberofsuccessesdetailedintheproject’s
finalreportisa10-percentage-pointincreaseinregularuseofITNs.CSH’ssuccesshighlightsa
meanswithwhichtoimplementtargetedIPC.TheChampionCommunities’useofcommunity-
generateddata,self-surveillance,andsenseofownershipresultedinpositivebehavioral
outcomes.
FormativeresearchindicatedthatmalariawassopervasiveinthelivesofmanyZambiansthat
itwasoftenviewedasanunavoidablepartoflife.Toaddressthisissue,CSHsetouttoinstilla
senseofurgencyamongthoseaffectedbymalariawiththeSTOPMalariacampaign.Working
withfivelocalcivilsocietyorganizations(CSOs)andcommunityleaders,CSHusedanapproach
theycalledCommunityChampions.CommunityChampionscombinedone-on-onecounseling,
communitymeetings,andmothers’groupswithaformofhouseholddatagatheringthat
helpedmeasureincreasesinbehaviorslikeregularITNuse.Communitymalariacounseling
agents(CMAs)mademonthlyvisitstohouseholdsandusedvisualaidstospeakaboutwaysto
preventmalaria.TheprogramranfromApril2013-September2014ineightdistricts.Oneor
twoCMAsworkedineachparticipatingcommunity,eachresponsibleforIPCto30households.
Aftereachvisit,CMAsrecorded
behaviorsreportedbythose
interviewedonscorecards.
Behaviorsrecordedincluded
care-seekingandappropriate
testingatthefirstsignoffever,
regularANCattendance,and
uptakeofIPTp.Scorecards
indicatedwhatissuesto
prioritizeineachhouseholdon
subsequentvisits.Usingthis
locallycollectedcommunity
data,Zambiangovernment
partnersandCSHmore
effectivelymonitoredthe
programandmadenecessaryprogrammaticadjustments.Forexample,severalcommunities
discoveredthatmanywereseekingcareforfever,butwerenotregularlysleepingunderITNs.
Inresponse,communitieslikeMweenduinMonguDistrictshiftedthefocusofhousehold
counselingsessionstofurtheremphasizeITNuse.CommunitiesintheWesternProvincethat
onceusedITNstofishwereencouragedtoreflectonthepracticeandcomeupwithanaction
plantochangetheunhealthybehavior.Ascommunitiesmettheirownbehaviorchangegoals,
theirsuccesswascelebratedbynamingthemChampionCommunities.
ChampionCommunitiesPerformanceScoreCard
18
Potentialefficacyinlowandverylowmalariatransmissionsettings:TheparticipatorynatureofCSH’sChampionCommunitiesinitiativeensuredthatcommunitiessettheirowngoalsand
createdlocalsolutionstohealthissueslikemalaria.Thenotionofcommunitiescollectingand
usingtheirowndatawaspowerfulbecausereductionsinmorbiditywerenoticeable.
CollectingdataisanimportantconsiderationgiventhescalabilityoftheChampion
Communitiesinitiative,asitrequiresasufficientnumberofmotivatedcommunityhealth
workers.Whileresultswerepromisinginsmallercommunities,bringingsuchanapproachto
scalecouldbedifficult.Thischallengemightbemitigatedbyusingadatacohortmodel,where
differentgroupsofpeoplewouldbesurveyedduringdifferenttimeperiods.Community
meetingswouldstillinvolveeveryone,buthouse-to-houseIPCcouldbestaggered,limitingthe
numberofcommunityhealthworkersneededandthetimerequiredofthem.
Replicatingthisinitiative’ssuccessinloworverylowmalariatransmissionareasmightmean
limitingtheactivitytoashort,introductoryphaseamonggroupsnotyetconvincedITNsarean
effectivemeansofpreventingmalaria.Theapproachwouldbedifficulttosustainovera5-year
projectcycleinonearea,butmightbesuccessfulifimplementedindifferentcommunitiesover
time.
TheChampionsCommunitiesapproachmightalsocomplementintegratedcommunitycase
management(iCCM)implementation,asvolunteersareoftenfrustratedbyhavingtoconduct
informationdisseminationwithoutthetools,services,andmedicinestodoanythingaboutthe
illnessitself,particularlyasmanycommunitieswherethisinterventionwasimplementedare
locatedfarfromhealthcenterswithtestsandtreatment.PairingthisapproachwithiCCM
wouldempowerhealthworkerstoplayaroleintreatingfebrilecasesthattestpositivefor
malaria,orreferthosewithseveresymptoms.Additionally,usingpassivecasedetection,would
addressbothvolunteerworkloadandprovideasamplingmechanismininterventionareas.If
theinterventionareamoved,theareawhereimplementationpreviouslytookplacecouldbe
coveredwithactivecasedetection,maintainingvolunteeractivitywithoutdemandingexcessive
orunrealisticamountsofwork.
TheChampionCommunitiesapproachillustratesseveralconsiderationspreviouslydescribed.
Thisparticipatoryapproachcombinesfrequentdatacollectiononcommunitybehaviorswith
IPC.Theapplicationofthisapproachinlowandverylowmalariatransmissionsettingscould
relyonfrequentdatacollectionanddisseminationatthecommunitylevel,nottoshow
dramaticcasereductions(aschangesatlowerlevelsoftransmissionwouldnotlikelybeas
dramaticallynoticeable),butaspromptsandreminderstomaintainhealthybehaviors.
19
CaseStudy2:GreaterMekongSub-Region
GeneralMalariaLandscape:Ascountrieswithhigh,moderate,low,andverylowmalaria
transmission,China,Thailand,Cambodia,LaosPDR,Vietnam,andMyanmarfittheWHO
designationofhighburdencountries.Fifty-fivepercentofmalariacasesandmostdeathsinthe
GMSareduetoPlasmodiumfalciparum.Inresponse,GMScountriescommittedtothegoalof
anAsia-Pacificfreeofmalariaby2030atthe9thEastAsiaSummit,heldinMyanmarin
November2014.TheStrategyforMalariaEliminationintheGreaterMekongSub-Region2015-2030outlinesprioritiesandobjectivestoachievethisgoal[35].
Overthepastdecade,malariapreventionandcontroleffortsintheGMShaveresultedina
significantdeclineincases.Withanestimated450,000confirmedcasesacrosstheregion
annually,healthpractitionersaredesigningtheirstrategiesformalariaelimination,withan
ultimategoalofeliminatingP.falciparumby2025andallmalariaby2030[36,37,38].
However,progresstodateisseverelythreatenedbythedevelopmentofresistanceto
artemisinin.WhiletheThai-Cambodianborderisconsideredtheepicenterofartemisinin
resistance[37],prolongedparasiteclearance,anearlywarningsignofresistance,hasbeen
identifiedalongtheThai-BurmeseandBurmese-Chineseborders,aswellasinsouthern
VietnamandLaoPDR.Thevastnumberofmobileandmigrantpopulations(MMP)livinginthe
regioncomplicatenationalcontainmentefforts,astheymovethroughhigh-risktransmission
areasandaredifficulttodiagnose,treat,andtrackduetoroutinetraveling.NotonlyareMMPs
difficulttomedicallytrackandfollow,theyalsooftenavoidinteractionwithpublicservices
becauseofundocumentedstatusortheinformalorillegalnatureoftheirwork.Additionally,
frequentmovementoftenleadstoincreasedrisk-takingbehaviors,which-alongwithlanguage
barriers,legalstatusissues,andlowersocio-economicstatus–preventMMPsfromreceiving
ITNsandprompttreatmentforfever.
Inresponse,healthpractitioners,countryleadershipandnontraditionalpartnershavecome
togetheraroundtheideaofeliminationandcontainmenttodevelopinnovativecommunication
strategiesforMMPsandensureconsistentmalariamessagesforthosewhoresideoneither
sideoftheborder.
SBCImplementation:ControlandPreventionofMalaria(CAP-Malaria),aUSAID-supported
projectthatimplementedmalariapreventionandtreatmentinterventionsintheborder
regionsofThailand,CambodiaandBurma,describesseveralwaysunderstandingmobilityasa
systemhasbeenusedtoengagewithatriskmobileandmigrantpopulations.Implementedby
CAP-Malaria’sApproachesforReachingMobileandMigrantPopulationsInterventions:Twin-citiesapproach,netlendingprograms,trainingnon-registeredproviders,transitmedia,
massmedia,IPC/communitymobilizationwithvillageandmobilemalariaworkersandhealthstaff
FormativeResearch:Baselineassessment,Burma,Cambodia,Thailandgenderassessments,AssessmentofITN
LendingScheme:PerceptionsonaccesstoandutilizationofITNsamongmigrantworkersSBCapproach:AddressingmobilityasasystembyinitiatingInterpersonalcommunicationwithtravelersat
multiplepointsonknowntravelroutes,aswellasindestinationworkplaces.
20
theUniversityResearchCo.LLC(URC),SavetheChildren,andtheKenanInstituteAsia,theCAP-
Malariaprojectranfrom2016-2017,withcross-borderactivitiescontinuinginto2017.CAP-
MalariafocusedonimprovingMMPs’accesstohealthinformationandservices.
Asmentionedearlier,MMPsareoftenconsideredhardtoreachbecausetheyarenotaseasily
identifiedoraccessedthroughtraditionalSBCapproaches.CAP-Malariaactivitiesdemonstrate
thatitispossibletoeffectivelycommunicatewiththesegroupsbydesigningactivitiesaround
specificsub-groupsandtheircharacteristics,socialnetworks,pointsofcontactandmigration
patterns.
CAP-Malariaidentifiedandworkedwithhotspotsandtouchpointstocommunicatewithits
prioritizedgroups.Forexample,toreachpopulationsconnectedtotheagriculturesector,CAP-
Malariadevelopedpartnershipswithprivatesectorcompanies.ITNlendingschemeswere
developedtoencouragefarmsandplantationstoexpandnetcoveragetohighlymobile
employeesforthedurationoftheirstay,expandingcoveragetothosenotreachedbyuniversal
coveragecampaigns.ITNlendingactivitiesalsoprovidedanopportunityforemployeesto
receivetailoredmalariamessagesthroughIPC,achannelthatdoesnotrequiretheaudienceto
overcomecommonhurdleslikereadingpamphletsorbillboards.AsMMPsinMyanmarhave
beenfoundtoself-medicateanddelaytreatmentseekingduetostigmatization,lackoffinancial
resources,andlongdistancestohealthcenters,engagingwiththeminpreventionactivitiesis
particularlyimportant.
CAP-Malariaactivitiesengagedmobilegroupsnotonlyinplacesofwork,butintouchpoints
throughouttheirjourneytoandfromareasofemployment.Onesuchactivityinvolvedworking
withbusandtaxidrivers.CAP-Malariaprovideddriverswithtrainingaboutmalariaprevention,
treatmentandlocalservices;aswellaspromotionalmateriallikeCDs,DVDs,stickers,seat
coversandbrochureswithmalariamessages.Throughthisapproach,nearly20,000passengers
(5,000ofthemestimatedtobeMMPs)wereexposedtomalariamessageseachmonth[39].
TheRaksThaiFoundationandtheAmericanRefugeeCommittee(ARC)usedasimilarapproach
wheretheycreatedbilingualSBCmaterialsthatpromotedmalariahealth-seekingbehaviors.
Thesemessageswerewornbymotorcycledriversandusedasfabriccoversforboats.
Beyondprevention,CAP-Malariaactivitiesfocusedonexpandingaccesstotestingand
treatmentaswell.CAP-Malariaaccomplishedthisbydesigningactivitiesthatcoordinated
betweensedentarypopulationsandMMPsub-groupstheyinteractwith.Withthe
encouragementoftheMyanmarNationalMalariaControlProgram,CAP-Malariaworkedwith
employerstoidentifyandtrainnon-registeredprivatehealthproviders,locallyreferredtoas
‘quacks,’whowereoftenthefirstpeopleMMPsorvillagerswouldgotofortreatment.Using
thismodel,employerswereaskedtoidentifynearbyquacksorothervolunteers.CAP-Malaria
providedtrainingandquality-assuredrapid-diagnostictestsandACTstothoseselectedto
ensurecontinuousandqualitycoveragetocommunities.Theyalsorecruitedandtrained
mobilemalariaworkersandclinicsinremotecommunitiesandprovidedthemwiththesupplies
totestandtreatmalariacases.Mobileclinicswerescheduledonceortwiceamonth,
dependingonthespecificsub-group’smalariaprevalence.Byleveragingtheseestablished
21
socialnetworks,CAP-Malariawasnotonlyabletoreachtheirtargetaudiencebutalsoformed
partnershipswithleaderswhocouldhelpsustainmessagedelivery,monitorcasesandevaluate
programimpact[39,40,41].
SuccessesdetailedinCAP-Malaria’sfifthyearworkplanincludeadecreaseinincidence,from
22.3casesper1,000in2011to11.4in2014forCAP-Malaria’stargetareas[42].CAP-Malaria’s
work,consistentwiththeWHOstrategyforthesub-region,usedhumanmovementpatternsto
determinewheretoprovidetreatmentbeforeandaftertravel,aswellasinplaceswhere
MMPswork.
CaseStudy3:AmazonMalariaInitiative
Asshowninthepreviouscasestudy,anindividualcountry’spotentialtoeliminatemalariais
oftendependentonthesuccessofitsneighbors.TheAmazonMalariaInitiative’s(AMI)
illustratesthenecessityofstrengtheningcommunicationstrategiesandSBCimplementation
throughsystemsstrengtheningandregionalcoordination.
GeneralMalariaLandscape:Malariaisendemicin21CentralandSouthAmericancountries,
endangeringanestimated132millionpeople[38].With24%oftheregion’smalariacases,
Brazilbearsthehighestmalariaburden,followedbyPeru(19%)andColombia(10%)[43].
PlasmodiumvivaxmakesupthemajorityofmalariainfectioninSouthAmerica,although
Plasmodiumfalciparumcasesmakeupasignificantportionaswell.Since2010,malariacase
incidenceintheAmericashasfallenby31%.Mortalityhasbeenreducedby37%.Between2000
and2012,Belize,Ecuador,Guatemala,Honduras,Nicaragua,andSurinamereducedmalaria
incidencebyover75%.However,specialpopulationslikemigrantsandindigenousgroupsface
adisproportionatediseaseburdenandrepresentalargerproportionofcases.
Toaddressthis,aneleven-countryregionalprogramcalledAMIwasintroducedandsupported
byUSAID.AMIwaslaunchedin2001withafocusongeographicareasconsistingof88%of
LatinAmerica’sPlasmodiumfalciparuminfections.Participatingcountriesandtechnical
partnerscametogetherinacollaborativedecision-makingmodelwiththegoalofeliminating
malariainCentralandSouthAmerica.ThegroupwasmadeupofBrazil,Colombia,Ecuador,
Guyana,Peru,Suriname,Belize,Guatemala,Honduras,Nicaragua,andPanama(aswellas
formerparticipantsVenezuelaandBolivia).
RegionalMalariaSBCStrategyCoordinationandSupportInterventions:Strategydevelopment,coordination,resourcemobilization,systemsstrengtheningFormativeresearch:Countryassessmentsconsistingofin-depthinterviewswithNMCPsandvalidationof
approacheswithPAHO/WHO.
SBCapproaches:• Cross-bordercollaboration,keypopulationengagement,multi-sectoralengagement,technical
assistance
• Lessonslearnedaboutcollaborationandcollectiveworkplanningwillbenefitotherregionslookingfor
bestpractices.
22
SBCImplementation:AMI’sframeworkofsixinterventionsincludedantimalarialmedicine
resistance,diagnosticqualityassuranceandaccesstodiagnosis,antimalarialmedicinequality,
antimalarialmedicineaccessanduse,vectorcontrolandentomologyandcommunicationand
informationdissemination.LINKSMEDIAsupportedthedevelopment,adoptionand
implementationofAMISBCactivitiesfrom2013-2016.Responsibilitiesincludedcommunication
strategydevelopmentandcoordinatingSBCeffortsbetweenthePanAmericanHealth
Organization(PAHO),PMI,theAmazonNetworkfortheSurveillanceofAntimalarialDrug
Resistance(RAVREDA)andNMCPofficesineachcountry.
AMI’sstructurewasdesignedtocombineindependentorganizationsandtheirworkplans
underthedirectionofPAHO’sDirectingCouncil.Usingthismodel,eachorganizationdeveloped
workplansfortheirparticulardomain(laboratoryimprovement,policy,leadershipand
governance,systemsstrengthening,communicationetc.)beforecomingtogethertocombine
thoseplansunderasingle,alignedworkplan.Borderingcountriesmettwiceayearinpersonto
discussopportunitiesforintegrationandcoordination.TheAMImandateforeachgroupto
workwiththeotherscanbecreditedwithmuchofitssuccess.
UnderPAHO,LINKSMEDIAworkedtoincreasetheevidencebaseformalariaSBCbybuilding
countries’capacitytoshareexperiencesthroughpeer-reviewedliteratureandexchangingideas
atsemi-annualin-personmeetings.LINKSMEDIA’sportfolioalsoincludedassessingtheSBC
needsofthe11participatingNMCPsintheregion,facilitatingthedevelopmentofnationaland
regionalmalariacommunicationstrategies,creatingtoolsandguidanceformalariaresource
mobilization,coordinatingNMCPs,MOHs,donorsandimplementingpartnersunderPAHO’s
DirectingCouncil,andfosteringregionalsharingofbestpracticesandresources.
The2015-2020StrategicMalariaCommunicationGuideforCentralAmericaincludedregional
SBCsub-strategiestoaddressissuesliketargetingprogramstoatriskmobilepopulationsand
ensuringstakeholderbuy-in[44].Thestrategyincludedcommunicationobjectivesand
messagesforMMPs,includingtourist,indigenousandmigrantpopulations.Italsoadvocated
forimprovedcommunicationbetweenhealthserviceprovidersandindigenousandmigrant
populations,andencouragedimprovedcross-bordercoordinationandinformationsharingto
avoidmissingcasesanddoublecounting(especiallydataonresidentsofbordercountrieswho
travelfrequentlyandmayhavebeendiagnosedineithercountry).Thestrategysuggested
leveragingandestablishingregionalforumsandmeetingstocoordinateeffortsandcreate
communicationmaterialsformigrantpopulations.
InadditiontoregionalSBCstrategydevelopment,LINKSMEDIAworkedwithnational
representativesfromsixcountriestodevelopcountry-specificcommunicationstrategiesfor
Brazil,Colombia,Ecuador,Guyana,SurinameandPeru,severalofwhichincludedstrategies
focusedonspecific,localmigrantgroupsatriskformalaria.Tofacilitatecountryownership,
LINKSMediaprovidedtechnicalsupportthroughwebinars,materialsdevelopment,meetings,
andinternalmonitoringopportunities,suchasaskingcountrieswithhigherstaffcapacityto
superviseotherlower-capacityteams.
23
Regionalstrategydevelopmentandsystemsstrengtheningwaspairedwithworkatthenational
levelaswell.In2014,LINKSMEDIAworkedwithGuyana’sVectorControlServicesandPAHOto
developanationalstrategythatfocusedonminersandtheirrationaldruguse[45].Theyalso
workedwithVectorControlServicestodevelopSBCmaterialsforusebyhealthprovidersin
remotelocations.LINKSMEDIAalsocollaboratedwithSuriname’sBureauofPublicHealth
(BOG)andPAHOtocreateastrategytoimprovemalariamanagementamongartisanalmigrant
goldminersworkinginareasonSuriname’sborders(FrenchGuyanaandBrazil)[46].Messages
weredesignedaroundthegroup’sparticularcharacteristicsandbehaviors(e.g.,theywerenot
completingtheirtreatmenttosavedosesforfutureinstancesandlackedawarenessoffree
malariatestingandtreatment).Theteambasedtheirstrategyona2013KAPsurvey,which
foundthat“geographicinfluencesweremorepowerfulthanindividualbeliefsindetermining
theuseofhealthfacilitiesandpropertreatmentamongthispopulation.”TheSuriname
strategyalsofeaturedasub-strategyforthoseinroutinecontactwithminers(e.g.,
accompanyingspouses,sexworkersandcooks),audiencesthatshouldbeconsideredbyother
pre-eliminationcountriescommunicatingwithmobilepopulations.Inaddition,bothGuyana
andSurinameincludedadvocacymessagingtogovernmentdecision-makerstoadvocatefor
continuedsurveillance,plantocoordinatecommonissuesandsharedatathroughmeetings
withborderingcountries.
TheAMIcasestudydescribeshowtocombinesystemsstrengthening,strategydevelopment,
resourcemobilization,andregionalcoordinationtoeffectivelyfightmalariainaregionwith
highlystratifiedtransmission.AnintermediateperformanceevaluationofAMIactivitiesfound
thattheinitiativeplayedamajorroleinthedeclineofmalariaincidenceinLatinAmericaand
theCaribbean[47].Thisdeclinewasdescribedastheresultofimprovedtreatmentand
diagnosisofmalaria,theintroductionofITNs,moreefficientmanagementofnationalprograms
andworkwithhigh-riskpopulations.
ConclusionOverthepast50years,malariapreventionandcontrolhasbeendefinedlargelyintermsof
provisionofmedicalcommodities,insecticides,andclinicalguidanceoncasemanagement.
Morerecently,significantstrideshavebeenmadeinputtingpreventivetoolsincludingITNsin
thehandsofcommunitiesatrisk.Thishasincreasedthedegreetowhichthosewhosufferfrom
malariainfectionareabletoparticipateinandcontributetotheirownwell-being.Country-
wideSBCcampaigns,thehighvisibilityofmalariainfection,andresultingsocialunderstanding
andcommunitynormsevolvesastransmissionisfurtherreduced.Atthesametime,economies
ofscaleandcostsavingsinherentinpopulation-levelSBCactivities,suchasmass-media
campaignsandnationallyrepresentativehouseholdsurveymeasurementtools,willbe
renderedaninappropriatemeansofmeasuringandreachingincreasinglyhomogenousat-risk
groups.TheRBMAIMcallsforhuman-centeredapproachestomalariapreventionand
elimination.Thislandscapedocumentexploredanumberofwaystoensurethatontheroadto
globalmalariaeradication,provisionofmedicalcommoditiesandclinicalservicesare
adequatelypairedwithahuman-centeredSBCresponsewithinspecificmalariatransmission
strataandsuggestedanumberofoperationalresearchquestionsforfurtherexploration.
24
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