‘PARTNERSHIPS FOR CHANGE’ & COMMUNICATION Guidelines for Malaria Control
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‘PARTNERSHIPS FOR CHANGE’ & COMMUNICATION
Guidelines for Malaria Control - extracted text
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‘PARTNERSHIPS FOR CHANGE’ & COMMUNICATION
Guidelines for Malaria control
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Division of Control of Tropical Diseases
World Health Organization
Developed in collaboration with
Malaria Consortium U.K.
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Acknowledgements
The final development of these guidelines has been influenced by the
review and comments by many professionals and colleagues from
These Guidelines have been developed and designed by Sunil Mehra
and Associates, UK, in collaboration with the Malaria Consortium,
London School of Hygiene & Tropical Medicine, with extensive
many parts of the world.
contributions by Dr. S.R. Meek. Special gratitude is due to Dr. R.L.
Kouznetsov and Professor D. Bradley for their steering
contributions. Overall guidance was provided by the the Malaria
Unit, Division of Control of Tropical Diseases and Division of Health
Division of Control of Tropical Diseases
Promotion, Education and Communication, World Health
CH-12H Geneva 27
Organization, Geneva.
Switzerland
World Health Organisation
Malaria Consortium
a collaborative project of the
Liverpool School of Tropical Medicine and
London School of Hygiene & Tropical Medicine
Keppel Street, London WCIE 7HT
Dr. S.R. Meek contributed significantly to Section 2; Ann Starrs,
Family Care International Inc., contributed generously to the
development of Sections I and 3. Technical contributions were also
U.K.
The production of these Guidelines has been supported by
made by Dr. I.S. Narula, Japan and Dr. J. Lines, U.K.
The Overseas Development Administration, U.K.
The Guidelines were edited by K. Attawell and are illustrated by
June D. Mehra. Many others have contributed to the development
of these Guidelines, including all the professionals who provided
summaries of effective strategies and case studies, especially Ane
Haaland, WHO and Marcia Griffiths, Manoff International.
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Table of Contents
Preface
Page
Malaria is not a new problem for human beings. At the height of
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Preface
3
Introduction
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Section 1:
'Partnerships for Change’
31
Resource 1: Checklist for 'Partnerships for Change’
malaria eradication efforts it was believed that malaria and the
mosquito could be controlled, liberating millions from illness and
death. But the mosquito has escaped our grasp., and for many
reasons, the control of malaria has remained difficult. Today
malaria is making a serious comeback.
Recent efforts in other areas of public health indicate that health
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76
93
Section 2:
2.1 Understanding Malaria
64
70
Resource 2: Peveloping a Profile for Your Area
promotion, communication and community action can play an
important role.
22 Helping Communities to Understand Malaria
and to Protect Themselves
Section 3:
Developing and Sharing Messages
85
Resource 3: Checklist for Peveloping and Sharing
Messages
We must use the knowledge and experience gained from other
public health programmes to foster a greater understanding of how
collective action can help to control malaria. It is worthwhile to
remember one particular lesson from the past - that simple
reliance on medical or scientific solutions is not enough - the
joining of forces between professionals AND communities is
Annexes
93
Resource 4: Social Marketing
98
Resources: Illustrations
necessary to control significant public health problems such as
malaria. These guidelines have been developed with the intention
of encouraging this dialogue, to promote common understanding
and collective decision-making to sustain community action.
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Introduction
We would greatly welcome your comments and suggestions for
improvement - a constructive dialogue can benefit us all by
strengthening our efforts in the control of malaria.
Global Strategy and Local Action
A global strategy for malaria control has been developed and
published. How relevant is this global strategy to your area? This
manual aims to help you to adapt and adopt the global strategy,
especially those aspects that deal with interactions, actions,
responsibilities and decision-making by the communities you serve.
Clearly, these Guidelines are published for international use, and
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therefore they cannot answer all questions for every situation.
With this in mind the main aim is to assist in the process of finding
appropriate answers to your situation. The purpose is not to
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prescribe simple solutions for the complex causes and conditions
that lead to the problem of malaria in different parts of the world.
The relevance of the strategy you develop will depend on the
relevance of your information and your clear understanding of the
problem - not just from a medical perspective but also from the
perspective of the community and people you aim to assist.
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Who are these Guidelines for?
In addition to understanding malaria, two factors are crucial to
developing appropriate strategies for health promotion and
communication for malaria control:
These Guidelines are for the regional, provincial or district level
manager of the malaria programme. This will vary in different
countries: you could be the Malaria Officer, Communicable Disease
Officer, Epidemiology Officer or Provincial or District Health or
Medical Officer. They are also intended for Planners and Trainers
•
Who makes the decisions ?
•
Who has adequate information to make
appropriate decisions ?
who assist and supervise district and/or community level
programmes and personnel. The size of a country, province or
Who makes the decisions ?
PARTNERSHIPS FOR CHANGE'
district varies; therefore, we hope these Guidelines will be useful
for officers at different levels depending on the size of your
country and the way it is organised administratively.
‘Partnerships for Change’ means implementing a process for
collaborative decision-making between all those involved and
affected. The emphasis is on partnerships - between families,
between households, between communities and with service
providers - and the process of joint decision-making in the
development of an effective and appropriate health promotion
strategy.
The GUIDELINES
The Guidelines should help you to define the malaria situation in
your area. Once you are able to define your situation you will be
able to develop strategies for health promotion and communication
Who has adequate information to make
appropriate decisions ?
COMMUNICATION'
leading to community action that are right for your area,
appropriate for the resources you have available and relevant to the
needs and perceptions of the communities you serve.
The purpose of a communication strategy is to provide
adequate, accurate and timely information to those who have to
make decisions. For a public health programme to be effective
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every level has to make decisions - the individual, family,
household, community, district, province or region, and
Section 3: Developing Messages
country. To maintain and sustain public health initiatives
This section includes basic guidelines for developing messages
about malaria and provides examples of illustrations that can
greater recognition needs to be given to the role of the family,
household and community. Collective understanding of the
be adapted and used by your programme . In addition, it
provides an introduction to social marketing, a strategy that
problem and decision-making about how to address it is
necessary if action is to become part of community life and to
be sustained.
may be useful.
The Guidelines are arranged in three sections:
Section 1: 'Partnerships for Change’
This section outlines the steps in implementing the process
with emphasis on joint decison-making and sharing of
information to sustain collective action with the community,
household or family.
Section 2: Understanding Malaria
There are two aspects to understanding malaria: the technical
aspects of malaria and the experience of the community
related to the malaria problem. This section also helps you to
adapt the global or national strategy to develop a “A Profile”
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which defines the problem in YOUR own area.
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To make these Guidelines of practical use the format emphasises
practical steps through the use of worksheets and exercises.
These can be used to develop a profile of the malaria situation in
your area or to develop local strategies for partnerships,
communication or community action.
The use of these Guidelines is only the beginning of the process.
We hope it will lead to a sustainable relationship between
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communities and health providers to control malaria in YOUR area.
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To begin with go out and meet people....find out what they think
and know.
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“
SECTION 1
Section 2 will help you to develop an understanding of malaria in
‘Partnerships for Change’
your area. The Guidelines will help you to identify what you already
know and gaps in your information. Unless you have a clear idea of
‘Partnership for Change’ means working together with the
community to achieve improvements in health. Working together
the problem of malaria in your area, you will have difficulty in
working with the community towards appropriate decisions to
tackle the problem. At the same time, with a clear understanding
of the problem the community can guide you on what is appropriate
effectively requires understanding not only the medical and
scientific situation but also the needs and perceptions of the
and possible.
community and the means for making decisions together.
Partnerships for Making Decisions?
At the same time the community needs to understand the work of
the health services and your ideas on what needs to be done.
Decisions about what needs to be done and how it will be done in
The aim of ‘Partnerships for Change’ is to implement a process
that provides the means for collaborative decision-making between
all those involved and affected. The emphasis is on partnerships
between families, between households, between communities as
collaboration with the community depend on the relationship you
establish between the health services and the people you serve.
This section of the Guidelines aims to help you to initiate and
well as between service providers. The process presented in
these Guidelines highlights the critical stages of joint decision
continue dialogue with the community through its representatives
and leaders.
making in the development of an effective and appropriate
strategy.
These Guidelines are written for malaria programmes and
Partnerships between the different programmes of the health
services are also very important for the effective implementation
therefore the focus is on improving the malaria situation in the
community. To do this you need a clear understanding of malaria in
and sustainability of malaria control strategies. At the same time
malaria control programmes can also develop partnerships with
your area.
other public sector programmes and the private sector where
appropriate. Inter-sectoral collaboration is not included in detail in
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these Guidelines as this has been covered in many other
publications and manuals.
‘Information Giving’
‘Partnerships for Change’
Sharing information to develop
'Sharing Information’: The Communication Process
partnerships
Neither the community nor provider
In communication programmes that rely only on ‘information giving’
has all the information
to achieve change, without adequate emphasis on ‘who makes
decisions’, the following characteristics tend to prevail:
Both the provider/planner and
Giving the correct information to
influence behaviour
The provider thinks s/he has all the
information
The planner/provider believes s/he
a.
The emphasis in communication is on ‘giving’ information
community need to strengthen
understands the information better
b.
Health providers/planners assume they have all the information that
each others’ understanding and
so should make the decisions
the community wants and needs
make decisions through
Health providers/planners believe that they understand information
partnerships
c.
better so they should help the community by making its decisions
d.
The community is the partner
The comm unity is the target
The process is jointly controlled,
The process is controlled by the
The community is seen as the ‘target’ not necessarily the partner in
the programme
e.
Planners collect and analyse all information and recommend solutions
f.
Planners focus more on understanding the community so that they can
analysis of information and
planners/providers and solutions
identifying solutions are carried
are identified by them
out jointly
influence community behaviour rather than on helping the community to
Efforts are made to improve two-
understand its problems and the health provision system
The following table summarizes the comparisons between
‘Partnerships for Change’ and ‘Information Giving’ especially when
they are used in isolation from each other.
Efforts are primarily made to
way understanding between
research the community by the
planner/provider and community
planner leading to one-way
understanding
Data are shared with the community
at each stage
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Data are usually kept at a central
place
‘Partnerships for Change’
The two approaches of ‘Partnerships for Change’ and ‘Information
Giving’ seem different from each other but, for effective malaria
‘Information Giving’
control, the two processes should overlap significantly and
The community is involved in each
The community mostly ‘complies’
stage: deciding what information
and participates during the
should be collected, what solutions
implementation stage with little
are appropriate, and in
involvement in choosing priorities,
implementation, monitoring and
monitoring or evaluation
evaluation
complement each other. The positive aspects of both processes
can be used to advantage to develop broader knowledge of malaria
control and sustained community participation and action.
‘Information giving’ is a one-way process but the aims of
Information gathering and analysis
are simple and as reliable as
possible
The process is appropriate for local
area strategies
Mas greater possibility of
sustainability of ‘maintained’
Information gathering and analysis
are complex with emphasis on
statistical ‘correctness’
‘Communication’ should be:
methods to spread information
To develop common understanding to improve the exchange
•
of ideas
To find the means for extending the reach of information
The process can operate for large
areas and populations
Mas greater effectiveness for ‘one
time’ behaviour change
These basic aspects of communication have been made very
behaviour change
Greater emphasis on interpersonal
methods and therefore slow
diffusion and considered
expensive; may need some ‘mass’
•
complex by many communication programmes. This is partly
caused by the assumption that information needs to be ‘given’ to
ignorant community members instead of an emphasis on
Greater emphasis on ‘mass’ methods
and faster diffusion with
recognition of interpersonal
methods to achieve behaviour
‘exchange’ of ideas, values or beliefs. When the emphasis shifts
from ‘giving’ to ‘exchange’ then the methods used become those
change
that can be used equally by both sides.
Focus on ‘understanding’ and mutual Focus on ‘messages’ and their
exchange of ideas
retention
To develop common understanding you can use the following
methods but with greater involvement of the community:
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•joint surveys
•focus group discussions
Joint decision-making is the key to the success of this process.
Good decisions require good information. Communication plays an
•participatory research involving the community
and others
ongoing role at each stage of the ‘Partnerships for Change’
process as its success depends on shared information and common
understanding.
To extend the reach of information you can use:
•interpersonal communication
•communication methods for groups
•mass media
•visuals
•stories
•extension activities or others
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Focus group discussions help to find out peoples perceptions and views
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To understand the interdependence between ‘Communication’ and
‘Partnerships for Change’ they can be viewed in the following way:
Based on a True Story*
It was early evening in the village of Zong Nosinfa*. The village elders
and chief had gathered with many people under the baobab tree. The
Communication
* Partnerships for Change’
increases the amount and improves
health workers and students were preparing their presentation on what
the quality of information available,
their survey, assisted by the traditional birth attendant, had found. They
and narrows the gap between the
had promised the community leaders that they would present what they
understanding of the provider/
had found in the village to them before they left that day. The village
planner and the community
chief and elders said they were very interested to hear their findings
helps to convert the understanding
because no one had done this before.
between the community and the
The nurses had collated the data and were very pleased with what they
planner/provider into.. A C T10 N
had found. They saw the figures and realised that community nurses
were doing a very good job in the village. The senior nurse presented the
summary with great enthusiasm and she said that her team was very
Information - Whose Information ?
pleased that 7 out of 10 pregnant women in the community (all
information was presented out of 10 instead of percentages) were taking
In all situations the attitudes of those controlling information and
resources are critical to encouraging collaboration and partnership
their malaria medicine regularly. She congratulated the community.
with the community. It is important to remember that:
wanted to say something. Me turned to the nurse and said,” Who are the
But then there was a hushed silence because one of the oldest elders
three women who were not taking their medicine?” The nurses went
a.
b.
The more complicated the information collection and analysis process
quiet and the discussion that followed planned how with the community
the further the decision-making tends to be from the community
they could achieve 10 out of 10 coverage among pregnant women.
No matter how accurate the information it will be interpreted
differently by different people
• Based on field experience, Mehra, Understanding Communities-Ghana, unpublished report, IQQ3
* Name of village has been changed
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There is a great difference between 30% as a statistic and ‘three
This experience showed us that
information close to the level of action will lead to better and more
women in our community’.
practical use. It also shows that interpretation of data should not
only be done by planners and health workers but also involve those
who have to participate, act or make changes.
The design of data collection instruments such as questionnaires,
the methods of analysis and presentation of results will influence
who makes the decisions and on whose behalf. The process
determines whether true dialogue occurs or whether those who
have information dictate to those who do not.
Information for Decision Making
Good decisions are joint decisions
There is often a tendency for those who have or collect information
not to share it with others. This thinking can slow the process of
sharing and putting the data to its proper use. Community data are
communities are capable of and willing to make decisions and take
actions. Health workers often do not adequately understand what
most useful if they lead to appropriate actions at the community
level.
the community knows, is doing or and can do; and information that
is shared is not relevant to their circumstances. The purpose
Community data can be converted into action only if health workers
accept that the community could use some of the information that
of dialogue is to build bridges between the health workers’ modern
knowledge and the community’s traditional knowledge
and experience.
health workers have. With adequate and appropriate information
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In the same way the community may think health workers do not do
their job properly. This is because people feel that health workers
do not pay attention to what is important to them. The
My ,
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‘Partnerships for Change’ process outlined here aims to provide
guidelines for overcoming the lack of understanding and
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collaboration between health workers and communities, and to
establish a dialogue to bring together these two sources of
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information to improve the situation.
The Individual’ and the Community
Many communication programmes place emphasis on the behaviour
of the individual. Although families, households and communities
are all made up of individuals it is important to recognise that life
Who is more knowledgeable?
styles and cultures are not behaviours of individuals but behaviours
of groups. Family, household and community behaviour has a
Based on a True Story
workers would gather together at the end of the day to share experiences. A
greater probability of being sustained than individual behaviour.
The role of family, household and community needs to be fully
common comment heard would be, “people are so ignorant about health matters.”
recognised if communication is to maintain health promoting
During initial design and testing of survey instruments in communities, health
behaviours.
When the group of health workers were asked “Who has the information that
people in the comMunity need to deal with the malaria problem?” A long silence
Individual behaviour change has been the basis of many
would follow and then they would admit that they had the information and would
recognise that it was health workers who had all the information that people in
communication programmes which aim to improve health.
Successful behaviour-oriented programmes have recognised that
the community need.
individuals in traditional communities live in a social context. In
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public health programmes, such as malaria control, families,
households and communities have to be seen as partners.
Exercise l.l
Try and think of an example from your own life when you had
to change your behaviour. Think of what made you change.
Mow we can we improve the dialogue?
Design instruments, such as survey questionnaires, that are short
Who influenced you most? Who supported you? Think of
and simple
how long it took you to change finally? Try and remember
2.
Include questions that the community wants information about
and write down the stages that you went through to change.
3.
Make a commitment that no data leaves the community
1.
without sharing the results with community members and leaders
4. Make sure some analysis can be done quickly and simply in the
community
5.
Make presentations using simple statistics
6. Do not make judgements on results but discuss them with the
community before reaching any conclusions
7.
Use this as an opportunity to discuss what should be done in the
community
Changing the way you do things is not easy. Therefore, it is
Learning the 'Change’ Process
important to assess the process that you go through yourself so
you can better understand what others have to go through to
The easiest way to understand the ‘Change’ process is to try and
recall from experience what you would go through if YOU wanted to
change your behaviour or you wanted your family to change their
behaviour.
change. Understanding yourself also helps you understand others.
The next stage is to understand how change can be brought about
within a social context such as the family.
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Exercise 1.2
Exercise 1.3
Now try and think of the process you would use or the steps
Try and describe the process you would have to go through
you would take to make your family (e.g. including your
so that all the members of the household use mosquito nets
spouse, and two children) all sleep under a mosquito net
everyday and maintain that level of use. Describe the
every night. Think of what you would do within the family;
stages you would go through and how you will work with
what would be the differences in convincing different family
different members and with the household as a whole.
members? Draw the process or list the steps you
List the steps you would have to take.
could take.
Most of us find that promoting behaviour change for someone else,
another family or group seems much easier than doing it for
Now imagine that your household consists of your parents who are
about 65 years old; your sister, her husband and their two young
ourselves. But unless we are able to understand what it means to
change behaviour in a social or cultural environment we cannot
develop a programme that builds on the social and cultural
children - an ? year old boy and 11 year old girl; your spouse, your
I6 year old daughter and M year old son.
influences that affect the change process.
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• The need of everyone for information to understand the problem
Exercise 1.4
• The desire to share information and discuss with others with the aim of
Now try and list the main steps that you would take to
reaching some agreement on what can be done
influence change amongst different groups in the
• A search for an answer to the questions why and how something needs
community. For example, you would like to suggest that
to be done
they protect themselves from mosquito bites after sunset.
• Adequate and appropriate information for everyone to make a decision
Who are the different groups? What reasons would they
about what they would do, and why and how
have for not wanting to change? What would you have to do
• A decision together on what should be done first
differently with each group? What steps would you take?
• A means for finding out if the joint efforts are providing encouraging
results
• A means for finding out if the family was able to do what it set out to do
and, if not, what it could do to improve the situation
What stages have you identified that are similar or different from
those given above? Develop a process for change that you might
use with your communities and groups within them.
Some factors usually emerge when change affects more than the
individual. One of the key factors is the need to inform and involve
everyone who needs to be part of the change process. Using the
exercises on the ‘change’ process the following stages usually
emerge (not necessarily in the same order):
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These exercises introduce the ‘change’ process and this is further
developed in these Guidelines as the ‘Partnerships for Change’
'Partnerships for Change’ Process
process for working with communities.
Collaboration and voluntary cooperation with the community
require the development of lasting relationships based on trust and
mutual respect - or partnerships. Narrowing the gap between
community perspectives and priorities and those of the health
services is of prime importance in public health programmes that
aim for changes at the community, household, family or individual
level.
The ten steps shown in the table on the next page form the
basis for establishing and maintaining partnerships.
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Step 1: Identifying Information Needs
‘Partnerships for Change’ Process
STEPS
Step I: Identifying Information Needs
Involving the Community in
Information Gathering
Step 3: Analysing Information
Analysing together and
Presenting Results to the
Community
Step 4: Identifying Solutions
Identifying Solutions
Together
What do both the community and the health
services know and need to know?
Finding out What the community
knows and does not know;
What the Health Services know
and do not know
Step 2: Gathering Information
Step 5: Choosing Priorities
Partnerships:
PARTNERSHIPS
Existing information and experiences are the starting point for the
process. Section 2 should help you to summarize the information
from the health services’ point of view; you should be able to
develop an “epidemiological picture” from completing the “Profile
of Malaria in Your Area.” Even with this profile an information gap
remains between the health services and the communities.
Epidemiological and other scientific data are important but
community perspectives, understanding and values are just as
Identifying Priorities
Together
relevant, especially when it is the community that has to make the
changes. More significantly, there is a wealth of information and
experience about malaria in the community. This information may
£tep 6: Developing Goals and
Objectives
Developing Joint Goals
and Objectives
Step 7: Assessing Resources
Identifying Resources of the
Community and Health Services
be based on knowledge handed down through generations.
Step?: Taking Actions
Taking Actions Together
Step Q-. Monitoring and Evaluation
Evaluating Activities Together
Both the health services and the community have information
needs. Jointly identifying the information needs of the community
Step IO: Developing an Ongoing
Commitment
Activities to be Continued;
Sustainability
and the health services also provides the means for uncovering the
common ground that exists between the two. This is the starting
point for working together to narrow the information gap. Make
plans together on what information needs to be collected and how
it will be collected. The information needs of different groups in
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the community may vary as do those of health workers. You will
need to identify which group requires what information. You also
In summary, the existing information helps you to define:
need to find out what information already exists.
The extent of the problem
Mow common it is, who is most
affected, where in the area the
problem is most severe
Gather Existing Information
Medical causes and non-medical
factors, including beliefs,
Why it happens
Find out what is already known in your area about the extent of the
problem:
practices, knowledge and
• Extent of malaria illness and impact - who is affected, how many, how
seriously, how many deaths. Are some groups or areas more affected?
perceptions in the community
• Causes of malaria illness and death
The capacity and quality of
What can be done
• High risk groups or areas:
Age groups
existing health services, and
what people can do
Ecological areas
Economic/occupation groups, work habits
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Social factors, living conditions - types of dwellings, sleeping habits
Migration
• Breeding sites of mosquitoes
• Use and quality of existing services:
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Availability of drugs and mosquito nets (and insecticides to re-treat
them) through private and public channels
Distance to health services
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Partnerships are the means for sustainability
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Step 2: Gathering Information
Partnerships:
actions. Simplifying the process of gathering information provides
the community with an opportunity to understand its own problems
better.
Involving the Community in Information Gathering
You can use both formal and informal methods for collecting
information. Involving different groups in the community in
For example the community can play an important role in
identifying mosquito breeding sites or groups in the community
collecting information begins the process of communication. Find
out what the community calls malaria and what it knows about the
causes and stages of the illness. Share with the community what
you know and what information is needed.
who are most affected by malaria. Communities are then not
You may also use simple surveys or discussion groups to gather
information together on the malaria situation such as:
Learning about the Community
a.
surprised when health workers suggest certain interventions or
focus resources on particular households.
The extent of malaria and its impact: who is affected most, how many get
For an effective communication programme you need to identify
sick, how seriously, how many deaths. Are some groups or areas affected
whom you are trying to reach and what their needs may be. In
addition, you need to know what the programme is trying to
achieve: who or what behaviour or patterns of living may be
affected.
more?
b.
The causes of malaria illness, fever, shivering, fits, and death. Beliefs
about causes and seasonality.
c.
The use of health services or other sources for treatment. What kind of
Types of information you need
treatment do they provide? What works, when and perceptions of
effectiveness.
d.
Is the situation getting better or worse compared to previous years?
Good information helps the community and you to make good
e.
Why do they think the malaria situation is getting better or worse?
decisions. The clearer your understanding of the problem - the
more focused will be the communication programme.
It is important for the community and health workers to share an
understanding of these areas of information to take appropriate
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The types of data you need fall into five categories:
Knowledge & perceptions
Types of Data
what community groups know and
think, what they do not know, and
what they want to know
Attitudes
Practices
Obstacles
what influences what they do,
what is important to them
what they do about key issues
related to malaria
What does the group know and
believe?
What causes malaria?
What don’t they know?
Can malaria cause high fever and fits?
What do they want to know?
Where can they get malaria medicines
or how can they protect their children?
What are their attitudes and
perceptions?
What do they think of sleeping under
mosquito nets? To whom do they
prefer to go for treatment?
What are their practices?
What do they use to prevent or care for
malaria? What activities increase their
risk of malaria?
Why do they do what they
do..what values do they have,
what constraints do they face,
what motivates them to act?
Why are they not able to give/take
medicines; why can women not sleep
under mosquito nets?
What are their sources of
information and how much trust
do they have in various sources?
Do they listen more to older or younger
groups? Do they believe health workers
or traditional healers more? Do they
travel to see cinema/theatre?
outside influences that prevent
them from doing something they
want to do
Sources of information
and how much trust they have in
these sources
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Examples
Although it is interesting to research all community groups and
everything about them, collecting data costs money. Therefore it is
The best methods for conducting research for a communication
programme are focus group discussions or in-depth interviews.
important that you focus your efforts on a few groups and a few
topics.
These methods are useful for gathering information on what
people think and do, and why, which is necessary for designing
appropriate and effective messages. Other publications can tell you
Who
in more detail how to use these research methods.
- Be clear about whom you are trying to reach and whom you want to take action
Advantages and disadvantages of research methods
- You may want women and children to sleep under mosquito nets but that may not
happen unless men allow them to do so, or mothers-in-law agree
METHOD
- Convincing women to take preventive measures may not be possible unless men
or decision-makers in the family or household allow them to buy necessary
Focus group
discussions
medicines or provide resources for transport to health centres
Research Methods
Using research methods effectively requires careful preparations.
These preparations include developing questionnaires or
checklists, training interviewers, making logistical arrangements,
and selecting participants.
There are four methods usually used in community research:
1. In depth interviews
2. Focus group discussions
3. Direct observation
4. Knowledge, Attitude and Practices (KAP) surveys
22
ADVANTAGES
DISADVANTAGES
• Allows knowledge,
beliefs, attitudes and
practices to be
explored freely
• Flexible - allows
topics of particular
concern to
participants to be
raised
• Can provide a sense
of how people in the
community interact
• Lengthy
preparations needed
to :
- design and pretest
checklists or
questionnaires for
each group
- train facilitators
carefully
• Participants need to
be screened and
chosen carefully
• Can be difficult
logistically to
arrange group
meetings
• Analysis of results
can be difficult and
time-consuming
(although quicker
than in-depth
interviews)
METHOD
ADVANTAGES
DISADVANTAGES
In-depth interviews
• Usually more topics
can be covered than
in group discussions
• Encourages honest,
open, detailed
answers
• Provides some
information on what
individuals say they
do
• Lengthy preparation
needed to:
- design and pretest
questionnaires for
each community
group
- train interviewers
• Participants must be
chosen carefully
• Analysing results
can be difficult and
time-consuming
Direct Observation
• Provides information
on what community
groups actually do,
rather than what they
say they do
• Useful for
supplementing data
gathered through
interviews or focus
group discussion
• Especially useful if
messages/materials
are being prepared
for use in health
facilities
• Having an observer
present often leads
people to change
their behaviour
• Very time
consuming,
especially if need to
observe rare events
METHOD
KAP surveys
ADVANTAGES
DISADVANTAGES
• Provide quantitative
information on:
- how common a
belief or practice is
- whether beliefs,
attitudes or practices
have changed
• Provide scientifically
valid (representative)
data, if done properly,
against which impact
can also be
measured
• Preparations are
time-consuming,
expensive and
difficult; technical
skills are needed
• Large numbers of
trained interviewers
are needed
• Computers and
skilled technicians
are usually required
to process the data
and analyse the
results
• Information provided
is not qualitative (i.e.
does not reveal why
people believe or do
something)
Step 3: Analysing Information
Partnerships:
Analysing Information Together and
Presenting Results to the Community
Analysis provides a fuller understanding of the problem. It gives
the community an opportunity to compare its own understanding of
the problem with new information that has been gathered. It also
gives the community the information it needs to make decisions
based on a fuller understanding of the problem. To achieve this
23
health workers have to be able to analyse information in a way that
the community can use to identify solutions.
Analysis of Results
Research results should be analysed and tabulated according to
key topics or problems that will be addressed in the communication
Topic
Community
Group
Findings
Antenatal care
attendance to
provide antimalarials to
pregnant women
Rural women with
0-3 years of
schooling who
have had at least
one pregnancy
• Women believe it is bad
luck to go for antenatal
care before the Sth or
6th month of pregnancy
• Women go for antenatal
care primarily to get
antenatal cards that will
allow them to give birth
at the health facility; they
don’t believe antenatal
care helps them directly
• Women think antenatal
care is “better” if they
receive some medication
or injection
• Women do not like going
for antenatal care
because they have to
wait a long time and
because they think the
nurses and midwives are
too impatient
Nurses and
midwives at rural
health facilities
• Health staff are
frustrated because they
believe women come too
late and then won’t
follow the advice they
are given
• The idea of risk
screening is poorly
understood and
therefore rarely used
programme. For each topic tabulate what each group knows and
does. Here is an adapted example* from a communication
programme focusing on antenatal care to encourage pregnant
women to take anti-malarial drugs during pregnancy. You can
adapt the table to the research findings on malaria from your area.
* This section is based on, "Getting the Message Out: Designing an Information
Campaign on Women’s Health,”by Ann Starrs, Family Care International Inc.; and has
been adapted for malaria control programmes
24
Topic
Community
Group
Findings
Older women
(e.g. mothers and
mothers-in-laws
of women of
reproductive age
• The benefits of attending
antenatal clinic are not
recognised
• The advantages of taking
anti-malarials are not
generally known and some
do not believe medicine
can help the health of the
woman or baby
Husbands of rural
women of
reproductive age
Also
Information
Channels
Step 4: Identifying Solutions
Partnerships:
Identifying Solutions Together
Based on shared collection and analysis of information, health
workers and the community can work together to identify solutions
that may be necessary to improve the situation. Even though all
the solutions at this stage cannot be implemented it is useful to
share ideas on the causes and solutions to community problems
from different perspectives.
• The idea that pregnant
women are at risk from
malaria or its effects is not
familiar to most men
• While men may be
somewhat concerned
about the health risks of
pregnancy, they are more
concerned about the costs
of sending women
regularly for antenatal care
You need to involve community groups important for the malaria
control programme- parents with young children, pregnant women
or working adults and other groups whose knowledge, beliefs and
attitudes may have a strong influence. These ‘influencing’ groups
could be community leaders, heads of households, religious
leaders or local politicians and government officials. Their support
may be critical to the success of your efforts.
Rural women of
reproductive age
with 3-6 years of
education
• Women are “too busy” to
listen to the radio, and
think that what they hear
does not apply to their
lives
• Advice from traditional
birth attendants and
healers is usually listened
to, because they are
sympathetic and listen to
women’s problems
Identify which groups are expected to perform what behaviours for
the success of the malaria control programme.
25
The research findings are useful because they:
•
might use them to request more funds for health programmes;
Reveal the main problems and gaps in information that the
research institutes might use them for background information when
communication programme should aim to improve.
planning a new research project.
•
Provide a record of people s response that your organisation or other
Help you to monitor and evaluate the communication programme by
groups can use in the future. Health organisations may be able to
providing an indication of what people’s knowledge, attitudes and
use the results to help plan training activities; community leaders
practices were before and after the communication programme.
SIS®
o
Only together can we decide how to control malaria
26
Objectives for the Communication programme
Step 5: Choosing Priorities
Partnerships:
Identifying Priorities Together
The communication programme objectives provide the overall
Every action required by the community or by the health services
may not be possible to begin with. Therefore, together with the
framework. They state:
community, health and other development workers, you should
identify what are the most important things to do first. Develop
criteria with the community which you can apply to all the solutions
What you plan to accomplish
Whom you want to reach
Mow much change you expect
identified in Step 4 above. The use of the same criteria will help
you and the community to select the most important solutions for
How long it will take
the malaria problem in your area.
Objectives should be measurable. If you do not have data on what
the situation is now, it may be difficult to say what you want to
achieve. For example you may want to increase knowledge among
Step 6: Identify What You can Achieve Together
Developing Goals and Objectives
Partnerships:
parents of the importance of protecting young children from
mosquitoes, but if you do not know what their knowledge currently
Developing Joint Goals and Objectives
is you cannot say by how much you can increase it.
Jointly identified priorities become the basis for deciding what can
be done. These should be mutually agreed goals and objectives
that are realistic, appropriate and achievable. A simple way
One difficulty for a communication programme in setting objectives
is that a change in people’s behaviour often cannot be achieved as a
to develop objectives is to identify what change you hope to see
by the end of your programme, and by whom. Those who are to
be involved in implementing the solutions need to be involved in
result of information alone. For example, more pregnant women
may need to take anti-malarials to protect themselves; but if the
right medicines are not available, the communication programme
the planning.
will not be able to achieve this objective. This is why the step
“Gather Existing Information” described earlier is important.
27
It will provide essential information about what services or
supplies are available or how good they are.
Step 7: Assessing Resources
Partnerships:
Identifying Community and Health Services
Resources
Sample Objectives for Communication Programme
To achieve objectives successfully both the community and health
OBJECTIVES:
services have to assess what resources would be needed and
compare these with what is available. List all the activities you
intend to carry out and the resources needed for each activity.
Within six months of the start of the programme, to:
•
Increase knowledge among women, their husbands, and their
Now identify where these resources would come from. Often only
resources that are to be bought are listed; make sure you include
all contributions, whether they are in cash or kind, to get a fuller
mothers-in-law about the importance of anti-malarials during the
pregnancy
•
Ensure at least 75% of pregnant women take anti-malarials regularly
picture of how the community, other programmes and the health
services are contributing to the overall achievement of joint goals
during pregnancy (note: assumes anti-malarials are available)
or
•
and objectives.
Ensure at least 75% of pregnant women report to health workers for
treatment if they have fever
An effective programme can require many resources. It may help
to find out what other programmes cost. Estimate your costs by
talking to others who may have conducted similar communication
programmes. Then develop a rough budget according to each
Adapt the goal and objectives above for a communication
programme for malaria control in your area.
activity you plan to conduct. At this stage you are estimating the
costs; as you plan your activities better you will also be able to
prepare a more accurate budget. Now you need to know if support
Your Objective(s)
will be available to conduct your communication programme and
what resources may be available. You may need to provide a
proposal to request funds.
28
Step 8: Taking Action
Partnerships:
Monitoring
Implementing Activities Together
Monitoring begins with your first activity and continues
Activities and changes may not necessarily occur as planned.
Based on the assessment of resources in Step 7 you identify the
activities which are possible and practical. The collaboration
throughout. It is ongoing and helps you to find out how things are
progressing in terms of:
between the community, the health services and other
development sectors requires that each of the contributors is
involved in finding out how much progress is being made towards
Overall process: whether the workplan and budget are
appropriate; if coordination among other organisations
and the community is working well; or if all workers are
fulfilling their roles and responsibilities
the objectives and what activities need to be modified. Again
collaboration in identifying the measures to be used and the
process of monitoring activities can assist the community to find
ways to improve what is being done.
The process and outcome at each stage: whether the
activities went according to the workplans; what
problems were encountered; whether new information
Step 9: Monitoring Evaluation:
How Good were the Actions?
Partnerships:
was uncovered during the research, message
development, pretesting, and distribution stages
Evaluating Activities Together
Monitoring activities can include field visits, staff reviews, and
meetings with representatives of the community. Where
necessary, changes should be made in the workplan, budget, or
To learn from your and communities’ experience and improve the
programmes you should invest in monitoring and evaluation from
the beginning of your plans. Joint assessment of the activities and
actions is critical to maintain the programme. It is important in
time line of activities.
deciding what should be done next and how. Only on the basis of
understanding of success or failure will the community be willing to
make an ongoing commitment to improving the situation.
29
Evaluation
but could get worse. This has been the experience in the past.
A formal evaluation looks at the strengths and weaknesses of
Therefore, the main purpose of this ‘Partnerships for Change’
process should be to ensure that the community and its members
different activities in a communication programme and at what
happened as a result. Evaluation examines:
have not only decided what actions are necessary for controlling
malaria in their area but also chosen the actions they will continue.
Your methods and management of resources
The success of different stages of the programme
This section has covered the ‘Partnerships for Change’ process.
Joint decision making is the key to the success of this process. As
stated earlier, good decisions require good information.
Communication plays an ongoing role at each stage of the
The impact of the communication programme
Evaluation methods include: a review of written records,
‘Partnerships for Change’ process as its success depends on
interviews with the staff, in-depth interviews with members of
community groups, group discussion, observation of community
groups, and surveys to see whether people’s knowledge, attitudes
shared information and common understanding.
and behaviour have changed because of the programme.
Step 10: Developing an Ongoing Commitment
Partnerships:
Activities to be Continued-Sustainability
Sharing information and expecting changes is not enough for
effective malaria control programmes. If the actions and
behaviours are not sustained then the problem will not only return
30
Resource 1:
U)hy it happens)
Checklist for Partnerships for Change'
• Causes of malaria illness and
death
Step 1
a.
Medical causes
Non-medical causes:
Beliefs
Practices
Identifying Information Needs
Existing Information
10hat can be done)
• Use and quality of existiny
services:
Find out ulhat is knoidn in your area about the extent of the
problem, vdho is most affected and at greatest risk:
Information
- Availability of druys throuyh
private and public channels
Findings
Extent of mataria problem and
impact:
• Moul many cases)
Partnership:
• HotO serious)
VES
Indotted community in identifying
• Moul many deaths)
information needs?
• Hiyh risk yroups or areas:
b.
- Aye yroups
- Ecotoyicat areas
- Economic/occupation yroups,
lOork habits, miyration
- Social factors, tiOiny
conditions, construction,
- Steepiny habits
Experience of Other Programmes
Find out u)hat methods, messages or materials are available and
hade been used, and hoa) successfully.
What are the problems?
Discuss vdith other organisations conducting these programmes.
Com
06331
31
>
-------P 4 MA
Experiences of previous
programmes
Experiences of previous
programmes
What factors
Wfiat methods and media
contributed to success
tOere successful?
or failure?
U/fiat materials vOere
most successful?
What problems did
they face?
U?ho utere the main
organisations and
institutions involved?
What lessons can be
learnt and hoiV to
improve?
Partnership:
Involved community in review of
previous programmes?
32
WES
b.
Step 2 Gathering Information
Types of information you need from each group
Types of data
needed
a. Who>
List the community group (s) you iCant to reach and some of
their characteristics:
IChat does the group
knout and believe?
IChat does the group
not knout?
What are the
group's attitudes and
perceptions?
U/hat are the
group's practices?
33
Community Group
Research method (s)
to be used
Types of data needed
Community Group
continued..
Step 3 Analysing Information
Research method (s)
to be used
For each topic and each community group tabulate What each
group knows, does and other details. }/ou can then link this With
What mag be best means of reaching them.
What Values do they
have? What
constraints do they
Topic
face?
Communitg
Group
Findings
What motivates the
group?
What are the sources
of information the
group trusts?
Others
Partnership:
Involved community in gathering
j/ES
Partnership:
Involved community in analysing
information and discussed the purpose of
information)
information andpresented results
to community members and leaders)
34
i/ES
Step 5 Choosing Priorities
Step 6 Identifying Solutions
Main Research Findings
Possible Solutions
Possible Solutions
Priorities
Involved community in identifying
Partnership:
Involved community in identifying
solutions together)
solutions together)
Partnership:
i!ES
35
PES
Step 6 beUetoping Goals and Objectives
Step 7 Assessing Resources
GOAL:
Activities
Resources
Source
required
Where uJitt resources
come from}
OBJECTIVES:
Partnership:
i/ES
Partnership:
DeVetopedjoint goats and objectives
Identified community resources and
cVith the community}
health services resources}
36
jlES
Step 9 Monitoring and Evaluation:
HoW Good Were the Actions?
Step 8 Taking Actions
Activities
Who is inOotCed?
When iVitt activities
be done)
a.
Monitoring
Activities
Partnership:
Involved community in implementation
of activities?
VES
37
Problems encountered?
NeuJ information
By tfhen
should be
By utfien
actually
Action to be taken?
completed?
completed ?
b.
Evaluation
Objectives
Step 10 Developing Commitment
IChen
Partnership:
Effective or Successful
Activities
Level of
Achievement
Level of Community
Commitment
Partnership:
1/ES
Involved community in monitoring
Discussed cVhat activities the community is
and eValuation)
iVi/tiny to support and sustain)
38
i/ES
SECTION 2
particularly during their first pregnancy, malaria being an
important cause of low birth weight and high neonatal mortality. It
Understanding Malaria
content of ‘Partnerships for Change’: the first is to define the local
also causes anaemia in children and in pregnant women and
increases their vulnerability to other diseases. Some of the most
severe malaria epidemics In recent years have taken place in
highland and desert fringe areas of Africa.
malaria problem to improve your own understanding; the second is
to help the communities to understand malaria and how to protect
themselves from it.
Despite continuous efforts to keep malaria under control, the
situation in the Americas and Asia (except China) is either the
2.1 Defining the Malaria Problem
same or worsening. The total number of cases recorded in malaria
endemic countries outside Africa is approximately 5 million per
In this section we shall build two important areas to provide the
year, of which 30% are found in Asia. However, the real number
Global Malaria Situation'
may be five times higher. In these areas, malaria is often
occupation-related. While all population groups may be equally
affected, as in Africa young children and pregnant women suffer
most from the disease.
Globally, the malaria situation is serious and getting worse. Each
year between 300 and 500 million people in the world fall ill with
malaria, and 1.5 to 2.7 million die from this disease. Over 30^ of
these cases and deaths occur in Africa, south of the Sahara, where
High mortality and complications due to malaria are to a large
degree related to late diagnosis and inadequate or inappropriate
treatment. The provision of prompt treatment is being made
malaria accounts for about 10% of hospital admissions and 30 % of
outpatient consultations.
difficult in many areas by the spread of drug-resistant Plasmodium
falciparum. Multi-drug resistant P.falciparum malaria is now
Young children suffer the most in sub-saharan Africa. It is
estimated that 140 to 2?0 million clinical cases and I million
common in areas of South-east Asia and the Americas and the
deaths occur annually in children less than 5 years old. Pregnant
problem is compounded by uncontrolled use of anti-malarial drugs.
women are also at risk of malaria and its complications,
1 Extracts from “A Global Strategy for Malaria Control", WHO, 1993
39
How serious is the situation in your area?
Is the situation getting better or worse?
Malaria disproportionately affects those living in conditions of
poverty, and is a serious problem in the frontier areas of economic
development and in countries affected by social disruption. In
these areas, environmental disturbances, movements of under
privileged populations and the absence of health care
The extent, causes and interventions may vary not only between
countries, but also within countries, regions or districts. It is
therefore important that what is known globally or nationally is
infrastructure have been responsible for malaria problems, even in
areas where the disease was under some measure of control.
adapted to design effective and appropriate measures locally. The
problems of malaria and solutions to malaria control are local in
The worsening malaria problems in the world led the World Health
nature. This process of local adaptation has to be encouraged at
Organization to convene a Ministerial Conference on Malaria in
Amsterdam, the Netherlands, in October 1^2, which endorsed a
each level of the public health system. At the same time local
information can be useful for redefining the national strategy and
Global Malaria Control Strategy. This strategy calls for prevention
of mortality and reduction of morbidity and economic loss through
strengthening local capabilities for provision of early diagnosis and
activities.
prompt treatment, implementation of selective and sustainable
preventive measures including vector control, and control of
to define the situation, strategies and activities for your province
or region. This exercise could be continued at sub-provincial,
epidemics; all supported by local research and epidemiological
assessment. It stresses the importance of collaboration between
the health sector, relevant development programmes in non-health
district and sub-district levels where appropriate.
sectors and communities. It clearly states that:
countries. On the contrary, each country’s circumstances will
interpretation of information and data to define the local situation.
An important feature is to identify the major gaps in the
information you have about your area. In some areas local
influence the organisation of practicable programmes to identify
information is available and can be put to use; in other areas, this
local problems and priorities and to design and implement
information needs to be collected.
The worksheets and tables provided in this section should help you
The purpose of this section is to encourage the understanding and
“no single prescription can be made for the control of malaria in all
appropriate interventions. The key is in competent local action.”
40
Developing a Profile for Your Area
Good information and understanding of the local problem can lead
to development of appropriate and effective strategies. Your clear
Resource 2 in this Section has been provided to assist you in the
understanding of the problem and sharing this with the community
will help in plannning and implementing better health promotion
process of collecting and collating information on your area. When
you have filled in the worksheets on the next pages, you will be able
activities and appropriate community actions to control malaria in
your area.
to fill in parts of this profile, and see what else you need to find out.
Mosquito hets, especially if impregnated with insecticide, protect you from mosquitoes and malaria
41
From the Global to the Local Malaria Situation
Worksheet 2.1 on page 43 lists ten factors of relevance to
describing the malaria situation. It also provides a country
example that could guide you in outlining the situation in your own
country. You should also try and assess whether the malaria
situation has changed over the past two years - is it improving or
getting worse? Consider also whether or not drug resistance is a
problem. At this stage it is not important that you have all the
answers but recognise the important gaps in your information.
Describing the Malaria Situation in a Country
1. Characteristics of malaria (epidemiological)
2. Number of people at risk
3. Type of people at greatest risk
4. Vectors (Anopheline)
5. PlasModiuM species
6. Annual OPD attendance due to malaria
7. Percentage of all OPD attendance due to malaria
Number of deaths due to malaria
fl ■' 5j
Q. Potential for epidemics
5
lO.Types of environment and malaria transmission
42
WORKSHEET 2.1
Understanding the Malaria Situation in YOUR Country
FACTORS FOR DEFINING
THE MALARIA SITUATION
COUNTRY SITUATION
An Example: GHANA*
IN YOUR COUNTRY
Hyperendemic, stable, perennial, peak after start
1. Characteristics of malaria
of major rainy season (July-August)
(epidemiological)
2. Population at risk
15,500,000
3. Type of people at risk
Young children, pregnant women
4. Vectors (Anopheles)
gambiae, melas, funestus, arabiensis
5. Plasmodium species
falciparum, malariae, ovale
6. Annual OPD attendance due
2,342,438
to malaria
7. Percentage of all OPD attendance 40.31%
due to malaria
8. Number of deaths due to malaria
Data not available
9. Potential for epidemics
Yes, in the northern savannah and forest fringe
areas
SAVANNAH: Intense perennial transmission
lO.Types of environment and
malaria transmission
but somewhat reduced during the dry season
(November-March) in the north savannah.
Southern savannah same as coastal eco-zone
FOREST (Agriculture, highland and forest
fringe): Stable, hyperendemic with intense
perennial transmission with a peak shortly after
the major rainy season
COASTAL (Lagoons and mangrove swamps):
High endemicity, stable with intense perennial
transmission, but markedly reduced during dry
season (November -March)
URBAN (and peri-urban): Transmission is not
intense but with some seasonal fluctuations
DEVELOPMENT (Gold and diamond mining
and water resource development): Transmission
in these areas is intense and perennial with
seasonal peaks
* The Health Sector in Ghana, Facts and Figures, Ministry of Health, Ghana, December 1994
43
Worksheet 2.2 uses the same ten factors but now we are looking
at a smaller area. An example of a regional situation is provided to
10. Types of environment and
malaria transmission
assist you in completing this worksheet. Again it is important that
you develop an understanding of the malaria situation in your
province or region and identify the important gaps in your
information.
URBAN (and peri-urban):
Transmission is not intense but with
some seasonal fluctuations
Describing the Local Malaria Situation
FACTORS FOR DEFINING THE
MALARIA SITUATION
DEVELOPMENT (Gold and
diamond mining and water resource
development): Transmission in these
areas is intense and perennial with
seasonal peaks
DEFINING THE SITUATION
IN THE REGION
An Example: Eastern Region in
Ghana*
1. Characteristics of malaria
(epidemiological)
Hyperendemic, stable, perennial,
peak after start of major rainy season
(July - August)
2. Number of people at risk
2,300,000
3. Type of people at greatest risk
Young children, pregnant women
4. Vectors (Anopheles)
gambiae, melas, funestus, arabiensis
5. Plasmodium species
falciparum, malariae
6. Annual OPD attendance due to
malaria_____________________
7. Percentage of all OPD attendance
due to malaria_______________
8. Number of deaths due to
malaria_____________________
9. Potential for epidemics
393,000
FOREST (Agriculture, highland and
forest fringe): Stable, hyperendemic
with intense perennial transmission
with a peak shortly after the major
rainy season
38.41%
Data not available
No
44
WORKSHEET 2.2
Understanding the Malaria Situation in YOUR Area
FACTORS FOR DEFINING
THE MALARIA SITUATION
COUNTRY SITUATION
An Example: GHANA
DEFINING THE SITUATION
IN THE REGION
An Example: Eastern Region in Ghana*
1. Characteristics of malaria
Hyperendemic, stable, perennial, peak after start
(epidemiological)________
of major rainy season (July - August)________
2. Population at risk________
15,500,000
Young children, pregnant women
3. Type of people at risk
4. Vectors (Anopheles)
gambiae, melas, funestus, arabiensis
5. Plasmodium species______
falciparum, malariae, ovale________________
6. Annual OPD attendance due
2,342,438
to malaria______________
7. Percentage of all OPD
40.31%
attendance due to malaria
8. Number of deaths due
Data not available
to malaria______________
9. Potential for epidemics
In the northern savannah and forest fringe areas
10. Types of environment and
SAVANNAH: Intense perennial transmission
malaria transmission
but somewhat reduced during the dry season
(November-March) in the north savannah.
Southern savannah same as coastal eco-zone
FOREST (Agriculture, highland and forest
fringe): Stable, hyperendemic with intense
perennial transmission with a peak shortly after
the major rainy season
COASTAL (Lagoons and mangrove swamps):
High endemicity, stable with intense perennial
transmission, but markedly reduced during dry
season (November -March)
URBAN (and peri-urban): Transmission is not
intense but with some seasonal fluctuations
DEVELOPMENT (Gold and diamond mining
and water resource development): Transmission
in these areas is intense, perennial and seasonal
peaks
• Annual Report 1993, Regional Health Administration, Eastern Region, Ministry of Health, 1994
45
Hyperendemic, stable, perennial, peak after start
of major rainy season (July - August)_________
2,300,000
Young children, pregnant women
gambiae, melas, funestus, arabiensis_________
falciparum, malariae_____________________
393,000
38.41%
Data not available
No___________________________________
FOREST (Agriculture, highland and forest
fringe): Stable, hyperendemic with intense
perennial transmission with a peak shortly after
the major rainy season
URBAN (and peri-urban): Transmission is not
intense but with some seasonal fluctuations
DEVELOPMENT (Gold and diamond mining
and water resource development): Transmission
in these areas is intense and perennial with very
seasonal peaks
WHAT IS THE SITUATION
IN YOUR AREA?
Defining the Malaria Control Activities
As a basis for identifying who can play a part in ‘Partnerships for
Change’ and health promotion, use Worksheet 2.3 to describe
what malaria control activities take place at different levels of the
i
zFOf
health services (both public and private). Table 2.3 provides an
example of a completed worksheet. Adapt this table to your
situation to help you complete Worksheet 2.3.
Ml ■
zo
■■■
I
im \
I
■Z \ \ \ 11
Z
M
Ik
nfw
'Sv
/
MS
Together with health workers, the whole community can help dip mosquito
nets in a special insecticide solution to kill mosquitoes and other insects
46
I? -
Table 2.3
Malaria Control Activities in Different Parts of the Health System
AN EXAMPLE
POLICY
STRATEGY
SETTING
DEVELOPMENT
PLANNING
TRAINING/
MICROSCOPIC
CLINICAL
SUPERVISION
DIAGNOSIS
DIAGNOSIS
TREATMENT
VECTOR
PERSONAL
HEALTH
CONTROL
PROTECTION
PROMOTION
COORDINATION
INVOLVE
OTHER SECTORS PRIVATE SECTOR
LEVELS
NATIONAL
REGIONAL OR
PROVINCIAL
EVALUATION &
MONITORING
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
DISTRICT
SUB
DISTRICT
COMMUNITY
OR VILLAGE
RESEARCH
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
?Yes
HOUSEHOLD
?Yes
?Yes
Yes
Yes
Yes
FAMILY
?Yes
?Yes
Yes
Yes
Yes
INDIVIDUAL
?Yes
?Yes
Yes
Yes
Yes
47
Worksheet 2.3
Malaria Control Activities in Different Parts of the Health System
POLICY
STRATEGY
SETTING
DEVELOPMENT
PLANNING
TRAINING/
MICROSCOPIC
CLINICAL
SUPERVISION
DIAGNOSIS
DIAGNOSIS
TREATMENT
VECTOR
PERSONAL
HEALTH
CONTROL
PROTECTION
PROMOTION
COORDINATION
INVOLVE
OTHER SECTORS PRIVATE SECTOR
RESEARCH
EVALUATION &
MONITORING
LEVELS
NATIONAL
REGIONAL OR
PROVINCIAL
DISTRICT
SUB
DISTRICT
COMMUNITY
OR VILLAGE
HOUSEHOLD
FAMILY
INDIVIDUAL
48
Table 2.4a: Treatment of Plasmodium vivax, P. malariae,
Treatment of Malaria in Your Area
P. ovale and chloroquine-sensitive P. falciparum
Tables 2.4 a, b & c show the usual treatment regimens for
uncomplicated malaria according to the species and to the degree
(i) Chloroquine dosage -150 mg base tablets
of drug resistance of Rfalciparum. Most countries have developed
Note dosage by base, not salt
national treatment protocols, which should be followed and used
Weight
Day 1
Day 2
Day 3
Total
(kg)
10 mg/kg
10 mg/kg
5 mg/kg
25 mg/kg
<6 months
<7
1/
6-11 mos.
7-9
1
1 -3 years
10-14
4-6 years
7-8 years
Age
when sharing with the community, private practitioners and
shopkeepers. If you do not know the national protocol, contact
your Ministry of Health for a copy, and use it to complete
Worksheet 2.4.
Treatment of severe or complicated malaria requires specially
trained and qualified staff, so detailed drug schedules are not
given here.
49
1/4
1%
14
%
2
1
1
%
2%
15-19
1%
1%
%
3%
20-30
2
2
1
5
9-15 years 31-45
3
3
11/
71/
>15 years
4
4
2
10
>45
Table 2.4b: Treatment of Chloroquine-resistant
(ii) Chloroquine dosage -100 mg base tablets
P. falciparum
/Vote dosage by base, not salt
Age
Weight
(kg)
Day 1
10 mg/kg
Day 2
10 mg/kg
Day 3
5 mg/kg
(i) Sulfadoxine-pyrimethamine dosage - 500+25 mg tablets
(30+1.5mg/kg single dose)
Total
25 mg/kg
<6 months <7
3/4
6-11 mos. 7-9
1
1
1/
21/4
1 -3 years
10-14
11^
V/i
/i
31/
4-6 years
15-19
2
2
1
5
7-8 years
20-30
3
3
V/
7%
9-15 years 31-45
4!4
41/
2%
111/4
>15 years >45
6
6
3
15
Age
Weight (kg)
1%
Note: Some countries add primaquine for radical cure of P.vivaxor
gametocytocidal effect on P. falciparum; others do not
50
Sulfadoxine-pyrimethamine tablets
(single dose) 500/25mg tablets
< 2 months
0
2-12 months <10
/
1
1 -4 years
10-19
1
5-8 years
20-30
V/
9-15 years
31-45
2
>15 years
>45
3
(ii) Mefloquine treatment dosage - 250 tablets
Treatment of chloroquine and sulfadoxine-
Table 2.4c:
pyrimethamine resistant P. falciparum
Mefloquine has been introduced in a few countries. Dosage varies
from 15 to 25 mg/kg depending on the level of mefloquine resistance.
Find out your national recommended dosage before use.
(i) Quinine and Tetracycline dosage
(Quinine 300 mg tablets - 30 mg/kg/day
Tetracycline 250 mg tablets - 25 mg/kg/day)
These treatment schedules may not be easy for non-medical
persons or people in the community to understand. The following
Age
Tetracycline tablets
Quinine tablets
Weight
dose/
8 hrs
dose/
days
Total
7 day
31%
1%
4%
31%
42
2
6
42
(kg)
dose/
8 hrs
dose/
days
Total
7 day
< 6 months
<7
%
%
5/4
6-24 mos
7-15
%
1%
10%
2-8 years
16-30
1
3
21
9-15 years 31-45
1%
4%
>15 years
2
6
>45
schedule is an example of how to simplify the treatment schedule
so it is easy for people to understand. Make a similar schedule for
people in your area.
Note: Depending on levels of resistance some countries only give 3 days of quinine.
Check national protocol. No tetracycline for pregnant women.
51
COm H
06331
> *
An example from one country
Chloroquine treatment for chlorquine sensitive malaria*
Chloroquine tablets - 100mg base
DAY
TABLETS
100 mg
base
number
of tablets
AGE (years)
number
of tablets
1 -3
1
11/2
1
over
3
4-6
7-11
11
2
3 1/2
6
x
x Z—Z—
OCJ ooOo
11/2
2
1/2
TABLETS
DAY
2
1/2
base
number
of tablets
3 1/2
number
of tablets
oooo
1
11/2
J
DC
AGE (years)
less
than
1
1 -3
4-6
7 -11
over
11
1/2
1
11/2
2 1/2
4
JJ JJ
J J
1
1/2
1
1 1/2
2 1/2
3
SYRUP
50 mg
base /5ml
amount
of syrup
1
1/2
1/2
1/2
1
J
3
The regimen of amodiaquine treatment is the same as that of chloroquine (150mg base),
provided the tablet contains 150mg of amodiaquine base.
5 ml
5 ml
TOTAL = 7.5 ml
TOTAL= 15 ml
5 ml
5 ml
2.5 ml
5 ml
5 ml
amount
of syrup
2
5 ml
1 -3
5 ml
amount
of syrup
TOTAL = 7.5 ml
TOTAL= 15 ml
5 ml
5 ml
TOTAL = 5 ml
TOTAL= 5 ml
3
One full teaspoon contains 5ml.
*From “The Treatment of Malaria: information for non-pharmacists selling anti-malarial drugs" WHO, Geneva, 1994
52
less than
2.5 ml
2
number
of tablets
AGE (in years)
1
4
2
OQ
number
of tablets
Chloroquine syrup - 50mg base/5ml syrup
150 mg
less
than
1
1
DAY
Chloroquine tablets - 150mg base
have mixed behaviour. In addition, logistic and economic factors
are very important in determining vector control strategy. Find out
Biological Features of Some Vectors and Control
Measures
about your national policy on this.
Table 2.5 shows the biological features of some vectors in Asia
and Africa, which are relevant to their control. Use Worksheet 2.5
People’s Knowledge, Beliefs, and Practices Related to
Malaria in Your Area
to describe the vectors in your area. With this information, look at
the control measures listed in Worksheet 2.6, and note which
control measures may be effective against your local vectors. Note
that this worksheet is for guidance only, as many mosquito species
Worksheet 2.7 lists the type of information you need on people’s
understanding to develop a true ‘Partnership for Change’.
Screening the house helps to protect the whole family from malaria and other diseases
53
TABLE 2.5
Significant Biological Features of the Major and Some Secondary Malaria Vectors of Cambodia, Laos, Myanmar, Thailand and Vietnam*
Anopheles
Species
Resting Location
1. dirus
complex (7
sibling species;
described as A.
balabacensis in
earlier literature
2. minimus (at
least 2 sibling
spp)_________
3. maculatus )
complex
(8spp.
4. sundaicus (2
spp. suspected)
Mainly out
Feeding time/
location
Mainly Late (or
Host preferences
Breeding Sites
Insecticide
susceptibility
Mainly man
Small shady pools mainly
in forest and plantations,
footprints, stream
seepages, wheel ruts, gem
pits, hollow logs,
sometimes wells
Streams in forested
foothills
Susceptible to
DDT and others
20-02.00 hrs,
out and in
Mainly out
(previously in)
Mainly out
Out and in
All night,
mainly out
(previously in)
Peak 19-20.00
or 21-24.00,
mainly out
All night, peak
20-24.00 h, out
and in
Man and cows
Mainly non
human
Sunlit streams.
Sometimes ponds, tanks,
riverbed pools
Brackish or salt water near
coast. Rockpools, river
mouths
Man and
domestic
animals
Health Promotion Notes
Susceptible to
DDT
Susceptible to
DDT and others
DDT resistance
in Indonesia and
Vietnam
Significant Biological Features of the Major African Malaria Vectors0
Anopheles
Species
Resting Location
Feeding time/
location
Host preferences
Breeding Sites
Insecticide
susceptibility
1. gambiae
Mainly in
Mainly human
In and out
3. melas
Out and in
4. merus
Out and in
5. Junestus
Indoors
Sunlight temporary pools,
rice fields______________
Temporary pools, rice
fields
Salt water lagoons,
mangrove swamps
Salt water lagoons,
mangrove swamps
Semi-permanent and
permanent water especially
with vegetation, swamps,
slow streams, ditch edges
Some resistance
reports
2. arabiensis
Mainly late,
indoors______
Mainly late, in
and out
Mainly late, in
and out
Mainly late, in
and out
Mainly late, in
Human and
animals
Animals and
human
Mainly animals
Mainly human
Health Promotion Notes
* Meek, S.R., Vector Control in some Countries of Southeast Asia: Comparing the Vectors and the Strategies, Ann. Trop. Med. Parasit. (1995) 89 135-147
° Developed by S.R. Meek and J. Lines
54
Worksheet 2.5
Biological Features of Malaria Vectors in your Area3
IN YOUR AREA?
Anopheles
Species
Resting Location
Feeding time/
location
Host preferences
Breeding Sites
aDeveloped by S.R. Meek
55
Insecticide
susceptibility
Health Promotion Notes
WORKSHEET 2.6
Vector Control Measures and the Types of Mosquito which would be most readily controlled by them^
Feeding
Location
Feeding
Time
Resting
Location
Vectors showing optimum features^
Breeding Site
Optimum Biological Features
Control Measure
Host
Preferences
Africa
S.E. Asia
Residual indoor house spraying
In
Late
In
Human
0
Ultra low volume outdoor
spraying*
Out
Early
0
0
0
Insecticide treated mosquito nets
In
Late
In
Human
Removal of breeding sites
0
0
0
0
Larva control by chemicals
0
0
0
0
0_____
Accessible, not
numerous
Accessible, not
numerous, still
water
Mosquito repellents
0
0
0
0
0
Mosquito coils
In
Early
In
0
0
House screening
In
0
In
Human
0
Clothing for protection
0
0
0
0
Public information
0
0
0
0
sundaicus______
maculatus,
minimus,
sundaicus______
Indoor feeding
part of all species
some maculatus,
sundaicus______
sundaicus
gambiae complex,
funestus
0
gambiae complex,
funestus_______
funestus, some
gambiae complex
0
All_________
Part of
population: all
species______
Part of
population: all
species
All_________
Part of
population: all
species
0
All
All
0
All
All
All
0 = not important or relevant
* only for epidemics (and usually in town or camps); too expensive to consider in most rural areas
§ Even where the biological features suggest a control measure could be effective, there may be economic and logistical reasons not to attempt it
^Developed by S.R. Meek
56
IN
YOUR AREA?
Worksheet 2.7
People’s Knowledge, Beliefs, and Practices related to Malaria in
10. Now much does treatment cost?
your Area*
II. What do you think of the quality of
Source
treatment from different sources?
Quality
Question
I.
Community Response
12. What do you do to prevent malaria?
Is there a local name for malaria?
13. What makes the prevention difficult?
2. What are the symptoms of malaria?
14. Mow much do you pay for prevention?
3. What is the cause of malaria?
15. Do you have any mosquito nets?
4. Where do you get information on
16. Mow much do mosquito nets cost?
malaria?
17. If you do not have any mosquito nets,
5. Where do you go first for treatment of
would you buy one?
fever?
1?. Mow much would you pay for a mosquito
6. Where do you go first for treatment
net?
of malaria?
W. Do you have any ideas to improve
7. If the first treatment does not work.
malaria control?
where do you go next?
20.Does your community have any
committees or regular meetings?
If yes, what are they?
8. Mow do you travel for the first and
second line of treatment?
Q. Mow much does transport cost?
* If your area includes different socio-economic groups, you may need to complete a
separate worksheet for each group e.g. urban and rural, ethnic minorities, immigrant
labour. If you do not have this information you may need to do a study to find out.
57
Global to Local Strategy
Table 2.? provides characteristics of major malaria types and
control strategies appropriate for each type. Assess the relevance
of this global information to the needs and environment in your
area. If you do not have it already, ask your Ministry for your
national malaria control strategy. Based on the national strategy,
adapt and modify the information in Table 2.? to your conditions
and start to define your local strategy in Worksheet 2.?.
A Country Example - Uganda may help you in outlining your
strategy.
58
Table 2.8
Characteristics of Malaria and Possible Actions Required *
EPIDEMIOLOGICAL
TYPES
Savannah or
grassland (Africa
south of Sahara,
Papua New Guinea)
Plains and valleys
outside Africa (Central
America, China, Indian
subcontinent)
Highland and desert
fringe (African and
south-east Asian
highlands, Sahel,
southern Africa, south
west Pacific)
CHARACTERISTICS OF
MALARIA
MANAGEMENT NEEDS
DISEASE MANAGEMENT
ACTIVITIES REQUIRED
PREVENTION AND
CONTROL ACTIVITIES
• Generally present
throughout the year
• Seasonal increase
• Drug resistance, mainly
P. falciparum
• Mainly affects children and
pregnant women
• Increased coverage by
health services
• An appropriate national
malaria control programme
• Increase coverage by health
services through
collaboration between
formal and informal sectors
to treat malaria
• Training of HWs in
treatment
• Assess drug resistance
• Health Promotion
• Mosquito nets (insecticide
treated, if possible)
• Other types of personal
protection
• Chemoprophylaxis for
pregnant women
• Elimination of mosquito
breeding sites
• Moderate transmission and
varies during the year
• Often mainly P. vivax
• Strong seasonal variations
• Risk of epidemics
• Drug resistance well
established
• Effectiveness of large-scale
insecticide spraying
programmes needs review
• Increase reach and quality of
public and private services
• Epidemiological and
entomological surveillance
• Disease management by
general health services
including private providers
• Proper and complete
treatment
• Health Promotion
• Mosquito nets (insecticide
treated, if possible)
• Other types of personal
protection
• Elimination of mosquito
breeding sites
• Spraying of houses may be
considered
• High risk of epidemics
• Major seasonal variation
• Influenced by agricultural
practices
• Migration may lead to
outbreaks
• Preparedness for
management of malaria
cases may be poor and
needs to be improved in
malaria-free but epidemic
prone areas
• Special operational
strategies for remote
communities are needed
• Management system for
early assessment of
epidemics
• Epidemiological and
entomological surveillance
• Rapid response to outbreaks
• Treatment of fevers
• Awareness and preparedness
of health services for
dealing with outbreaks
• Health Promotion
• Spraying of houses may be
considered
• Localised spraying in time
with insecticide during
epidemic or outbreak
• Mosquito nets (insecticide
treated, if possible)
* Adapted from “Global Strategy for Malaria Control”, WHO, 1993 and further developed by I.S. Narula, S. Mehra, S.R. Meek and J. Lines
59
EPIDEMIOLOGICAL
TYPES
Agricultural, irrigation
or industrial projects
(Africa, Asia,
South America)
Urban and peri-urban
(Africa, South
America, south Asia)
Forest and forest
fringe (South-east
Asia, South America)
Refugee malaria
CHARACTERISTICS OF
MALARIA
MANAGEMENT NEEDS
DISEASE MANAGEMENT
ACTIVITIES REQUIRED
PREVENTION AND
CONTROL ACTIVITIES
• Increase in transmission
because of water bodies
• Seasonal outbreaks due to
immigration
• Beware of insecticide resistance
in cotton-growing areas
• Preparedness for possible
epidemics because of nonimmune labour populations
• Involve projects’ management
and facilities
• Early detection and prompt
treatment
• Increase malaria awareness
by training health workers
and community
• Environmental management
at planning stage
• Health promotion
• Mosquito nets (insecticide
treated, if possible)
• Other personal protection
• Insecticide spraying or
chemoprophylaxis if needed
• Elimination of mosquito
breeding sites
• Transmission highly variable
• Immunity of the population
variable
• Specially adapted vectors
responsible for epidemics in S.
Asia
• Better targeting of larva control
and better urban development
plans
• High preparedness for epidemics
• Regulation but no restriction on
commercial outlets
• Need for prompt and full
treatment
• Develop standard treatment
regimen and promote
among public/private
providers and community
• Health promotion
• Mosquito nets (insecticide
treated, if possible)
• Other personal protection
• Control breeding sites by
larviciding or environmental
planning and manaagement
• Spraying of houses in
selected areas
• Focal intense transmission
• Many risk groups, often
occupational
• Drug resistance very high
• Assess benefits, if any, of house
spraying and larval control
• Regulation but no restriction of
commercial outlets
• Special needs because of ethnic
and geographical isolation
• Occasional entomological surveys
• Standardise treatment
practices
• Prompt and full treatment
• Health promotion to improve
community involvement
• Mosquito nets (insecticide
treated, if possible)
• Other personal protection
• Consider siting of dwellings
• Movement of non-immune
populations into malaria zones
• Increased contact with
mosquitoes
• Environmental degradation
leading to increase in
mosquitoes
• Epidemics
• Curative services need to be
established
• Environmental control methods
should be implemented
• Early detection and full
treatment
• Standard treatment protocol
disseminated
• Health promotion
• Mosquito nets (insecticide
treated, if possible)
• House and space spraying
where possible and
appropriate
• Environmental measures
to reduce breeding sites
60
Characteristics of Malaria and Possible Actions Required *
A COUNTRY EXAMPLE - UGANDA*
CHARACTERISTICS OF
MALARIA
MANAGEMENT NEEDS
DISEASE MANAGEMENT
ACTIVITIES REQUIRED
PREVENTION AND
CONTROL ACTIVITIES
Stratum 1
• Stable perennial transmission
Rural areas:
• Incidence and prevalence of
a. Population engaged in
malaria high
traditional agriculture and • Morbidity and mortality
settled
concentrated in infants &
b. Nomadic pastoralists
preschool age children
• Adults relatively clinically
immune
• Improve logistics for provision
of supplies and equipment
• Introduce laboratory services
especially in peripheral areas
• Improve referral systems
• Provide early diagnosis and
management of malaria
• Provide appropriate anti
malaria drugs to all suspected
and diagnosed cases
• Encourage use of appropriate
doses by establishing definite
treatment regimens
• Increase public awareness
of malaria, importance of
early and complete
treatment
• Promote self-protection
measures e.g. mosquito nets
• Mobilise community for
mosquito source reduction
• Establish simple early warning
signs for epidemic
• Preparedness for rapid
mobilisation of resources
• Improve surveillance of
morbidity and mortality using
district monthly reports
• Improve logistics for provision
of supplies and equipment
• Introduce laboratory services
especially in peripheral areas
• Improve referral systems
• Provide early diagnosis and
management of acute malaria
• Provide appropriate anti
malaria drugs to all suspected
and diagnosed cases
• Encourage use of appropriate
doses by establishing definite
treatment regimens
• Increase public awareness
of malaria, importance of
early and complete
treatment
• Promote self-protection
measures e.g. mosquito nets
• Mobilise community for
mosquito source reduction
• Conduct surveys to assess
morbidity among workers and
school children
• Improve logistics for provision
of supplies and equipment
• Improve laboratory services
• Improve referral systems
• Improve availability of drugs
at work place and schools
• Strengthen hospitals to
manage complicated and
severe malaria
• Provide early diagnosis and
management of acute malaria
• Provide appropriate anti
malaria drugs to all suspected
and diagnosed cases
• Encourage use of appropriate
doses by establishing definite
treatment regimens
• Increase public awareness
of malaria, importance of
early and complete
treatment
• Promote self-protection
measures e.g. mosquito nets
• Mobilise community for
mosquito source reduction
EPIDEMIOLOGICAL
TYPES
Stratum 2
High altitude areas with
traditional agricultural
systems
• Unstable transmission
• Possibility of epidemics
Stratum 3
• Lower prevalence of malaria
Urban and sub-urban
areas with well developed
infrastructure; factories,
small scale enterprises
★Based on information from “Uganda National Plan of Action for Malaria Control, 1993-1996, Communicable Diseases Control Division, Ministry of Health
61
WORKSHEET 2.8
Characteristics of Malaria and Possible Actions Required
IN YOUR AREA? *
EPIDEMIOLOGICAL
TYPES
CHARACTERISTICS OF
MALARIA
MANAGEMENT NEEDS
DISEASE MANAGEMENT
ACTIVITIES REQUIRED
★Developed by I.S. Narula, S. Mebra, S.R. Meek and J. Lines
62
PREVENTION AND
CONTROL ACTIVITIES
The previous tables and worksheets help you to define the malaria
situation and what actions and activities may be appropriate for
your area. Complete the “Profile for Malaria in Your Area” that is
provided at the end of this section as Resource 2 with the
information you collect on all the worksheets. This information
when completed will provide the basis for developing a programme
that is appropriate and relevant for your area.
The information in the “Profile” will also help you in establishing
partnerships with the community for appropriate malaria control
strategy and activities in your area.
63
i
f
RESOURCE 2
Developing a Malaria Profile for Your Area
(Obtain or draw a map of your area to use with this Profile)
INFORMATION
Why it is important
Characteristics
How it may
be used
INFORMATION FROM YOUR AREA
I. Host
1. Population size
2. Distribution
3. Occupations
4. Mobility
5. Types of dwellings
and location in
relation to breeding
sites
6. Income levels
Indicates the total number
of people at risk
Indicates accessibility of people,
urban and rural environment
To plan amount of drugs needed
and to plan health facilities
To determine the type of
surveillance and malaria control
activities required
Indicates risk of acquiring malaria To find out who needs to know
e.g. farming, fishing, hunting,
more about malaria and control
wood cutting, wood gathering,
activities required
cattle herders, salespersons etc.
Increases possibility of epidemics To plan control activities. To
with movement of cattle herders, allocate resources where they are
travel from urban to rural areas,
most needed
labour movement with
development projects, dams,
refugees etc.
Open dwellings are difficult to
Helps to determine appropriate
spray. Different ones need
vector control measures
different net designs. Proximity
of breeding sites increases risk
Ability to buy health care,
To design cost-effective but
protection measures, quality of
equitable systems of health care
dwellings
supply (e.g. treatment, nets)
64
INFORMATION
Why it is important
Characteristics
7. Night time
behaviour
8. Treatment seeking
behaviour
9. Environmental
maintenance
10. Personal protection
activities
11. Community
protection activities
INFORMATION FROM YOUR AREA
How it may
be used
To protect children by suggesting
when they should be indoors and
using a net
To identify barriers to obtaining
early diagnosis and treatment. To
determine information needs of
the community and of health care
providers
To determine information needs
Poor maintenance of canals and
water pumps or poor drainage can of the community, water
authorities and municipalities
create breeding sites for
Anopheles
Reduces mosquito-human contact To determine materials
and information required
(number of bites) so reduces
transmission_________________
To support community efforts to
Indicates community’s concern
arrange accessible health care,
about malaria
finance nets and insecticide,
reduce breeding sites
If people are outdoors during the
mosquito biting time, their risk
of infection is higher
Influences access to early
and effective diagnosis and
treatment
II. Disease
12. Endemicity
13. Morbidity (number
of cases of disease
per year)________
14. Mortality (number
of deaths from the
illness per year)
Determines the type of control
activities needed
Helps determine the scope of the
problem and impact on the
community_________________
Helps determine the scope of the
problem and impact on the
community
To make a plan of control
measures
To plan health facilities
To plan health facilities, to assess
quality of health care and needs
for training and improvement
65
INFORMATION
Why it is important
How it may
INFORMATION FROM YOUR AREA
be used________________
15. Sex distribution of
cases (ratio of male
to female)
Shows who is at more risk,
where transmission occurs and
immune status of population
16. Parasite species
(percent of each
species)
Determines treatment regimens.
If predominantly P falciparum
there will be more complications
and mortality
Influences choice of effective
drugs, effectiveness of self
medication and cost of drug
provision
If mainly males, it may be
occupational, if pregnant women,
they should be focus of control
efforts
Health promotion and rapid access
to health services are more
important where P falciparum
is predominant
Resistance increases need for
more peripheral laboratory
services
Characteristics
17. Drug resistance
status
III. Vector
18. Species
19. Preferred breeding
sites
20. Resting habits
(indoors, outdoors)
21. Biting habits (time,
host preference,
location)
Different species have different
behaviour
Indicates which water bodies are
important and whether larva
control is feasible
Influences mosquito control
strategy
Helps to decide which control
methods to use and determines
role of community and other
service sectors, industry;
determines content of
communication
House spraying and insecticide
Helps to decide which control
treated nets may be more effective methods to use and determines
against indoor testers
role of community and other
service sectors, industry;
determines content of
communication____________
House spraying and insecticide
Helps to decide which control
treated nets may be more effective methods to use and determines
against indoor biters and if people role of community and other
are inside at peak biting time
service sectors, industry;
determines content of
communication
66
INFORMATION
Why it is important
Characteristics
22. Seasonal density
changes
INFORMATION FROM YOUR AREA
How it may
be used________________
Affects seasonal pattern of disease Helps to determine content of
communication and timing of
control activities by communities
and health sector
IV Environment
Affects suitability for
23. Climate, rainfall,
transmission
surface water,
temperature,
vegetation,
topography_____________________
V. Control activities (by community and health services)
24. Types of health care Public health services, private
sector, non-governmental
(list of all facilities,
organisations; all contribute to
whether they have
provision of health care, but vary
supplies,
in quality, accessibility and
microscopes, staff,
affordability_________________
etc.____________
Different countries use residual
25. Types of mosquito
house spraying, occasionally
control (list types
outdoor ultra low volume
used by health
services and
spraying in towns or camps,
chemical or biological larva
community)
control, removal of breeding sites
or nothing
Indicates acceptability and
26. Types of personal
availability of repellents, nets
protection
coils etc
Determines mosquito control
strategies and prediction of
outbreaks
To provide the best access for all
affected people to early effective
diagnosis and treatment and to
appropriate prevention. To
determine content of
communication______________
To determine content
of communication
To build on current practices and
make them more effective
67
INFORMATION
Why it is important
How it may
be used________________
It may be difficult to encourage
women to take prophylaxis
regularly
It is important that all drug
providers and users know the
most appropriate treatment for the
area________________________
In some areas outbreaks of
malaria are increasingly important
and can cause deaths
To develop the most efficient and
acceptable distribution system
Characteristics
27. Chemoprophylaxis
of pregnant women
28. Availability of
treatment protocols
29. Outbreak control
activities
To train health providers and
educate mothers
To involve community in
reporting fevers and
implementing control activities.
To ensure drug supplies are
readily available
OTHER
Developed by Narula, Mehra, Meek and Lines, 1995
68
INFORMATION FROM YOUR AREA
r w/7/i®^
Rs^wjf^'1 •-^
T3I®
IW:!
Ch,
s'
C*’ ^iJli
> /
/I
Find out also what people think, what they do and why
69
2.2
Helping Communities to Understand Malaria
and to Protect Themselves
Knowing when to suspect malaria
Much of severe disease and death from malaria could be avoided if
people presented earlier for diagnosis and treatment. Use
The first step is to make a list of all the types of people you need
to work with, such as mothers, fathers, schoolchildren, shop
Worksheet l.Q to find out how the community defines malaria.
keepers, community leaders, private practitioners, religious
leaders and others.
Based on their definition you will see where you may need to
supplement their knowledge.
There are three main areas where community members can be
involved in reducing the burden of malaria:
Even when a person suspects that they have malaria, there are still
i.
many factors which may delay their seeking treatment, such as:
lack of money, lack of time, or the decision can only be made by the
head of the household. You need to discuss with the community
problems relating to delays in seeking treatment and the
complications that can arise with late treatment.
Knowing when to suspect malaria by knowing the signs and symptoms
of both mild and severe malaria
2. Knowing how to obtain prompt and effective diagnosis and treatment
Knowing how to obtain prompt and effective diagnosis
and treatment
3. Knowing how they may prevent malaria
This would help them to decide if malaria is a problem against
which they should take action.
The first of the four basic components of the Global Malaria
Strategy is “to provide early diagnosis and prompt treatment.”
This is an area where you can make a major contribution to
reducing suffering from malaria by providing information to
communities, shopkeepers and private practitioners and by
improving communication between them.
70
Worksheet 2.Q
Severe or Complicated Malaria
Some of the Signs and Symptoms of Uncomplicated (mild) Malaria
Tick what signs the community
associates with malaria
and Severe or Complicated Malaria
Uncomplicated Malaria
Community Beliefs
Main Signs in addition to those for
uncomplicated malaria:________
Coma__________________
Delirium_______________
Agitation_______________
Somnolence_____________
Convulsions_____________
Very high fever (3Q degrees)
Very pale colour__________
Much vomiting___________
Dehydration_____________
Little urine of dark colour
Hypoglycaemia___________
Uaemoglobinuria
Community Beliefs
Tick what signs community
associates with malaria
Main Signs:___________
Fever_____________
Chills____________
Sweating__________
Other signs often seen:
Headache_________
Aches___________
Joint pains_________
Anaemia___________
Jaundice__________
Enlarged spleen or liver
There are many different ways that people can seek diagnosis and
treatment of their illness. Some of the strengths and weaknesses
of different sources of treatment and what the patient needs to
know are shown in Table 2.10.
71
Table 2.10
Use of Different Treatment Sources
Treatment Source
Possible Advantages
Possible Disadvantages
1. Traditional healer
May visit home, may help with other
problems
May relieve symptoms, but not
remove causes
2. Shop
Very convenient, always has some
medicine
Not qualified to diagnose and treat;
may not know dosage; may give
dangerous, unnecessary or out of
date medicine; may be expensive
3. Private Practitioner
May visit home, friendly, always has
some medicines
May be expensive and give
unnecessary medicines
3. Community health worker
Close to home, worker has some
training; worker should know if
person needs to go to hospital
Trained staff; facilities for treating
severe and complicated malaria
Sometime worker not available,
medicine out of stock
4. Public clinic or hospital
Footnote:
What the Person Needs to
Know when Using this
Source of Treatment______________
See Footnotes
Although traditional healers can help
with some types of illness, malaria
today needs exactly the right drugs______
See Footnotes
If seller does not know the dosage, go
somewhere else for treatment, drugs
should not be old; if it is not getting better
after two days it is very important to go
to a trained health provider, as it may
be another illness or the drugs may not
be working
See Footnotes
Injections are not better than tablets
when a person is not seriously ill; does
the practitioner have a good reputation?
See Footnotes
Far from home; sometimes staff
See Footnotes
unfriendly; long waits; medicine out
of stock and has to be bought______
1. Treating severe malaria costs much more than treating malaria early. A person should not delay seeking treatment if he/she suspects malaria. The longer the person waits
the worse it can become and it can be dangerous or even fatal
2. Take proper and complete treatment. It is very important that the person follows instructions about taking medicines and takes the full treatment. Ask health
provider to explain instructions if not clear
3. See a trained health provider ifperson is not better in two days or if becoming worse
4. See a trained health provider if signs of malaria return a few weeks afterfull treatment
5. Some anti-malarial drugs can be very dangerous if taken in the wrong dose
72
remove breeding sites such as pools around leaking taps in Africa
Knowing How to Prevent Malaria
and India.
There are three main ways that people can protect themselves
killing larvae with insecticides is expensive, but is sometimes done
by health services or private companies. Killing adult mosquitoes
is done in some countries by the health services in residual house
from malaria:
a. reducing the number of malaria vectors
b. avoiding mosquito bites
c. taking drugs to prevent malaria (chemoprophylaxis)
spraying programmes. Many people refuse to have their houses
sprayed for a variety of reasons including beliefs that:
You can reduce the number of mosquitoes by removing their
breeding sites, avoid creating conditions for new breeding sites,
and by killing adult mosquitoes or their larvae.
•
it is not effective
•
•
it increases other insects
it makes a mess
• spray teams are rude
Where spraying is to be done these issues should be discussed
Removal of breeding sites may be effective in certain conditions.
Not all standing water is suitable for breeding of mosquitoes and
between the health services and the community and resolved.
especially not for Anopheles mosquitoes.
• Anopheles rarely breed in containers, which Aedes
Many countries do not have any spraying programmes, but
mosquitoes use
Anopheles generally do not like very polluted water, where
households kill mosquitoes with sprays, mosquito coils or with
insecticide-treated mosquito nets. People may need more
information to get the best value for money from these methods.
•
Culex mosquitoes are often found
Insecticide treatment of nets is likely to become more widespread.
It is important to explain to people how to treat their mosquito nets
Different vectors in different countries prefer different breeding
sites. This why it is important to get local information. Some
properly:
- how to mix the insecticide
breed in streams, and some in ricefields, which cannot be removed.
Some adult mosquitoes can also fly more than a kilometre from the
breeding site. There are still many cases where the community can
-
73
when to treat the nets
and the problems of washing nets and thus losing the
insecticide
Helping the community to make the best decisions
Developing your strategy for health promotion will require much
discussion with the community. It is important to give enough
emphasis to training of the health providers who will be involved, so
Promotion of treated nets needs a lot of effort especially where
people are not in the habit of using nets or have little money to pay
for them or for the insecticide.
that they have the information they need, and know how to involve
the community.
People can protect themselves, especially young children and avoid
mosquito bites by doing the following:
•
sleeping under mosquito nets
•
using screens on their windows and staying indoors
•
wearing clothes and covering their arms, legs and feet
during times when mosquitoes usually bite (during
evenings and at night)
To develop your ‘Partnership for Change’ strategy you need to
consider which members of the community usually make the
decisions. Provide these persons with adequate and appropriate
information so they can make good decisions.
For instance, a mother may suspect her child has malaria, but the
father decides whether they have enough money to go to the clinic.
Some people buy mosquito repellent or use local leaves which they
rub on the skin. Others may burn leaves on their fires to keep
School children may not make decisions now, but they learn
mosquitoes away. All these activities can help in reducing the
malaria risk if done properly.
quickly, and can pass information to their families, and remember it
when they grow up. The following BOX gives some ideas of how to
develop a ‘Partnership for Change’ in schools. Think of other
Chemoprophylaxis is only recommended in certain countries and
usually only for pregnant women. Find out your national policy and
members of the community, and develop your strategies for them.
what drugs are recommended, if any. Compliance is often rather
low, so look for ways to improve it.
74
Malaria Control for School Children
1. Provide the basic information on the cause, prevention and
treatment of malaria and who is at risk
2. School Projects:
Primary School
Secondary School
Boarding School
Draw a mosquito and where it lives in
your area
0^0
Write and perform a play on what a
mother does when her child is sick
Xi.
Keep the school malaria-free. Find
i
mosquito breeding sites, fix drains and
leaking taps, put screens or curtains
(treated with insecticide) on dormitory
windows.
Provide treated mosquito nets.
All Schools
v*\
Set up a service for dipping of nets in
insecticide.
75
O
SECTION 3
2.
Identify whom in the population you want to reach with the
messages
DEVELOPING and SHARING MESSAGES*
The main community groups for the malaria control programme
may be parents with young children, pregnant women or working
For Communication and ‘Partnerships for Change’ programmes,
messages are developed according to what people know, what they
do, and through methods that they believe in or trust. The
adults. But there are also other groups whose knowledge, beliefs
and attitudes may have a strong influence on their actions. These
‘influencing’ groups could be community leaders, heads of
households, religious leaders or local politicians and government
officials - these groups may be just as important for malaria
following steps will help you to develop and share your messages.
Most of the information you need to carry out these steps will
come from the information you gather with the community and
about the malaria situation.
I.
messages. The support from ‘influencers’ may be critical to the
success of your communication efforts.
Identify which groups you want to reach for the success of the
malaria control programme.
Define clearly what ideas you are trying to promote or
actions you want people to take
What people do and know are central to a communication
programme and are the basis for developing your messages and
materials. For example:
•
Bring your child with fever to see the health provider
•
Make sure all young children sleep under a mosquito net
3.
Learn about the existing knowledge, beliefs and behaviour of
community groups
Become familiar with present behaviours related to malaria and
attitudes, beliefs, social and economic factors which determine
these behaviours. This information will help in designing messages
* This section is based on, ‘‘Getting the Message Out: Designing an Information
Campaign on Women’s Health,”by Ann Starrs, Family Care International Inc.; and has
been adapted for malaria control programmes
which build upon the existing knowledge and beliefs of the
community. Learn with the community about these. It can also
76
serve as a useful baseline for the evaluation (Step II) of the
communication programme at a later stage.
Mass Media:
Radio, television, newspapers, magazines, comic books
Small Media:
Posters, cassettes, leaflets, brochures, slidesets, video, flip charts,
4. Find out what are community groups' sources of information
about health at present
flash cards, T-shirts, badges or loudspeakers
Traditional folk media:
Drama, songs
To reach community groups find out how information gets to them.
Find out what sources of information community groups feel they
can believe.
Do not rely on a single means of communication. Always use a mix of various
channels and media so that community groups receive consistent messages
from different sources.
5. Select the communication channels and media which are most
capable of reaching community groups
6. Decide on the content of the messages
and means may be most effective for which community groups.
The data you have gathered about your area provide the
information for creating messages for your communication
These will include a mix of:
programme. Messages are not just information; they must
present an argument that will convince people to do something.
Use the information from steps 3 and 4 to work out what channels
•
Messages should also address the concerns of community groups.
Content of programme messages should be:
Interpersonal Channels:
Health professionals, community health workers, religious and community
leaders, traditional health practitioners, women’s and youth organisations,
•
information that the community group needs but does not have
school teachers and school children, trade union leaders, development
•
actions that the community group may need to take
workers, government officials, charitable and non-governmental
•
suggested ways to overcome obstacles to taking the action
organisations.
77
Outlinmg the Content of Communication Messages
extend the hours that antenatal care is available, or make waiting
time more useful and entertaining. Also, develop messages for
husbands and other family members about helping women with
their work so that they have time to go for antenatal care
Women do not like being scolded and treated badly by nurses
and midwives when they come for antenatal care.
Suggestion: Provide training or arrange group discussion with
nurses and midwives and discuss women’s concerns and
motivate health workers to treat women with respect if they want
to encourage regular attendance
Mere is an example from an antenatal programme. Try and adapt this using the
information you have about the malaria situation in your area.
Topic:
Encouraging antenatal care attendance so pregnant women take antimalarials
Community group.
Rural women who have had at least one pregnancy
SAMPLE MESSAGES
Information community group needs'.
•
Serious complications or diseases can develop during pregnancy,
even if there are no obvious signs. Regular antenatal care can
detect these problems
•
Drugs given during antenatal care such as anti-malarials can
help to ensure the good health of the mother and her baby
•
Important information is given during antenatal care about what
women can do to stay healthy during pregnancy and after
delivery
During antenatal care pregnant women will receive anti-malarials
that help to protect them and baby
Women need to go regularly for antenatal care during their
pregnancy to receive anti-malarials
Actions they need to take.
• A woman needs to go for her first antenatal visit as soon as she
thinks she is pregnant
•
A woman needs to make regular visits during pregnancy
•
Women need to follow advice they are given during antenatal
care, including advice about taking anti-malarials
7. Create Messages for Different Information Channels
Deciding on the content of the message is only half of the process
of getting it to the community groups who need the information.
You need to find the best way to reach the community groups: what
Obstacle they may face:
•
Women believe it is bad luck to go for antenatal care before the
5th or 6th month of pregnancy because the baby might be cursed
if the mother “boasts” about her pregnancy before it is visible.
Suggestion: Emphasise the “protective” benefits of antenatal
care, and of anti-malarials provided
•
Women, with their busy schedules, do not have the time to wait
for antenatal care. Suggestion: Work with the health facilities to
channels are the best for reaching them. Choose channels that
community groups use and trust the most and also those which are
best suited to the message.
78
Creating Messages
Well designed messages have the following characteristics:
•
Aimed at a specific group, based on research findings about which
community group needs what information
•
Focused on a problem, based on research findings, about what
community groups think, do and believe about the problem
•
Action-oriented to suggest solutions
•
Simple and easy to understand
•
Appropriate to the community groups and the problems, addressing
the obstacles they face and suggesting practical ways to overcome
these obstacles
•
Attractive and interesting to get people s attention and encourage
them to take action
Let your baby sleep in peace - free from troublesome mosquitoes.
Always use a mosquito net
79
Choose Information Channels
The information channel is the means for getting the message to
community groups. Each channel has strengths and weaknesses.
Some rely on the visual and others on the verbal content.
Therefore the message has to be tailored to the strengths of the
channel you choose. You may need to use different channels for
different messages.
Although you may want to focus your efforts and resources on an
information channel that is most effective to reach a particular
community group, it is important to use a variety of information
channels. That way, people will get the message from different
sources, and it is more likely to reach them and to be believed by
them. When using different channels it is important that the
messages are consistent.
Communication Channels
Print media
• Materials for reading:pamphlets, booklets and brochures
• Materials for display:posters, calendars, wall charts
• Materials for use with groups: flipcharts, flashcards
• Comics
Even if you are feeling better, take full treatment
or malaria will come back
80
These materials can be designed for literate and non-literate people. They
Special events
can encourage people to take action, they can convey information quickly and
• Competitions, contests, and debates
effectively, and they can reach many people.
• Parades, fairs, and rallies
• Public awareness days
These can raise awareness, mobilise groups and share information while
Folk media
entertaining people.
• Theatre, plays, puppet shows, role plays, story-telling
• Songs, poems, drumming, and dance
Personal communication and counselling
• Messages printed on cloth
Folk media are especially useful for raising awareness, generating interest,
These are contact information channels where health workers share ideas
and encouraging people to think about and discuss important topics.
with community groups directly. These methods support other information
channels by answering questions, correcting misunderstandings and
reassuring people.
Mass media
• Newspapers and magazines: feature or news stories, advertisements,
Select a Package of Messages and Information Channels
• Radio: announcements, advertisements, dramas
• Television: advertisements, features or news stories, dramas
These media are useful for raising awareness, reaching many people at the
In order to decide on a combination of messages and information
same time and conveying simple messages.
channels consider:
•
the different community groups you want to reach, how many people in
each group you want to reach, and the best channels to reach them;
Visual electronic media
• Video
•
the different messages you need to convey;
• Film
•
the information channels community groups use the most often and trust
the most.
• Slide shows
These are usually used with groups. They can increase the interest of people
in certain topics, convey messages in a memorable and dramatic way, show
how to do certain things.
81
g. Pretest Messages
<7. Produce and Distribute the Materials
You need to test out the messages you have drafted in the medium
Production and distribution of materials are critical aspects of a
communication programme.
you want to use to find out if they are appropriate. You need to
test the ideas with representatives of community groups before
you reproduce them in large numbers. Pretesting is essential to
Production
avoid costly mistakes. Pretesting will tell you whether the
messages are:
Production will depend on the channel and media you choose.
• Understandable
Production requires special skills and equipment and it may be
useful to contract another organisation to do this. There are many
• Culturally acceptable and appropriate
• Relevant to the community group (s)
processes and methods of production which are not covered in
these Guidelines.
Mow to Pretest
Production costs can be high so test your materials because
Pretesting is usually done through in-depth interviews and focus
group discussions. These methods help to find out what
correcting mistakes during or after production can be very costly.
Estimate your requirements for each item as accurately as possible
because in many cases reproducing the same items again can
community groups think and feel about the messages and the
medium in which they are delivered. During pretesting you can find
out:
increase the costs.
Distribution
Content of the messages: Do people understand the message?
Is it accurate?
Distribution is the key to ensuring that all the investment in
developing and producing materials reaches the community groups
they are intended for.
Mow the messages are presented: Do people like the tone of the
words or the style of pictures? Do they recognise and identify with
the people, objects or situations shown?
82
10.
Print media
Posters, wall charts, and other display materials need to be placed where they
Coordinate your communication programme with other health
and development services
will reach the greatest number of people. Materials for use with groups, such
clubs or schools. Booklets and pamphlets can be distributed at health
Find out about activities of other health and development
programmes and services and how they link up with what you are
facilities, through shops or used during counselling.
planning to do. Identify areas for coordination and share your plans
Folk media
with others. Malaria control efforts will require working together
with many other sectors and with all health programmes in your
Special events can be organised especially at markets or festivals where the
area.
as flipcharts or flashcards, can be used at health clinics, women’s clubs, youth
community gathers.
11.
Mass media
Evaluate the effect of your messages
Radio or TV announcements, advertisements, dramas should be broadcast
when the community groups you want to reach are most likely to be listening
Using the baseline data (step 3) for comparison, check the extent
or watching. Print newspaper advertisements, features or stories in issues
and place them on pages and on days that your community groups are most
to which community groups are carrying out the new health
behaviour(s). Find out why some members or groups are not
likely to read.
carrying them out.
Visual electronic media
A formal evaluation looks at the strengths and weaknesses of
Films, videos and slide shows could be shown during special organised events
or during markets or festivals.
different activities in the programme and at what happened as a
result. Evaluation methods include: a review of written records,
Special events
interviews with the staff, in-depth interviews with members of
community groups, group discussion, observation of the community
Involve the community in planning and organising rallies, parades or contests
groups, and surveys to see whether people’s knowledge, attitudes,
to increase their participation and announce them well in advance.
and behaviour have changed because of the campaign.
83
12.
Repeat and adjust the messages at intervals
Modify and revise your materials and your activities based on your
experiences and the evaluation. Develop a new schedule and plan
for conducting your communication programme based on your
evaluation.
WK \
I
Test your messages with representatives of community groups
84
2.
Resource 3: Checklist
Developing and Sharing Messages
1.
State clearly what you are trying to promote or
actions you want people to take
Identify whom in the population you want
to reach
Idea/action
Ideas/actions
85
Group(s)
3.
Identify existing knowledge, beliefs and
behaviour of community groups
4.
List sources of information about health of
community groups
(Developing a baseline to assess the impact of your messages)
Community Groups
Community Group(s)
Sources of information
Existing knowledge, beliefs and behaviour(s)
5.
Select the channels and media which are most
capable of reaching community groups
Community Groups
86
Communication channels
6.
7.
Decide on the content of the messages
Create messages for different channels
Message(s)
Topic:
Community group :
Information Community group needs:
Actions they should take:
Obstacles they may face
SAMPLE MESSAGES
87
Information Channel(s)
8.
Pretest
b.
a.
Design messages and test whether they are appropriate
You should also test your communication materials with representatives of the
Develop and test communication materials
community groups that they are designed for.
Once again you need to find
Pretest your messages with groups and people they are intended for. Find out
out whether your materials can be understood, are culturally appropriate.
whether your messages can be understood, are culturally appropriate.
practical, relevant and technically correct.
practical, relevant and technically correct. Use the following worksheet to
record and compare pretesting results of various messages.
Materials
Messages
Easy to
understand
Right for
the culture
Practical &
Relevant
Technically
correct
Total
e.g. Use mosquito nets
at night
3
I
2
2
12
E.g. A booklet on
Using Mosquito nets
Scoring:
Easy to
Right for
Practical &
Technically
understand
the culture
Relevant
correct
2
/
2
2
O=definitely no
l=not sure
2=somewhat
Total
8
3-yes, definitely
Multiply your scores in each row for the total column
Scoring:
O=definitely no l=not sure
2=somewhat
3=yes, definitely
Multiply your scores in each row for the total column
Based on the scores of your materials, reproduce and use ones that score an
acceptably high level. At the same time, improve aspects that are weak in
other materials.
Based on the scores of your messages select ones that score the highest. At the
same time, you need to strengthen the aspects of other messages that are
weak.
88
9.
Produce and Distribute the Materials
a.
Production
b.
Distribution
Material(s)
Material(s)
Quantity
Complete by
required
when
Distribution points/places
Distributed by
Production by whom
10. Coordinate your communication programme
with other health and development services
Your planned
activities
89
Activities of other health
& development services
Areas for
coordination
11. Evaluate the effect of your messages
Community Group(s)
12. Repeat and adjust the message at intervals
Messages/materials
Knowledge, beliefs and
Modifications needed
New schedule
and plans
behaviour(s) after your
messages
Using the baseline data (step 3) for comparison, check the extent to which
community groups are carrying out new health behaviour(s)/actions. Find out
why some members or groups are not carrying them out.
90
Sample Messages
a.
Protect young children from mosquito bites, especially at night
Malaria is spread by the bite of a mosquito. Care should be taken to
keep mosquitoes away from young children. There are several ways
of doing this:By using protection methods:
• mosquito nets (preferably treated with an insecticide)
• fumigants such as mosquito coils
• screens on house windows and doors
• killing mosquitoes in the house
All members of the community should be protected against mosquito
bites. A mosquito can take malaria from an infected person and pass
it on to someone who is uninfected.
b.
•
Destroy mosquito larvae and prevent mosquitoes from breeding
Different types of mosquitoes breed in different places. Some breed
wherever stagnant water can collect: in ponds, swamps, pools, pits,
drains. Other types may breed along the edges of streams or even in
water collected in hoof prints. Filling in or draining places where
water collects, or spreading oil on ponds and swamps, can remove
some mosquito larvae. Where mosquitoes breed will vary from area
to area. Help the community to understand the link between the
larvae and the adult mosquito. Find out where they breed in your area
and choose the appropriate action with the community.
Regular clean-ups of the neighbourhood help to reduce mosquito
breeding in some areas.
Wherever national policy recommends it, ask pregnant women to
take anti-malarial tablets throughout pregnancy
Pregnant women are much more likely to suffer from malaria. The
disease is also more dangerous during pregnancy. It can lead to
severe anaemia (‘weak blood’), and may cause a miscarriage,
premature birth or still-birth. Babies bom to women with malaria are
also very likely to be small, weak, and vulnerable to infections.
Pregnant women can protect themselves against malaria by taking
Where appropriate, ask pregnant women to take anti-malarial tablets
throughout pregnancy
91
anti-malarial tablets regularly throughout pregnancy. In some places
they may be called ‘Sunday tablets’ to help pregnant women
remember to take them weekly or ‘breakfast tablets’ to remember to
take them daily.
The right anti-malarial tablets can be obtained from a clinic or trained
health provider. NOT all anti-malarials are safe to take during
pregnancy.
d.
•
•
A child with fever
should be taken to a
health provider
Wherever malaria is common, ask parents to take the child who
has fever to a health provider. Give the child a full course of an
anti-malarial drug if malaria could be the cause.
A child with a fever, believed to be caused by malaria, needs a course
of anti-malarial tablets (give young babies anti-malarial syrup).
A child needs the full course of treatment, even if the fever disappears
rapidly.
Anyone with malaria needs complete treatment!!
e.
f.
A child with a fever should be kept cool but not cold by:
• Giving a temperature-reducing medicine (e.g. paracetamol).
• Sponging or bathing with cool (not cold) water.
• Not covering with too many clothes or blankets, and keeping in a
well ventilated area.
A child recovering
from malaria needs
plenty of liquids and
food
A child recovering from malaria needs plenty of liquids and food.
Malaria bums up energy and the child loses a lot of liquid through
sweating. Give food and drink to the child as soon as the child can
take them. Plenty of food and liquid will help to prevent malnutrition
and dehydration.
Adapted from Facts for Life: A Communication Challenge, UNICEF
Ttlelnra,
92
ANNEXES
Resource 4
participation of the target group, and of groups that influence them, in
formulating and testing products, programme strategies, activities, and
Social Marketing of Insecticide-treated mosquito nets
specific messages and materials. Social marketing is a systematic strategy
for Malaria Control Programmes*
where acceptable concepts, behaviours, or products, and how to promote,
distribute and price them for the market are defined.
Social marketing is another approach to communication that has been
successfully used in many public health programmes. This section presents
All social marketing programmes build up from the basic programme
the social marketing of mosquito nets as an example. The social marketing
objectives. In the case of insecticide-treated mosquito nets, the objectives
process can also be useful for other products for malaria control programmes
would include:
such as drugs for treatment.
1.
to have every sleeping place in the community covered with a
treated mosquito net;
What is Social Marketing^
2. to have family members using the nets regularly and properly;
3. to have the community re-treating the bednets at least once or
Social marketing is the use of commercial marketing methods to create a
twice a year.
demand for a socially relevant product or service and a systematic approach to
assess the demand and the means to satisfy it. In public health programmes
this could include adoption of health-promoting behaviours such as enhanced
As a planner for promoting treated mosquito nets you have to make technical
use of services, the trial and continued use of a product, and the improvement
decisions related to programme costs, management, and effectiveness. You
of household or community practices.
will also have to make marketing decisions because they represent the
interplay between the product or idea and how attractive or acceptable the
In social marketing programmes the consumers' perspectives, preferences
product is to the consumers, i.e. how likely the target group is to acquire, use
and behaviours form the basis for promoting better practices. Social
and re-treat the mosquito net. The four main decisions in a social marketing
marketing techniques can lead to innovations in the design of other
programme are described on the next three pages.
programme components that may be involved in the production or delivery of a
* This section is based on contributions by Marcia Griffiths, Manoff Group including:
Griffiths, M. & Favin, M. "Social marketing of insecticide-treated bednets for malaria
control programs,” Manoff Group and Griffiths, M. “Social Marketing: Achieving changes
in nutrition behavionfrom household practices to national policies”, Manoff Group
product or service. To be successful, the social marketing process requires
93
Decision I The Product
•
Mow does this compare with the family budget on non-food items?
•
At what times of year do families have cash for non-food items?
Form of the Product
There are two aspects to the product: the mosquito net itself and the
This information may tell you something about how much people may be willing
insecticide for impregnation or re-impregnation. The first steps you need to
or able to pay for mosquito nets or their treatment. A proper test market may
take are to find out the patterns of current use of bednets in your area:
provide a better picture of what price people are really willing and able to pay
•
What types of nets are available?
once people are aware of the benefits of nets or treated mosquito nets. Only
•
Which nets do people prefer and use most?
after a test market you can decide whether the nets should be donated,
- what size, colour or shape?
subsidised or paid for over time.
- what material?
•
Decision 2 The Market
Are any nets produced locally?
Cost of the Product
At the beginning of your programme you should decide on the scope of your
For the mosquito nets to be successfully marketed you need to know what is
programme.
the cost to a family of such a purchase.
•
•
Mow much do nets cost in your area? Mow much would the treatment
•
•
Will it cover the entire area or only high risk areas?
•
Decide on the phasing of your efforts during the year(s) to plan
of nets for one year cost?
whether a continuous effort is to be made or a concentrated effort
Mow much will people be willing to pay for a net or for its regular
during a particular season.
•
treatment?
•
•
Are they easily available or what would be the cost to travel to a
Decide on the focus within a cohimunity: high risk
individuals/families or everyone?
market where they are available?
To define the scope of the market you also need to know:
Mow does the cost of a net compare with what the family may spend
•
The epidemiology of malaria in your area.
on other items to protect themselves from malaria?
•
The status of the population, in terms of:
Mow does this cost compare with what a family may spend on
their current use of mosquito nets and
treatment of malaria?
their perception of the problems mosquitoes cause
94
•
How many people use each net?
•
Who uses the nets at home?
•
How are nets used? For individuals sleeping separately or as
How the product will reach people is the most important part of a social
families or sub-families?
marketing strategy. Without access to or availability of the product or service
OecisioM 3 The Delivery Strategy
your objectives cannot be achieved. In the case of mosquito nets, these
Where the nuisance of mosquitoes is unbearable the use of nets by people
should be easily available to those who have been convinced of their
may be high and a programme for treating them may be able to reach everyone
usefulness.
from the start. Where nets are not so much in use or not so well accepted,
the demand for them can grow with the number of people who become
You need to find out:
convinced to use them. In such situations high risk areas should be targeted
•
how long nets last;
first and mosquito nets could be promoted for children and pregnant women
•
or how often a family replaces its net(s).
who are the most vulnerable.
This would give you some idea of how many nets over time may be needed in
your area. You also need to work out:
Mosquito net programmes will not be effective and will not be sustained
•
unless:
the level of service you have to provide for treating mosquito nets
every six months.
•
Health workers are motivated to promote nets.
•
Health workers are capable of carrying out their roles.
This service needs to be made easily available and accessible to families in
•
Opinion leaders and policy-makers are informed and convinced about
your area. Therefore identify the distribution points and work out the
the advantages of mosquito nets.
frequency with which the service needs to be provided.
Training and educating health workers, opinion leaders, and policy-makers are
The major decisions you need to make related to delivery systems are
likely to form part of any social marketing effort. These “sales agents” are
whether to use public sector delivery system, private sector outlets, or a
an important part of the market.
combination of the two, and the degree to which public sector delivery takes a
vertical or integrated approach.
95
Experience from some programmes has shown that a combination of private
accept mosquito nets and their treatment and comply with instructions for
sector efforts (small scale production units, artisans or more commercial
using bednets and for treating them. Policy makers, media representatives,
units) combined with public sector efforts using the existing primary health
NGO officials, and the public also need to be convinced. Therefore, you need to
care infrastructure is likely to be the most effective way mosquito nets can be
take decisions with regard to three functions of communication:
•
delivered and treated. However, it is possible that the entire operation could
advocacy for nets, whether at the policy level, with private sector
manufacturers, or the community;
be handled privately through commercial outlets to produce treated mosquito
•
nets and establish the service for re-treatment. You could also look into
programme support or public information on where to get nets, when
and where they will be treated;
providing the product and service through a consumer's cooperative or a non
•
government organisation (NGO).
behaviour change to address the regular and proper use of nets.
Many pilot efforts suggest that using the primary health care system can
In a social marketing approach to communications, activities to achieve these
offer the best chance for success. It provides a “sales force” at the
objectives are based on formative research and testing of messages and
community level that can educate about the use of the mosquito net and assist
behaviours with the target groups themselves. Research is designed to
with its treatment. Community participation is always important for the
understand cultural, attitudinal, economic, and logistical resistances to
success of your efforts.
carrying out the desirable behaviours and to give insights into a combination of
programme actions (i.e., making the purchase of nets and services more
Decide for your area what delivery systems may be most appropriate and try
convenient or the mosquito net more appealing) and messages that address
and assess different options and their effectiveness.
these resistances.
Decision 4:
Messages should be very carefully designed and tested so that they are
Communication Strategy
interesting, believable, motivating, and practical to implement. They should
The need for education of the population has been identified as the most
convincingly show the importance and feasibility of the following key
significant factor in the level of practice in existing programmes. However,
behaviours: regular and proper use of mosquito nets, re-treatment, washing
the need goes beyond just education of the population to effective
of the net etc.
communication to encourage desirable behaviours by the public, i.e. to seek or
96
Well designed communication is creative, i.e. it does not merely accept a
Social marketing could provide an appropriate framework and the tools to
conventional approach to information. Based on formative research, an
assess what it will take to achieve the proper use of insecticide-treated
attractive “image” of the treated mosquito net is portrayed and supported in
mosquito nets. Because all social marketing decisions regarding the product,
mass and interpersonal media. Messages contain effective appeals or
market, delivery system and communication are made using sound consumer
motivational statements. What is it that is of greatest concern to families? Is
research prior to and throughout implementation, consumer need and
it their health (disease prevention), being free of annoying pests while
technical requirements can be met. By satisfying these requirements, the
sleeping, added privacy? The treated net and the process for obtaining it
programme will have a better chance of reaching the goal and being sustained
should be positioned in the most appealing way possible and creatively
at a community or family level.
marketed.
97
Resource 5
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