Part IV: The Role of the RBM Partnership
8. Communication and Behavior Change Methodologies
Achieving the RBM 2010 and 2015 targets requires effective communication between service providers and consumers of interventions, whether patients, family members or communities. Communication can be used to increase knowledge of:
- the transmission and prevention of malaria;
- the link between bed net use and malaria control;
- the recognition of signs and symptoms, risk groups, rapid treatment-seeking behavior and full compliance with treatment;
- the consequences of malaria in pregnancy and the need for antenatal care which includes LLINs and, as appropriate, IPTp; and
- the motivation and intention to use tools for malaria prevention and control.
Motivating households to prevent and treat malaria requires sustained communication interventions guided by well-planned and locally appropriate communication strategies. Communication programs embrace basic strategies to increase demand for and acceptance of malaria interventions and services, including information, education and communication (IEC) and behavior change communication (BCC) methodologies.Also known as Communication for Behavior and Social Change (CBSC) and Communication for Development (C4D). IEC is broadly defined as providing knowledge to enable individuals, families, groups, organizations and communities to play active roles in achieving, protecting and sustaining their own health. BCC includes the basic components of IEC, but starts with a focus on the key individual and group behaviors to be changed and employs a wider range of interventions beyond cognitive-based, knowledge transfer. Communication for Social Change is a more participatory approach to engaging communities that focuses more on the client-identified end actions in regard to the health intervention. There is wide agreement that communication programs need to combine both the delivery of messages and other behavioral interventions and opportunities for dialogue, shared learning and consensus-building to produce results.
Regardless of the methodology, any effective communication program aims to affect the health-seeking or care-providing behavior of individuals and communities creating demand and sustaining use of malaria services and products.Global Advocacy Framework. Roll Back Malaria, 2005.
Click for source It is important to not only create demand via communication, but also to focus on increasing appropriate utilization of service and products, such as ensuring a household dynamic where pregnant women and children sleep under mosquito nets. The resulting field effectiveness due to appropriate utilization of preventive interventions is a key driver of treatment costs. For example, increasing operational effectiveness of LLINs and IRS from their current field effectiveness of 50-60% up to 98% can theoretically reduce incidence and therefore treatment costs, by almost 50%. Modeling a 98% effectiveness rate showed a potential cumulative savings globally of US$ 960 million from 2009-15. This makes a powerful argument for investing in communication and behavior change programs. (See Appendix 4: Assumptions behind Country Implementation Cost Estimates).
There are many steps in the process of engaging whole communities to prevent and treat malaria effectively. Such engagement requires a change in normative standards, which is most effectively achieved when local leaders are active in program planning and implementation, along with NGOs and other community organizations.
Communication programs should create opportunities and motivate people to discuss malaria issues, both among themselves and with decision-makers and service-providers. In addition to changing household practices, social norms and mobilizing communities to participate actively in malaria interventions, communication programs can also improve the quality of client-provider interactions by providing health workers with the interpersonal skills and the motivation to communicate more effectively with clients.The Role of Communication in Malaria Control in Africa. A concept paper for the Roll Back Malaria Communication Working Group, September 2003. See Roll Back Malaria webpage.
Click for source Communication objectives should include increasing knowledge, intention to act, a sense that actions conform to social norms, visible support from community leaders and modification of service delivery to increase opportunities for people to adopt appropriate health seeking behaviors.
Formative research, early research which helps to highlight the community context and how best to structure a program for that community, can be the basis on which to build effective communication strategies. Such research can help planners understand the basic social, cultural and political opportunities and challenges the intervention program faces. The communication program planners can then fashion service delivery and messages to address gaps in knowledge, perceived norms or other barriers to accessing and utilizing services. To ensure that the program has not deviated from the intended plan, planners need to monitor process indicators carefully and report on activities and results. An evaluation of the impact of malaria programs will include both intermediate objectives (knowledge, attitude, perceived norms and efficacy) as well as behaviors, such as the appropriate use of bed nets in homes.
Communication activities should be integrated into National Strategic Health Plans, malaria business plans, and education programs from the very beginning. Community involvement and participation during the design and implementation will ensure the activities are successful. Lessons learned in health promotion have demonstrated that neglecting community involvement in all stages of the program design and implementation will decrease the chances of the program succeeding.
When working in harmony, communication programs at international, national and community levels lead to more successful communications that are likely to increase demand for and utilization of services in communities and simultaneously improve service delivery. Given the importance communication has in achieving the RBM 2010 and 2015 targets, more dedicated funding for communication activities is necessary at international, national and community levels. Gaps in the current malaria communication structure are outlined below.
International level. In recent years, communication has not received the necessary attention at the international level to develop appropriate guidelines and tools to guide country efforts. This has led to a number of issues, including:
- Lack of a global coordinating mechanism such as a Communication Working Group
- Insufficient operational research to identify and evaluate best practices and to document lessons learned for malaria IEC / BCC programsBarker J and Payes R. Overview of Programmatic Interventions for Communication for IRS, Insecticide-treated nets, Case Management and Malaria in Pregnancy. Washington, D.C., USAID, 2008.
- Absence of sufficient evidence regarding the effectiveness of particular channels, specific messages and topics for discussion, or types of integrated approaches for malaria specific programsPMI Communication and Social Mobilization Guidelines. Washington, D.C., PMI, 2008.
Click for source
- Lack of consistent use of limited data to determine behavior and attitude patterns in the highest risk populations and monitoring and evaluation indicators to inform planners of the success of malaria communication programs
National level. At the national level there are a number of challenges around communication and behavior change methodologies. Some of the key cross-cutting issues include:The Role of Communication in Malaria Control in Africa. A concept paper for the Roll Back Malaria Communication Working Group,
September 2003. Also see Roll Back Malaria webpage.
Click for source
- Lack of time, capacity and resources for the design and implementation of communication programs due to low prioritization
- Ineffective advocacy to promote malaria control programs as priority interventions in national government agendas
- Failure to evaluate communication contributions to malaria program objectives
- Differing priorities and insufficient resources for communication programs
- Lack of sustained communication with multiple channels (schools, workplace, women’s groups, etc.)
- Poor capacity to engage in social research necessary to understand household and community dynamics and guide innovative, locally sensitive (season, venue, product availability) interventions
- Over-reliance on mass media and promotional items at the expense of participatory and interpersonal communication
- Insufficient partner coordination in creating harmonized approaches, messages and integrated messaging with national health education services
Community level. At the community level, national programs often fail to overcome a number of challenges, including:
- Failure to identify and ensure the participation of local political, religious and traditional leaders to facilitate information dissemination and malaria control within the community
- Insufficient attention paid to participatory methodologies, especially in the development of messages and interventions
- Insufficient communication targeted for home-based care and service providers
- Application of broad, generic strategies, including messages and specified behavioral outcomes, without understanding the unique dimensions of specific communities, especially the most marginalized populations that are often most at risk and will remain that way when other populations benefit from program interventions
- Insufficient insights drawn from community leaders and grass roots efforts
- Lack of integration of malaria communication activities with other health programs (Expanded Program for Immunization (EPI), etc.)
Funding. One of the main challenges for developing successful communication interventions is that they must be adequately funded and developed based upon research and existing evidence. Communication budgets should include the costs of research and evaluation, community mobilization, pre-testing messages and materials, training and supervising clinical and community based providers, developing IEC materials (tools for providers and information for households), and media and coordination costs of all of these budget items. The costs per capita or per household should be determined to communicate with people about malaria, bed nets, IPT and new treatment and to motivate them to use these means to keep their families healthy. In addition, budgets should include costs to reach each household, with multiple messages through multiple channels sustained through the entire project cycle.
Communication priorities for the RBM Partnership vary according to the malaria stage as described below.
Priorities for scaling up. Communication interventions must be designed with the active participation of those directly involved at the community level, e.g. service providers and intervention participants. Communication and community mobilization must be recognized as key to increasing the use and coverage of households protected by insecticide-treated nets, home-based management of fever and timely ANC services. Programs need to reflect the regional, community and individual characteristics that present barriers and afford opportunities for meeting malaria program objectives. In addition, there is still a strong need for advocacy with international donors, partners, national, regional and local leaders and the inclusion of basic principles for communication campaigns to guide selection of channels, message content and to evaluate outcomes. The priorities recommended by the RBM Partnership are as follows.
A) Advocate for communication programs. The RBM Partnership will encourage donors and organizations working in country programs to provide funding, capacity building, training or technical assistance for communication programs. A standard formula for calculating the need and cost for communication funding (e.g. cost per household, standard formative and summativeSummative research is research undertaken to assess a program on its completion. research activities) is required so that future budgets can be properly estimated. The RBM Partnership will also encourage malaria-endemic countries to increase attention and resources to malaria communication programs.
B) Advocate for operational research for communication programs. There is a need to identify and evaluate best practices and document lessons learned for malaria IEC / BCC programs, especially to address the challenges at the international level. The RBM Partnership will strongly advocate for more operational research for country communication programs.
C) Technical guidance. To support communication and behavior change efforts, the RBM Partnership will develop and provide guidelines for communication interventions based upon best practices:
- Guidelines for communication programs. The RBM Partnership will aim to achieve consensus around recommended approaches for IEC / BCC during scale-up for impact and make these guidelines available for country programs. The guidelines should cover the initial research protocols, design, implementation monitoring and evaluation of communication programs. They should also contain specific recommendations of key messages, identify appropriate communication channels and recommended participatory approaches. Furthermore, existing guidelines (e.g. the President’s Malaria Initiative (PMI) Communication and Social Mobilization Guidelines), lessons learned from other health communication efforts (e.g. polio eradication, control of diarrhea, measles) and tools for the design and implementation of communication programs will be reviewed and made available on the RBM Partnership website.
- Best practice sharing. Best practice examples and experience with malaria IEC / BCC exist in partner organizations (e.g. UNICEF, the President’s Malaria Initiative, Population Services International, MACEPA and Malaria Foundation International). Additionally, partners and other development agencies have accrued vast experience in communication programs for other health activities For example: Polio Eradication, StopTB, HIV/AIDS, TOSTAN. that can provide valuable insight on methods and approaches that could be adapted for malaria communication activities, which will be assessed and disseminated through the RBM Partnership.
- Resources clearing house. The RBM Partnership should consider establishing an international 'Resource Clearing House' to enable the easy access and sharing of guidelines and best practice examples on communication activities. While realizing that communication programs cannot be standardized and participatory programs are required in addition to messaging, the resource clearing house would be a useful source for malaria communication materials: pamphlets, posters, audiotapes, videos, training materials, job aids, tools, electronic media and other media/materials designed to promote effective prevention, proper treatment and control of malaria. The clearing house should include materials that target different age groups and educational levels, using a variety of locally relevant languages.
- Direct technical support for national malaria communication interventions. Besides providing guidelines and best practices, it is imperative that the RBM Partnership assist countries directly with their national malaria communication strategies, including the design, implementation, evaluation and scale-up of activities. One strategy recommended is to directly support the placement of staff at the NMCP to coordinate malaria communication strategies within each high burden country.
Priorities for sustained control and elimination. As the RBM Partnership moves into 2015 and beyond, country communication programs will be as critical as during initial scale-up periods to ensure sustainability of the individual and community behaviors regarding malaria prevention and treatment. The activities mentioned below need to be started today. Service delivery, access issues and positive health related behaviors at the community and individual levels will need to be maintained, while governments and the donor community will face other priorities in the wake of diminished mortality due to malaria. Communication activities under the RBM Partnership will need to adapt to large scale maintenance programs while simultaneously keeping resources and health systems focused on malaria-related objectives. The key areas include:
D) Integration of community-level activities. Malaria communication initiatives that embrace diverse strategies to adapt to community realities will need to be merged into standard health message programs. There is a need to provide training for health workers and supervisors and to give them guidelines to ensure that routine service delivery fully supports malaria control and treatment. Health education around malaria prevention and control will also be incorporated into routine communication protocols and checklists at the community-level. This includes implementing guidelines for merging malaria messages into school packages, community service outlets and other participatory approaches. Guidelines for malaria health promotion at schools already existFor example: Malaria Prevention and Control: An Important responsibility of a Health-Promoting School. Geneva, World Health
Organization, April 2008. Also see WHO webpage;
Malaria Foundation International's Student Leaders Against Malaria network (SLAM).
Click for source and can be developed further to support the multi-dimensional educational and cultural needs of all malaria endemic countries, regions and communities.
E) Strengthen communication and behavior change efforts for sustained control and elimination. Beginning today, activities to promote sustained malaria control will require different messages, channels and frequency of delivery. The RBM Partnership will facilitate consensus building and support operational research to provide guidelines for IEC / BCC programs for sustained control and elimination, as well as continuing to encourage monitoring and evaluation to ensure quality of interventions does not deteriorate and that activities remain adaptable to political, social-economic or epidemiological changes.
F) Additional considerations for elimination. While there is significant overlap in priorities for sustained control and elimination, there are some additional communication activities necessary as a program moves from sustained control to elimination. Specifically, given the length of each stage, varied communication approaches will be necessary as the program approaches elimination to ensure that messages evolve to reflect the changing epidemiology and maintain desired behaviors to achieve and sustain gains. In addition, it will be essential to emphasize the continued need for awareness and proactive intervention to avoid resurgence of the disease.
Currently, there is no structure within the RBM Partnership that coordinates partners’ country level communication support. Scale-up of activities to achieve the 2010 targets requires a significant increase in the RBM Partnership’s efforts in IEC / BCC as an integral part of the RBM package. Following a RBM Board decision in 2007, the MAWG was tasked with seeing where a revitalized focus on country level communication activities could be situated (e.g. as a task team or new WG).
Therefore, the RBM Partnership needs to clarify if a global coordinating mechanism (such as a working group) should be established and who/which group(s) within the RBM Partnership will coordinate the required communication and behavior change interventions. The decision on communication leadership within the RBM Partnership should involve close coordination and integration with partners, including donors and other stakeholders who have expertise in communication and behavior change methodologies with malaria, but must also link to the available expertise in other areas of health communication and health promotion to ensure adequate capacity and best practices are available.
Table IV.9: Summary of Communication and Behavior Change Activities
|Reference to priority||Major actions||Completed by||Coordinator (bold) / Sub-coordinatorsa|
|Organizational Priority||Establish a coordinating mechanism such as a working group (Communications Working Group)||2010||RBM Board|
|C, D||Facilitate consensus building and consolidation of guidelines for communications programs to increase appropriate use of interventions||2010||Communications Working Group*|
|C, E||Prepare and disseminate best practices on IEC / BCC for the national, regional and community level||2010||Communications Working Group*, RBM Secretariat, SRNs|
|A, C||Provide technical assistance to countries to develop, review and roll-out their national malaria communication and behavior change strategies||2010||Communications Working Group*, Regional Networks and SRNs, Regional RBM partnersb|
|C, D||Provide training guidelines, supervision guidelines and protocols/checklists to strengthen communication programs at the level of community health workers, etc.||2010||Communications Working Group*, SRNs, Regional RBM partnersb|
|C, E, F||Establish standardized M&E indicators to monitor communication programs around elimination||2010||Communications Working Group*, MERG|
|B, C, E||Encourage operational research of communication channels, messages and approaches in further develop impact of communication programs||2010||Communications Working Group*, Group facilitating OR agenda, Research and Academia, TDR|
* Assuming a Communications Working Group is established
a) Main coordinating group / body in the RBM partnership indicated in bold. Closely linked contributors within the RBM partnership are also listed. RBM partners are not listed explicitly as their involvement occurs through the Working Group.
b) Regional RBM partners are country/regional offices of the WHO, UNICEF, World Bank, NGOs and other organizations