Reducing the Burden of Malaria: Investing in Social Behaviour Change Communication and Community-based Health Service Delivery

“Designing tailored behaviour change communication strategies to improve communities’ knowledge of malaria control and prevention can increase uptake of malaria prevention interventions and early treatment seeking, particularly in remote communities.”

This learning brief examines the Malaria Consortium’s approach to increasing the uptake of healthcare services and positively changing behaviours towards malaria prevention interventions through social and behaviour change communication (SBCC) activities in two districts in Ethiopia. It highlights the methods and activities used as well as some of the successes and lessons learned during implementation. The activities described in this brief form part of the Integrated Community-based Interventions for Malaria Services (ICIMS), a three-year project funded by the James Percy Foundation, which focused on:

• improving the effectiveness of community-based health services for over 507,000 people in Southern Nations, Nationalities and People’s Region (SNNPR)’s Boloso Sore and Halaba districts, and strengthening existing community referral systems; and
• increasing the uptake of these services by using SBCC activities to change community attitudes and behaviours towards malaria prevention interventions.

The brief describes the evolution and structure of the community-based health care system in Ethiopia and the use of health development army (HDA) volunteers, who worked alongside health extension workers (HEWs) to encourage behaviour change by regularly visiting neighbours to teach them about global health initiatives and encouraging good health practices. However, as stated in the brief, “recognising malaria symptoms remained a challenge for HDA volunteers, which had a knock-on effect on providing those displaying signs of infection with timely and appropriate treatment. Communities were also not effectively engaged in the proper use of malaria prevention commodities and services, thus reducing the potential impact of these on preventing cases of malaria.”

To address these challenges, the brief explains how the Malaria Consortium worked with the regional and district health and education offices, firstly through efforts to improve understanding of malaria symptoms among HDAs, together with a more effective referral process for cases showing danger signs; and secondly through SBCC activities to increase communities’ awareness of malaria and prevention interventions, and for community engagement and mobilisation. For example, in order to improve understanding of malaria symptoms among HDAs, the project developed visual danger sign tools, which illustrate malaria symptoms. These were used for referral, to help villagers lean about the signs and symptoms of malaria, and to trigger discussions on how to prevent malaria.

The brief outlines some of the activities designed to promote behaviour change with respect to the proper and consistent use of long-lasting insecticidal nets (LLINs), early healthcare seeking behaviour, environmental management, and adherence to treatment, which included:

• anti-malaria clubs in schools, which received mini-media kits consisting of a cassette stereo, an amplifier, a loudspeaker, and a microphone to support the running of awareness raising activities within their communities;
• the training of HDA to run ‘community conversations’ using the danger sign tools; and
• mass media that included the development and dissemination of key malaria messages to communities through a mix of radio, mobile vans, and roadshows with music, drama, and competitions.

Some of the key lessons highlighted in the brief include:

• The existing HDA structure offered a unique opportunity to effectively engage the community and was key to the success of many SBCC activities, as HDA volunteers are already seen as role models in their neighbourhood, and community members were more likely to listen to and trust them.
• Anti-malarial clubs set up in selected schools provided an effective gateway to use students to disseminate messages to parents and their wider community.
• The road shows were effective in reaching a larger audience with key messages around proper and consistent use of LLINs and the need to seek early healthcare and adhere to treatment.

The report also offers some recommendations for future investments or scale up of this approach, and to address any gaps. The following are just a selection of these recommendations:

• Qualitative studies need to be conducted to identify factors that contributed to the low use of nets and uptake of other malaria interventions, such as behavioural determinants and community perception.
• Innovative SBCC approaches need to be explored to persuade households to continue sleeping under nets despite reductions in the malaria burden.
• Communication messages for malaria prevention and treatment need to be updated to reflect the changing epidemiology and maintain desired behaviours to achieve and sustain gains as the country is transitioning towards malaria pre-elimination.
• Changes in communities’ behaviour towards malaria prevention and control need to be measured through triangulation of different data sources, such as household surveys, to demonstrate the success of projects with an SBCC component.

Click here for a related photostory on the project's use of SBCC to reduce malaria in Ethiopia.