Socialandbehaviorchangeconsiderationsforareastransitioningfromhighandmoderatetolow,verylowandzeromalariatransmission

December2017

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AcknowledgementsHC3thanksAndrewTompsett(PMI/USAID),DonaldDickerson(PMI/USAID),LawrenceBarat(PMI/USAID),JessicaButts(PMI/CDC),ShelbyCash(PMI/CDC),BKKapella(PMI/CDC),andJimeeHwang(PMI/CDC)fortheircontributionstothisdocument.

ThisreportwasmadepossiblebythesupportoftheAmericanPeoplethroughtheUSAgencyforInternationalDevelopment(USAID)andtheU.S.President'sMalariaInitiative(PMI).TheHealthCommunicationCapacityCollaborative(HC3)isbasedatJohnsHopkinsCenterforCommunicationProgramsandsupportedbyUSAID’sBureauforGlobalHealthunderCooperativeAgreement#AID-OAA-A-12-00058.ThisdocumentwassupportedbytheOfficeofInfectiousDiseaseandPMI.ThecontentsofthisreportarethesoleresponsibilityofHC3.TheinformationprovidedinthisreportisnotofficialUSGovernmentinformationanddoesnotnecessarilyrepresenttheviewsorpositionsofUSAID,PMI,theUSGovernmentorTheJohnsHopkinsUniversity.

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TableofContents

Acknowledgements................................................................................................................2

Introduction...........................................................................................................................4

Background............................................................................................................................4

OverviewofSBCConsiderations.............................................................................................5TransitioningfromAreasofHighandModerateTransmissiontoAreasofLow,VeryLow,andZeroTransmission....................................................................................................................................7

Enhanceandoptimizevectorcontrol..................................................................................................7Enhanceandoptimizecasemanagement:testing,treatingandtracking.........................................10Increasesensitivityandspecificityofsurveillancesystemstodetect,characterizeandmonitorallcases..................................................................................................................................................12Population-wideparasiteclearanceandadditionalornewinterventions........................................12Investigateandclearindividualcases,managefociandfollowup...................................................14

StrengtheningIntegration..............................................................................................................15

RecentMalariaSBCinModerate,Low,andVeryLowAreasofTransmissionIntensity..........16CaseStudy1:Zambia.....................................................................................................................16CaseStudy2:GreaterMekongSub-Region.....................................................................................19CaseStudy3:AmazonMalariaInitiative.........................................................................................21

Conclusion.............................................................................................................................23

Bibliography..........................................................................................................................24

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IntroductionA37%reductioninmalariacasesand60%reductioninmortalityduetomalariainthepast15yearshavesavedanestimated6.2millionlivesandincreasedthelifeexpectancyamongthoseintheWorldHealthOrganization(WHO)AfricanRegionbyalmosttenyears[1].Theglobalcommunityhascalledforevengreaterprogressamongtheremaining3.2billionpeopleatriskofinfection.Tothisend,theWHOGlobalTechnicalStrategy(GTS)goalsincludereducingmalariaincidenceandmortalityratesbyatleast90%,eliminatingmalariain35countries,andpreventingre-establishmentinallmalaria-freecountries.Inareaswithhigh,moderate,low,andverylowtransmissionalike,useanduptakeofmalariainterventionsrelyheavilyoncommunityawareness,demand,andacceptanceofessentialcommoditiesandservices.WhiletheWHOhasrecentlydevelopedamalariaeliminationframeworkandhasanumberofestablishedpolicies,manuals,andrecommendations,detailedguidancedoesnotyetexistforsocialandbehaviorchange(SBC)indifferenttransmissionsettings.WhiletheRollBackMalariaStrategicFrameworkforMalariaSocialandBehaviorChangeCommunicationprovidesstandardapproaches,bestpractices,andindicators,itdoesnotdosoinmalariaeliminationcontexts.ThisdocumentdescribesthelandscapeofcurrentSBCprogramminginsuchcontextsandprovidesanumberofconsiderationsforfutureinquiryandresearch.Thisdocumentdescribeswaysinwhichprogramplannersandimplementersmighttailortheireffortstospecificmalariatransmissionstrataandsuggestsanumberofoperationalresearchquestions.ThreecasestudiesexemplifyconsiderationsraisedanddescribetheroleofSBCinstrengtheningthefightagainstmalaria:

• ThefirstcasestudyfromZambiadescribesasuccessfulinterpersonalcommunication(IPC)approachpairedwithcommunity-ownedsurveillance.

• ThesecondcasestudyfromtheGreaterMekongsub-Regiondescribesmulti-channel,cross-borderinitiatives.

• ThethirdcasestudyfromSouthAmericadescribestheAmazonMalariaInitiative’sregionalcoordination.

Thislandscapedocumentisanimportantfirststepinunderstandinghowtoscale-upandmaintaincoverageofproveninterventionsinallareasandsupportcountriestoeffectivelytransitionfromhighormoderatetolow,verylow,orzerolevelsofmalariatransmission.

BackgroundTheworldhasmadeastonishinggainsinthefighttoendmalaria.Thesegainsarenotevenlydistributed,however,andmayprovereversiblewithoutrenewedcommitmentandinnovation.AchangingepidemiologicallandscapedemandsnewglobalstrategiesandgoalsthattransitionSBCapproachesfromareasofhighormoderatetolow,verylow,orzeromalariatransmission,whilesimultaneouslypreventingreintroductioninareasthathavealreadyachievedmalariaelimination.ThefirstpillaroftheWHOGTSisensuringuniversalaccesstomalariaprevention,diagnosis,andtreatmentforallpopulationsatrisk[2].ThecornerstoneoftheGTSassumes

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adequateandsustaineddemandanduseofavailableservices.Evidencesuggestscurrentdemandanduseofmalariainterventionsisfarfromuniversal.Onlyhalfofsub-SaharanAfricansatriskofmalariasleptunderaninsecticide-treatednet(ITN)in2015.JustathirdofeligiblepregnantwomenreceivedWHOrecommendeddosesofsulphadoxine-pyrimethamine(SP)forintermittentpreventivetreatmentofmalariainpregnancy(IPTp).Only14%ofchildrenunderfivewithevidenceofrecentorcurrentPlasmodiumfalciparuminfectionandahistoryoffeverweretreatedwithanartemisinin-basedcombinationtherapy(ACT)[3].WhileitisimportanttonotethatITNuse,ACTprescription,andIPTpuptakeareheavilyinfluencedbyaccess(whichisincreasing),theimportanceofgeneratingdemandforandbuildingtrustintheselife-savingcommoditiescannotbeoverstated.Ifinterventioncoverageremainsatlevelsachievedbetween2011and2013,amoderateriseinmalariaincidencewilloccurby2030.Ontheotherhand,increasingcoverageofmultipleinterventionsto80%couldresultina40%dropinmortalityby2030comparedto2015levels[4].

OverviewofSBCConsiderationsMalariaSBCconsiderationsinthisdocumentareorganizedaccordingtothecategoriesoftransmissionintensityoutlinedbytheFrameworkforMalariaElimination(Figure1).ShiftsinSBCfocusaredescribedasatransitionfromareasofhighandmoderatetransmissiontoareasoflow,verylow,andzerotransmission.Whereapplicable,suggestionsforSBCoperationalresearchareprovided,andfollowedbyageneraldiscussionabouttheimportanceofstrengtheningintegrationacrossallinterventions.

“Servicedeliveryinmalariaisnotonlyaboutdeliveringproducts;itisalsoaboutensuringtheyareusedproperly.Communicationmethodologiesareessentialtoensuretheappropriateuseofinterventions.”-GlobalMalariaActionPlan

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Figure1:MalariaTransmissionIntensityandSBCFocus

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TransitioningfromAreasofHighandModerateTransmissiontoAreasofLow,VeryLow,andZeroTransmission

“Thefirstpriorityforallcountrieswheretransmissionratesofmalariaarehighormoderateistoensuremaximalreductionofmorbidityandmortalitythroughsustainedprovisionofuniversalaccesstoquality-assuredandappropriatevectorcontrolmeasures,diagnosticsandantimalarialmedicines,togetherwiththeimplementationofallWHO-recommendedpreventivetherapiesthatareappropriateforthatepidemiologicalsetting.Theseactivitiesmustbebackedupbyefficientdiseasesurveillancesystems,robustentomologicalanddrugefficacysurveillance,aswellasstrongpublichealthcommunicationandbehaviouralchangeprogrammes.”-GTS2016-2030Enhanceandoptimizevectorcontrol

WhileITNsandIRSreducemosquitoes’capacitytotransmitmalaria,theyaremosteffective

whenITNuseand/orIRSacceptanceishigh.ResearchdatashowsthatexposuretomalariaSBC

canincreasenetuse,netlongevity(Box1)andIRSacceptance(Box2).

Box1:Evidence-basedITNSBC–MeasuringtheeffectofSBConITNbehaviorsAnumberofstudieshavedemonstratedthatcombiningSBCwithvector-controlprogramshadapositiveeffect

onuseofbednets[5,6,7,8].InCameroon,netusewas10-15percenthigheramongthoseexposedtomalaria

messages[7].AstudyinNigeriafoundthatSBCencouragingnetcareandrepaircansignificantlyprolongthe

lifespanofITNs[9].ThemethodsusedtodeterminetheimpactofSBConnetuseandlongevityinthesestudies

includepropensityscorematchingandintervention-controldesign.TheseexamplesdemonstratethatSBCcan

haveameasurableimpactonITNuseandlongevityandthatthemethodsofmeasuringimpactmaynotbe

prohibitivelycomplicatedorexpensive.

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Inhightransmissionandmoderatetransmissionareas,focusingonindividualbehaviorchange

isnecessarybutinsufficient.Socialchange,shiftsinbehaviorbywholecommunities,is

necessarytoestablishandmaintainacultureofnetuseandIRSacceptance–andcoverage

ratesthatbestowacommunityprotectiveeffect[14].SBCthatencouragesmaintainednetuse

shouldbeongoing,notsimplyrelegatedtoITNpromotionduringmassdistributions.

Considerationsforkeepingcoverageanduse/acceptanceofbothITNandIRShighmaychange

ascommunitiestransitiontolow,verylow,andzeromalariatransmissionintensityareas.For

example,thedurationoftimecommunitiesspendineachlevelofmalariatransmission

intensitywilllikelycontributetobehavioraldeterminantslikeriskandseverity(bothrealand

perceived).Useofbehavioraltheory,programdesign,andtheframingofmessagesabout

Box2:Evidence-basedIRSSBC–CommunityengagementTheRBMActionandInvestmenttoDefeatMalariacallsforahuman-centeredapproachtomalariaelimination

thatbeginswiththosemostaffectedbymalaria,notsimplytreatingthemasrecipientsofaid.Atkinson,

WhittakerandSmithhavepublishedanumberofarticlesoncommunityparticipationinmalariaandother

healthprogramsincludinglessonslearnedfromasystematicreviewofcommunityparticipationininfectious

diseasecontrolprograms[10,11].Theyarguethatthemostcompellingreasonstoengagewithcommunities

willbetheneedtoaddressdecliningperceptionsofrisk.Theauthorsalsoadvisenottoclaimmalariaisthe

mostpressinghealthconcern,asthiswillnotlikelybethecase,butrathertoincludemessagingaboutthe

benefitsandpositiveeffectsmalariareductionhashadoncommunitiesandtodemonstratewhatcanbedone

tosustainthis.Theseauthorsdescribecommunityengagementonaslidingscalebeginningwithcommunity

non-complianceorrejection,ontopassiveacceptance,moderateparticipation,andfinallyactivecommunity

participationandcommunityownership.Atkinsonandcolleaguesdescribethosewithactiveparticipationand

ownershipas“competentcommunities[11].”

TheWHO’sAFrameworkforMalariaEliminationarticulatesthefollowingobjectivesofcommunity

participation:

• Encouragingappropriatehealth-seekingbehavior

• Strengtheningcommunityaccesstomalariatesting,treatmentandreporting

• Promotingacceptanceandappropriateuseofvectorcontroltools

• Empoweringcommunitiestostrengthenself-monitoringanddecision-makingaboutmalaria

• Buildingcommunityandlocalpoliticalsupportforeliminatingmalaria

• Increasingactivecommunityparticipationineliminationactivities,includingasurveillancesystem

linkedtodistrictandothersystemsuptonationallevel.

PromisingPractice:Horizontalparticipatorypracticestostimulatecommunitycontributions[12].The“openspace”approach,ameansofengagingwithcommunitiestodeterminetheirwillingnesstocontributeto

malariareductionefforts,wasemployedintheRuhuhasectorofRwanda.Workshopswereheldtolearnfrom

andcollectcommunityfeedback.Theoutcomesofthisactivityweremutuallyagreeduponactionstoreduce

malariaandplanningforfutureactivities.Thisapproachwasappliedamongcommunitiesthathadseenrecent

reductionsinmalaria(from60%to20%).Usedaspartofanintegratedmalariaeliminationstrategy,the“open

space”workshopsyieldedtwolocalsolutions:theestablishmentofarewardssystemandmalariaclubs.A

subsequentCommunityMalariaActionTeamsinterventionwasconducted.Attheendof2014theseteams

reportedareductionofpresumedmalariacases,attributinggainstoincreasesinuseandacceptanceofIRS

sprayingandcommunity-basedhealthinsurancemembership[13].Localhealthdataindicatedamalaria

burdenreductionof15.5%.Ahouseholdsurveyconducted6monthsaftertheinterventionfoundanincrease

inIRSacceptancefrom94.5%to98.7%,anda47%increaseinpromptcareseekingforfever.

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malariaseverityinareaswherehighmalariatransmissionhasexistedfordecadesshouldlook

verydifferentthanSBCinareaswheremalariahasrecentlybeeneliminatedorre-introduced.

SBCconsiderationsfortransitioningtolow,verylowandzerotransmission:Theimpactof

ITNsandIRSistemporary,andgainsmaybequicklyreversedifuseoracceptancefalls.Froman

SBCstandpoint,themereadoptionandscaleupofbehavioralpracticeisnotenough:

acceptanceofIRSsprayinganduseofITNsmustbemaintainedathighlevels.Whilebehavior

maintenancetheoryisnotyetcommonlyusedtoinformmalariaSBCprogramming,itsfocuson

theroleofmotives,self-regulation,resources,habits,andenvironmentalandsocialinfluences

[15]mayproveusefulwhereITNsandIRShavebeenimplementedforanumberofyears.

EstablishingorreinforcingITNuseinmobile,migrant,andvulnerablepopulationsduringthe

transitionfromhighandmoderatetolow,verylow,andzeromalariatransmissionwillrequire

newmeasurementtoolsandapproaches.Establishedsocialnormsinfixedorsedentary

communitiesmayfunctiondifferentlythaninsmaller,moremobile,moreheterogeneous

groups.Inadditiontousingroutinehealthfacilitydatacollection,theprocessofassessing

behavioral,environmental,andsocialinfluencesamongthosewhoengageinriskybehavior

(notusingITNs,forexample)mayrequirenewsurveysandsamplingtechniques(explored

furtherinthepopulation-wideparasiteclearanceandadditionalnewinterventionssection).Informationgleanedfromthesenewtechniquesmayuncoverbehavioralinfluencesthatdiffer

fromthosecommonamongsedentarygroups.

OperationalResearchQuestions:1. AlmostallstandardmalariaSBCindicatorsmeasureindividualbehaviorchange.Even

thosethatmeasuresocialnormsareenumeratedatthehouseholdlevel.Wouldthe

developmentofanindicatorthatmeasuresacceptableITNandIRSattitudesandbehaviorsatthecommunitylevelprovetobeamoremeaningfulwayofdeterminingif

socialnormshaveactuallybeenestablished?

Box3:Evidence-basedVectorControlSBC–Community-ownedvectorcontrolinthePhilippinesAprograminitiatedinthecommunityofSimbalaninthePhilippinesexemplifiesthekindofcommunity

ownershipthatwilleliminatemalariainthefaceofshrinkingresources[16].Themountainousareahasbeen

relativelyfreeofmalariaforquitesometime,withasinglepocketofstabletransmission.AcombinationofITN

distribution,IRScoverage,anduseofRDTsreducedmalariasignificantly.Theseapproachesareconsidered

successfulbecauseofcommunityownership.Communityactioncommitteesonmalariawereestablishedwith

thehelpoflocalofficials,healthworkers,teachers,andcommunity-basedgroupsthatplannedand

coordinatedmalariaactivities.Thesecommitteesoversawananti-malariabrigadeofvolunteerswhohelped

implementvectorcontrolatmonthlyintervals.Thesebrigadesassistedinhealthpromotion,ITNsurveys,

diagnostictestingandinsomeinstanceshelpedwithIRS.Asmall-scalepublic-privatepartnershipwithlocal

motorbike-taxiassociationswasestablishedtoprovidetransportation,usuallyforfree,insupportofmalaria

control.Thisincludedtransportforpatientsandmovementofbloodslidesandreports.House-to-housevisits

werecarriedoutby“personalsellers”,individualstrainedbyaprovincialhealthofficerwhopromoteduse,care

andrepairofITNsintheircommunities.Finally,educationonmalariatransmissionandvectorcontrolwas

incorporatedintoschoollessons.Acommunityactioncommitteedevelopedtheirownvisionstatement,which

includedthegoalofself-sufficiency–independentofexternalresources.Widespreadcommunity-driven

malariapreventionandcontrolthatmimicstheSimbalancommunitymotivationandenthusiasmwillbean

importantelementofmalariaeliminationinLatinAmerica,SSA,andAsia.

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2. CurrentITNandIRSSBCeffortsareofteninformedbybehaviorchangetheorythat

focusesonadoptionofnewbehaviors.WouldthedevelopmentofprogramsdesignedwithbehaviormaintenancetheoryprovetobemoreeffectiveinareaswhereITNand

IRSusehavealreadybeenestablished?

3. Monitoringshiftsinhumanattitudes,perceptions,andbehaviorswillremainimportant

ascountriestransitiontomoderateandlowtransmissionstrategies.Caninteractive

voiceresponse(IVR)andshortmessageservice(SMS)beusedtoquicklyandinexpensivelydetermineshiftsintheseimportantbehavioralantecedents?

Enhanceandoptimizecasemanagement:testing,treatingandtracking

ThecornerstoneofmalariacasemanagementSBCisincreasingtheproportionofthosewho

seekcareforfeverquickly,particularlypregnantwomenandchildrenunderfive.Program

implementerswhohaveusedthepositivedevianceapproach(Box4)havefoundthat

leveraginglocalvoicesandmodelingbehaviorcanhavepositiveimpactonpromptcareseeking

inhightransmissionareas.

SBCconsiderationsfortransitioningtolow,verylowandzerotransmission:Whileraising

awarenessaboutthebroadspectrumofcausesoffeverisimportantinareasofalltransmission

intensity,itisevenmoreimportantamongcommunitiestransitioningfromhighandmoderate

tolow,verylowandzerotransmissionintensitytoavoidconfusionandconcernaboutthe

increasingnumberoffeverstestingnegativeformalaria[18].Establishingtrustintestresultsis

equallyimportantamongcommunitymembersandserviceprovidersalike.Serviceprovider

SBCactivitiesshouldencourageadherencetonationalmalariacasemanagementguidelinesin

theeventofanegativetestresult,andensureadequatecounselingforfebrilepatientswhodo

notreceivetreatmentformalariawhenpresentedwithanegativeRDT.Thiswillavoidpatient

dissatisfactionandpreventerosionoftrustbetweenpatientsandproviders.TheU.S.

President’sMalariaInitiative(PMI)guidancerecommends“diagnostictestingbecloselylinked

withSBCactivitiesthatfocusonchangingtheexpectationsandpracticesofpatientsand

caregivers[19].”

Ascommunitiesexperiencefewerandfewercasesofmalaria,itmaybemoreeffectiveto

maintainlevelsofperceivedseveritythanperceivedrisk,asriskwill,infact,decreasebut

decreasednaturalimmunitywillmakeimportedcasesmoresevere.

Box4:Evidence-basedCaseManagementSBC-PositiveDevianceIntheGreaterMekongSub-Region,the“positivedeviance”approachwassuccessfullyusedtoincrease

knowledgeaboutmalariaandincreasepromptcareseekingforfever.Theapproachidentifiespeoplewhoare

alreadydemonstratingpositivebehaviorsandturnsthese“positivedeviants”intorolemodelsfortherestof

thecommunity.Thisapproachreliesonrealisticmodelingofbehaviorsbyindividualsthatcommunitymembers

considertobesimilartothemselves.Theapproachhasbeenusedtoimprovebehaviorsinavarietyofcontexts

andpopulationgroups,includingmobileandmigrantworkers[17].

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Epidemiologicalchangesinmalariatransmissionwillalsoshiftdemographicimportancefrom

pregnantwomenandchildrenunderfivetoincludeadultsandmenasallagesandbothsexes

loseacquiredimmunity.SBCinterventionswillneedtofocusincreasinglyonnewparasite

reservoirs(adolescentsandadults)tocontrolseasonaloutbreaksandepidemics[20].The

AmazonMalariaInitiativecasestudy(page25)includestoolsandmaterialsdevelopedforSBC

inCentralandSouthAmerica,whereadultmobileandmigrantpopulations,suchasminers,are

atargetaudience.

Seasonalmalariachemoprevention(SMC)involvestheoccasionaladministrationofafull

treatmentcourseofantimalarialmedicinetochildreninareasofhighlyseasonaltransmission

duringseason(s)ofhigherprecipitation.InareaswhereSMCisimplemented,communitySBC

interventionshavefocusedonraisingawarenessofthesafetyandefficacyofmedicinesand

encouragedcommunityacceptancetomaximizeprotectionandminimizedrugresistance(Box

5).PMIhasidentifiedcommunityhealthworkersasparticularlywellplacedtoidentify

householdswitheligiblechildrenasakeygroupofSBCagents.Reinforcingtrustbetween

communityhealthworkersandserviceprovidersandthosetheyservewillensuredosesgiven

forlaterconsumptionarecompleted.

Whererecommended,SBCshouldbepairedwithIPTpinterventionstoincreaseuptakeatthe

communitylevel.IPTpdeliveryatthecommunitylevelhasbeenpiloted[23]andisinthe

processofbeingscaledupinseveralSub-SaharanAfricancountries.SBCinterventionsshould

encourageANCattendanceinallareas,butparticularlythosewhereIPTpisbeingdeliveredat

thecommunitylevel.IncreaseddeliveryofIPTpshouldnotcomeatthecostoflowerANC

attendance.Agrowingbodyofevidencesuggeststhatserviceproviderattitudes,biases,and

behaviorsareakeydeterminantofIPTpuptake,implyingthatSBCinterventionsthatinclude

supportivesupervisionorparticipatorylearningapproachesmayincreaseserviceprovider

adherencetoIPTpguidelines(seeSBCCforMalariainPregnancy:StrategyDevelopment

GuidanceImplementationKit).The2016WHOrecommendationsonantenatalcarefora

positivepregnancyexperiencerecommendparticipatorylearningactioncycleswithwomen’s

groupstoencourageregularANCcontactsandaddressquestionsorconcernstheymighthave

aswell.

Box5:SBCforSMC:TheACCESS-SMCinitiativerolledoutSMCacrosssevencountriesintheSahelregion

between2015-2017.Knowledge,attitudeandpracticesurveysconductedintheGambia,Guinea,Maliand

NigerfoundhighcommunityacceptabilityofSMC.ExpressedintenttoacceptSMCinthefuturewasalmost

universal.Barrierstoacceptabilityincludedthetasteofthemedicineandconfusionwithotherhealth

campaigns,whileperceivedtreatmentefficacywasoftenlistedasafacilitatortoacceptability.Communication

channelsusedtoreachcommunitymembersandencourageacceptanceincludeddoor-to-doorvisits,

communitydialogues,andradioprogramming.Thosesurveyedoverwhelminglypreferrednurses,doctors,and

communityhealthworkersasmessageagents[21].

TheWHOSeasonalMalariaChemopreventionwithsulfadoxine–pyrimethamineplusamodiaquineinchildren:afieldguideprovidesdirectiononadvocacyforcommunityandsocialmobilizationandbehaviorchange

communication:“DeliveringkeymessagesaboutSMCshouldreducetheriskofmisunderstandingandanynegativeperceptionsaboutthestrategy.Communitymemberscanbeinvolvedinadvocacyforcommunityandsocialmobilization.”Acompletelistofpointstoemphasizeareincludedintheguidance[22].

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Increasesensitivityandspecificityofsurveillancesystemstodetect,characterizeandmonitorallcases

ComponentBoftheFrameworkforMalariaEliminationinvolvestestingallindividualswith

suspectedmalaria.Attimes,malariacasedetectionandreportingwillinvolvetheassentand

participationofasymptomaticcommunitymembers.Thisrepresentsanecessaryshiftin

messagingatthecommunitylevel,requiringattentionfromSBCprogramsandpractitioners.As

areastransitiontotreatindividualswithmalariawhoareasymptomatic,SBCactivitiesmust

substituteemphasizingexclusivetest-before-treatmessagingwithcallstoactionthat

encouragetrustofhealthworkersandtheirnewtreatmentregimens.

Activecasedetection*willbeemployedinlow,verylowandzerotransmissionareas.

Communitiesusedtoactivitiespromotingcareseekingandtestingforfevermaynowneed

messagingtoraiseawarenessandknowledgeaboutwhytestingandtreatmentisnecessaryin

theabsenceoffever.Thissensitizationshouldtakeplacebeforeroll-outandcontinueuntil

activecasedetectionactivitiescease.Asactivecasedetectionishighlyfocalized,traininghealth

workerstoeffectivelycommunicatewithsurroundingfamilies,neighbors,andcommunity

membersisimportant.Ascountriesbegintousepreventivetreatmentmoreselectively,among

smallertargetgroups,ensuringserviceprovidersareequippedasagentsofbehaviorchangeis

increasinglyimportantaswell.Patientcounselingmayreplacemuchoftheworkformerlydone

bycommunityhealthworkersatthecommunitylevelinzerotransmissionareas.

Population-wideparasiteclearanceandadditionalornewinterventions

ApplyinglessonslearnedfromotherinfectiousdiseasesandhumanmovementAshiftinhowweconceptualizethoseatriskofmalariawillrequirechangesnotonlyin

demographicfocus,buttheapplicationoflessonslearnedaboutinfectiousdiseasesandhuman

movementincludinghowtolocate,trackandinfluencebehaviorsofmobilepopulations.Smith

*Detectionbyhealthworkersofmalariacasesatcommunityandhouseholdlevels,sometimesinpopulation

groupsthatareconsideredhighrisk.Activecasedetectioncanconsistofscreeningforfeverfollowedby

parasitologicalexaminationofallfebrilepatientsorasparasitologicalexaminationofthetargetpopulation

withoutpriorscreeningforfever.

LessonsLearned:AsmalariacasesdecreasedinSwaziland,theNMCPconductedyearlyknowledgeattitudes

andpracticessurveystodeterminewhichcommunicationchannelstoprioritize.Basedonthesesurveys,the

NMCPisabletoadjustmessagesandcampaignsfromyear-to-year.ThecurrentSBCstrategyincludesactivities

toencourageuseofchemoprophylaxiswhentravelingtoareasofmalariatransmission[24].

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andWhittakerdescribethreewaysmalariaSBCpractitionersandNMCPprogramplanners

mightre-conceptualizeandrespondtomobilepopulations[25].

First,mobilepopulationsarenotasdifficulttoaccessaspreviouslyimaginedandtherisktheir

travelposesisoftenmisunderstood.Second,regardlessofhowdifficultitmaybetoreacha

particulargroup,workingwitheachpopulationasparticipantagentsintheirownhealthis

moresuccessfulthantreatingthemasrecipientsofoutsideinterventions.Andfinally,a

necessaryshiftinfocusfrommobilepopulationsasdemographicgroups,tomobilityasa

systemisimportant.Thecasestudyoncross-borderSBCinterventionsintheGMSillustrates

thefirstpointinatangibleway(page21).

Thelessonaboutaccessibilitycanbeunderstoodbyexaminingruralfarmsandplantationsin

ThailandandCambodiathatattractmigrantworkers.Theseareasarenotisolated,but

accessibleandconnectedtoroadsandeasilytracedtransportationroutes[23].Itwouldbea

mistaketoassumethatbecausemigrantsaremobile,andmovebetweenruralareasthatare

difficulttotravelto,thattheycannotbeeffectivelyreachedwithSBC.Ratherthanfocusingon

thedemographicandgeographicdifficulties,plannerscanexaminepointsofinterconnection:

wheremigrantsmove,wheretheycongregate,andwhocomesintocontactwiththemmost

often.MigrantsintheGMStravelandstayfordifferentperiodsoftimeandwithvarying

frequency.Reachingthosewhohavechangedresidencepermanently,whotravelperiodically

orseasonally,whotravelforashortterm,orthosewhotravelroutinely,ispossible,butmay

requiredifferentapproaches.Thisrequiresre-thinkingpreviousassumptionsaboutriskandthe

timing,frequency,speedanddurationofhumanmobilitybetweenmalariatransmissionzones.

OnesuchexampleisastudyofmalariatransmissionbetweenmainlandZanzibarandmainland

Tanzania.

Usingcellphonerecordstomeasurethenumberoftravelersanddurationoftheirstays,

researchersdeterminedthatthemajorityoftrafficfromZanzibarwastolowtransmissionareas

onthemainland.Mosttravelersreturnedwithinaweek.Thistravelpatternwasnotfoundto

poseasignificanttransmissionthreat[26].Whileitwouldbeeasytoassumetravelbetween

transmissionzoneswouldfacilitateimportedcasesofmalaria,itisn’tthetravelitselfthatis

important,butspecificorigins,destinations,andrespectivetransmissionlevels,malaria

receptivity,andvulnerability.Thishasbeenclarifiedusingresearchonhowdifferentdata

pointscanbeusedtotrackhumanmovementtodevelopmalariaeliminationstrategies.

Aclearerpictureofwhereand

whenhumanpopulation

movementcausesimportedcases

ofmalariaispioneeredbyPindolia

andcolleagues[27].Theirwork,

supportedbyotherresearch[28],

suggestsSBCpractitionersshould

focuseffortsonpotentiallyinfected

individualsorgroupsmovingfrom

Guyantetal.HumanPopulationMovementRiskIndex

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lowtransmission,highreceptivityareastohightransmissionareasandback,aswellasthose

movingpermanentlyfromhightolowtransmissionareas.Thesetravelersposeagreater

concernforeliminationthaninfectedtravelersmovingtohightransmission,highreceptivity

areasorlowtransmission,lowreceptivityareas.Datacollectiontoolsusefulindetermining

groupsamongmobilepopulationsthatposethegreatestriskincludeindicesofvulnerability,

exposure,andaccess[29].ThisdatawillhelpSBCpractitionerscomparemalariavulnerability

amonggroupsandprioritizeeffortsandresourcesaccordingly[16].

Finally,justasmanyHIVprogramsworkthroughsocialnetworksandpeereducators,and

involvethosetheyareattemptingtoreach,malariaeliminationeffortsshouldworkwiththose

whoengageinhigh-riskbehaviorstoinfluenceandrecruitindividualsintheirsocialnetworks,

focusingnotondemographicgroupsbutonhigh-risksituations[30,31,32].

SBCconsiderationsfortransitioningtolow,verylowandzerotransmission:SBCpractitionersshouldshiftfrommeasuringfixedgeographicallyanddemographicallydefinedpopulationsto

examiningmobilityasasystem,andlookingforwaysofreachingandinteractingwithpeoplein

thatsystemwhosharerisk-takingbehavior.Evidencesuggeststhatencouragingthemtotake

anactiveroleintheirownwell-beingwillyieldpositiveresults.Monitoringhumanmovement,

anddeterminingwhateffectthedirectionofthatmovementwillhaveondifferentareas,will

involveunderstandinganduseofmalariavulnerabilityandreceptivityindexes.Thiswill

necessitateuseofroutinedata,collectedwithgreaterfrequency.

TheGreater-MekongSub-Regioncasestudy(page21)describesSBCinterventionssuchasnet

lendingprograms,trainingnon-registeredmedicinevendors,andIPCwithtravelersatmultiple

pointsonknowntraderoutes.Programsdesignedforlowandverylowareasofmalaria

transmissionshouldbuildonlessonslearnedinthisregion.

OperationalResearchQuestions:1. Inareastransitioningfromhighandmoderatetransmissiontolow,verylowandzero

malariatransmission,mightsnowballsampling[33],aformofrespondentdrivensampling,beusedtoobtainrepresentativesamplingofhardtoreachpopulationsanddeterminingriskfactors?

2. Timesamplingisanapproachthathasbeenusedtoreachgroupswithcommonrisk-

takingbehaviors.Thisapproachinvolvessamplingatasettimeandlocationwhererisk-

takersgather,suchasclubs,bars,marketstalls,orbusstops[34].Ascountriesexpand

pocketsofverylow,low,andzeromalariatransmission,couldtimesamplingbeusedtoreachgroupswithcommonmalariariskbehaviors?

Investigateandclearindividualcases,managefociandfollowup

ComponentDoftheFrameworktoEliminateMalariainvolvescloseinvestigationofeverysingle

malariacase,andthedevelopmentofasystemtofollowupwitheachcase.Riskofre-

establishmentofmalariacanbedefinedasthecombinedeffectofanarea’sreceptivityand

15

vulnerability,whichinturnarefunctionsofecological,climatic,socio-demographic,

epidemiological,entomological,andhealthsystemfactors[1].Receptivityandvulnerability

mustbothbepresentforre-establishmenttooccur.Ifeitheroneortheotherisconsidered

zero,re-establishmentisnotpossible.Useofroutinedataathealthfacilities,traveler

movement,andsurveillancedataaboutallmalariacaseswillbecomeincreasinglyimportantfor

programplanners,particularlyatinlowertransmissionintensityareas.

Channelselectionandprioritizationwillbecomeincreasinglyimportant.Asvectorsofthe

parasitedecreaserapidly,masscommunicationchannelslikeradioandTVwillbecomelessand

lessrelevantaswillwide-spreaduseofhealthworkerstocommunicatewithcommunities

aboutmalaria.

Pointsofentry,includingcountryborders,willbecomeincreasinglyimportantfocalpointsof

malariacommunication.FromanSBCstandpoint,coordinatingwithneighboringcountrieswill

alsobecomeincreasinglyimportant.Thiscanbeaccomplishedthroughparticipationinregional

strategydevelopmentandsharingofbestpracticesthroughSBCcommunitiesofpractice,such

astheRollBackMalariaSocialandBehaviorChangeCommunicationWorkingGroup.

StrengtheningIntegrationThecaseburdenofmalariastrainspublicandprivatehealthsystems.Inhightransmission

settings,malariacomprises50%ofhospitalvisitsandadmissions,andcanaccountfor40%of

publichealthspending,timeandresourcesatpeaktimes[33].However,inareasoflowand

verylowtransmission,evenasmalariacasespersistatlowerfrequency,SBCeffortstoaddress

themmayhavetobepairedwithothercompetingillnesses.Reportedcasesofmalariawill

becomethemostimportantindicatorofprogresstowardseliminationandserviceproviderswill

becomethechiefmeansofcommunicatingwithpatientsaboutmalaria.Asthishappens,itwill

beincreasinglyimportanttoprioritizemessagesandpromotemalaria,emphasizingactionsto

avoidmorethanonediseaseorillness.Infact,theWHOrecommendstakingadvantageof

opportunitiestocommunicateaboutmultiplevector-bornediseases(thosecurrentlyposinga

riskaswellasmalaria)whenpossible.Inareaswhereothervectorbornediseasesarepresentit

maybepossibletopackageSBCmessagingandmaterialsinawaythatprovidesasetof

behaviorsfamiliescantaketoavoidmultipleillnesses.

WhiletightintegrationbetweenNMCPandmaternalandchildhealthandreproductivehealth

unitsisimportantinareasofeverytransmissionintensity,asmalariabudgetsareadjusted,so

toowillthenumberofthoseemployedbythegovernmenttofocusexclusivelyonthedisease.

ItwillbecomeincreasinglyimportantforSBCofficialstoworkwithmultipleMOHunits.Inroads

witheducationandtourismministriesandprivatesectorcompaniesmayprovebeneficialas

well.

Thefirstsectionofthisdocumenthasreviewedmalariainterventions,categorizedbyWHO-

definedmalariatransmissionlevels,discussingSBCrecommendationsforeach.Inthenext

section,threecasestudiesillustrateSBCactivitiesindifferentpre-eliminationcontexts.Each

16

casestudyhighlightschallengesandpromisingpractices,eachpreparedwiththeinputofthe

responsibleimplementingpartners.

RecentMalariaSBCinModerate,Low,andVeryLowAreasofTransmissionIntensity

Thefollowingthreecasestudieshavebeenselectedbecausethedifferentapproachesspanthe

rangeofmalariatransmission,eachofferinguniqueinsights.TheZambiacasestudydescribesa

highlyparticipatoryinterventionthatmayproveeffectiveinhigh,moderate,andlow

transmissionsettings,makingitapragmaticchoiceforcountriesintransition.TheGreater

Mekongprovidesadetaileddescriptionofchallengesinvolvedinreachingandinfluencing

mobileandincreasinglyheterogeneousgroupsofthoseatrisk.Finally,adescriptionof

collaborationbetweenthegovernmentsofLatinAmericancountriesillustratesthedegreeof

cohesionnecessarytosustaingainsinaninterconnectedregion.

CaseStudy1:ZambiaGeneralMalariaLandscape:Asacountrywithmoderatetohighmalariatransmission,Zambia

fitstheWHOdesignationofahighburdencountry.NinetypercentofZambia’s15million

inhabitantsareatriskofmalariainfection.Locatedinaregionwithbothhighburdenand

pocketsoflowerandzerotransmission,ZambiaisasignatoryoftheElimination8(E8)regional

cross-borderinitiativeandhassetacountryeliminationgoalby2020.Whilestilllargelyfocused

onmalariacontrol,Zambia’sparasiteprevalenceandtransmissionvarieswidelythroughoutthe

country,necessitatingstrategiestailoredfordifferentregions.

SBCImplementation:ZambiaNMCP’sstrategiesandactivitiesreflecttheneedsofdifferent

transmissionintensities.SBCimplementationbytheUSAID-fundedCommunicationSupportfor

Health(CSH)projectexemplifiesanapproachwithbenefitsforareasofhighandlowmalaria

transmissionintensity.

CSHimplementedmulti-componentSBCactivitiesinZambiafrom2010-2014.Implementedby

ChemonicsInternational,ManoffGroup,andICFInternational,CSHbuilttheZambian

government’sinstitutionalcapacitytoinfluenceHIV,nutrition,maternalhealth,andmalaria

ChampionCommunitiesIntervention:Interpersonalcommunication

FormativeResearch:AssessmentofbarriersandinfluencingfactorsrelatedtoANCservicesandITNuseSBCapproach:Behavior-CenteredProgramming(BCP)&CommunityChampions

• Keyelementsincludeuseofresearchtodetermineprogramstrategy,tailoredmediamessagesto

addressspecificbarriersidentifiedbyformativeresearch,multi-channelapproach,useofmessage

pre-testing,activecommunityparticipation.

• SixstepsofBCP:1)Situationalassessment2)Behavioralanalysis3)Programdefinition4)Strategic

behavioralchangeactivities5)Communicationsplan6)M&Eplan

• Workingwithcommunitiesasagentsofbehaviorchangeincreasesthelikelihoodofownership.

17

behaviors.CSH’sBCPapproachfocusedonbringingaboutchangeattheindividual,community,

andorganizationallevels.Families,healthworkers,andcommunitymemberswereincludedin

aparticipatoryprocessthatensuredbeneficiariesofSBCplayedanactiveroleinthedesignand

testingofhealthpromotionactivities.Amonganumberofsuccessesdetailedintheproject’s

finalreportisa10-percentage-pointincreaseinregularuseofITNs.CSH’ssuccesshighlightsa

meanswithwhichtoimplementtargetedIPC.TheChampionCommunities’useofcommunity-

generateddata,self-surveillance,andsenseofownershipresultedinpositivebehavioral

outcomes.

FormativeresearchindicatedthatmalariawassopervasiveinthelivesofmanyZambiansthat

itwasoftenviewedasanunavoidablepartoflife.Toaddressthisissue,CSHsetouttoinstilla

senseofurgencyamongthoseaffectedbymalariawiththeSTOPMalariacampaign.Working

withfivelocalcivilsocietyorganizations(CSOs)andcommunityleaders,CSHusedanapproach

theycalledCommunityChampions.CommunityChampionscombinedone-on-onecounseling,

communitymeetings,andmothers’groupswithaformofhouseholddatagatheringthat

helpedmeasureincreasesinbehaviorslikeregularITNuse.Communitymalariacounseling

agents(CMAs)mademonthlyvisitstohouseholdsandusedvisualaidstospeakaboutwaysto

preventmalaria.TheprogramranfromApril2013-September2014ineightdistricts.Oneor

twoCMAsworkedineachparticipatingcommunity,eachresponsibleforIPCto30households.

Aftereachvisit,CMAsrecorded

behaviorsreportedbythose

interviewedonscorecards.

Behaviorsrecordedincluded

care-seekingandappropriate

testingatthefirstsignoffever,

regularANCattendance,and

uptakeofIPTp.Scorecards

indicatedwhatissuesto

prioritizeineachhouseholdon

subsequentvisits.Usingthis

locallycollectedcommunity

data,Zambiangovernment

partnersandCSHmore

effectivelymonitoredthe

programandmadenecessaryprogrammaticadjustments.Forexample,severalcommunities

discoveredthatmanywereseekingcareforfever,butwerenotregularlysleepingunderITNs.

Inresponse,communitieslikeMweenduinMonguDistrictshiftedthefocusofhousehold

counselingsessionstofurtheremphasizeITNuse.CommunitiesintheWesternProvincethat

onceusedITNstofishwereencouragedtoreflectonthepracticeandcomeupwithanaction

plantochangetheunhealthybehavior.Ascommunitiesmettheirownbehaviorchangegoals,

theirsuccesswascelebratedbynamingthemChampionCommunities.

ChampionCommunitiesPerformanceScoreCard

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Potentialefficacyinlowandverylowmalariatransmissionsettings:TheparticipatorynatureofCSH’sChampionCommunitiesinitiativeensuredthatcommunitiessettheirowngoalsand

createdlocalsolutionstohealthissueslikemalaria.Thenotionofcommunitiescollectingand

usingtheirowndatawaspowerfulbecausereductionsinmorbiditywerenoticeable.

CollectingdataisanimportantconsiderationgiventhescalabilityoftheChampion

Communitiesinitiative,asitrequiresasufficientnumberofmotivatedcommunityhealth

workers.Whileresultswerepromisinginsmallercommunities,bringingsuchanapproachto

scalecouldbedifficult.Thischallengemightbemitigatedbyusingadatacohortmodel,where

differentgroupsofpeoplewouldbesurveyedduringdifferenttimeperiods.Community

meetingswouldstillinvolveeveryone,buthouse-to-houseIPCcouldbestaggered,limitingthe

numberofcommunityhealthworkersneededandthetimerequiredofthem.

Replicatingthisinitiative’ssuccessinloworverylowmalariatransmissionareasmightmean

limitingtheactivitytoashort,introductoryphaseamonggroupsnotyetconvincedITNsarean

effectivemeansofpreventingmalaria.Theapproachwouldbedifficulttosustainovera5-year

projectcycleinonearea,butmightbesuccessfulifimplementedindifferentcommunitiesover

time.

TheChampionsCommunitiesapproachmightalsocomplementintegratedcommunitycase

management(iCCM)implementation,asvolunteersareoftenfrustratedbyhavingtoconduct

informationdisseminationwithoutthetools,services,andmedicinestodoanythingaboutthe

illnessitself,particularlyasmanycommunitieswherethisinterventionwasimplementedare

locatedfarfromhealthcenterswithtestsandtreatment.PairingthisapproachwithiCCM

wouldempowerhealthworkerstoplayaroleintreatingfebrilecasesthattestpositivefor

malaria,orreferthosewithseveresymptoms.Additionally,usingpassivecasedetection,would

addressbothvolunteerworkloadandprovideasamplingmechanismininterventionareas.If

theinterventionareamoved,theareawhereimplementationpreviouslytookplacecouldbe

coveredwithactivecasedetection,maintainingvolunteeractivitywithoutdemandingexcessive

orunrealisticamountsofwork.

TheChampionCommunitiesapproachillustratesseveralconsiderationspreviouslydescribed.

Thisparticipatoryapproachcombinesfrequentdatacollectiononcommunitybehaviorswith

IPC.Theapplicationofthisapproachinlowandverylowmalariatransmissionsettingscould

relyonfrequentdatacollectionanddisseminationatthecommunitylevel,nottoshow

dramaticcasereductions(aschangesatlowerlevelsoftransmissionwouldnotlikelybeas

dramaticallynoticeable),butaspromptsandreminderstomaintainhealthybehaviors.

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CaseStudy2:GreaterMekongSub-Region

GeneralMalariaLandscape:Ascountrieswithhigh,moderate,low,andverylowmalaria

transmission,China,Thailand,Cambodia,LaosPDR,Vietnam,andMyanmarfittheWHO

designationofhighburdencountries.Fifty-fivepercentofmalariacasesandmostdeathsinthe

GMSareduetoPlasmodiumfalciparum.Inresponse,GMScountriescommittedtothegoalof

anAsia-Pacificfreeofmalariaby2030atthe9thEastAsiaSummit,heldinMyanmarin

November2014.TheStrategyforMalariaEliminationintheGreaterMekongSub-Region2015-2030outlinesprioritiesandobjectivestoachievethisgoal[35].

Overthepastdecade,malariapreventionandcontroleffortsintheGMShaveresultedina

significantdeclineincases.Withanestimated450,000confirmedcasesacrosstheregion

annually,healthpractitionersaredesigningtheirstrategiesformalariaelimination,withan

ultimategoalofeliminatingP.falciparumby2025andallmalariaby2030[36,37,38].

However,progresstodateisseverelythreatenedbythedevelopmentofresistanceto

artemisinin.WhiletheThai-Cambodianborderisconsideredtheepicenterofartemisinin

resistance[37],prolongedparasiteclearance,anearlywarningsignofresistance,hasbeen

identifiedalongtheThai-BurmeseandBurmese-Chineseborders,aswellasinsouthern

VietnamandLaoPDR.Thevastnumberofmobileandmigrantpopulations(MMP)livinginthe

regioncomplicatenationalcontainmentefforts,astheymovethroughhigh-risktransmission

areasandaredifficulttodiagnose,treat,andtrackduetoroutinetraveling.NotonlyareMMPs

difficulttomedicallytrackandfollow,theyalsooftenavoidinteractionwithpublicservices

becauseofundocumentedstatusortheinformalorillegalnatureoftheirwork.Additionally,

frequentmovementoftenleadstoincreasedrisk-takingbehaviors,which-alongwithlanguage

barriers,legalstatusissues,andlowersocio-economicstatus–preventMMPsfromreceiving

ITNsandprompttreatmentforfever.

Inresponse,healthpractitioners,countryleadershipandnontraditionalpartnershavecome

togetheraroundtheideaofeliminationandcontainmenttodevelopinnovativecommunication

strategiesforMMPsandensureconsistentmalariamessagesforthosewhoresideoneither

sideoftheborder.

SBCImplementation:ControlandPreventionofMalaria(CAP-Malaria),aUSAID-supported

projectthatimplementedmalariapreventionandtreatmentinterventionsintheborder

regionsofThailand,CambodiaandBurma,describesseveralwaysunderstandingmobilityasa

systemhasbeenusedtoengagewithatriskmobileandmigrantpopulations.Implementedby

CAP-Malaria’sApproachesforReachingMobileandMigrantPopulationsInterventions:Twin-citiesapproach,netlendingprograms,trainingnon-registeredproviders,transitmedia,

massmedia,IPC/communitymobilizationwithvillageandmobilemalariaworkersandhealthstaff

FormativeResearch:Baselineassessment,Burma,Cambodia,Thailandgenderassessments,AssessmentofITN

LendingScheme:PerceptionsonaccesstoandutilizationofITNsamongmigrantworkersSBCapproach:AddressingmobilityasasystembyinitiatingInterpersonalcommunicationwithtravelersat

multiplepointsonknowntravelroutes,aswellasindestinationworkplaces.

20

theUniversityResearchCo.LLC(URC),SavetheChildren,andtheKenanInstituteAsia,theCAP-

Malariaprojectranfrom2016-2017,withcross-borderactivitiescontinuinginto2017.CAP-

MalariafocusedonimprovingMMPs’accesstohealthinformationandservices.

Asmentionedearlier,MMPsareoftenconsideredhardtoreachbecausetheyarenotaseasily

identifiedoraccessedthroughtraditionalSBCapproaches.CAP-Malariaactivitiesdemonstrate

thatitispossibletoeffectivelycommunicatewiththesegroupsbydesigningactivitiesaround

specificsub-groupsandtheircharacteristics,socialnetworks,pointsofcontactandmigration

patterns.

CAP-Malariaidentifiedandworkedwithhotspotsandtouchpointstocommunicatewithits

prioritizedgroups.Forexample,toreachpopulationsconnectedtotheagriculturesector,CAP-

Malariadevelopedpartnershipswithprivatesectorcompanies.ITNlendingschemeswere

developedtoencouragefarmsandplantationstoexpandnetcoveragetohighlymobile

employeesforthedurationoftheirstay,expandingcoveragetothosenotreachedbyuniversal

coveragecampaigns.ITNlendingactivitiesalsoprovidedanopportunityforemployeesto

receivetailoredmalariamessagesthroughIPC,achannelthatdoesnotrequiretheaudienceto

overcomecommonhurdleslikereadingpamphletsorbillboards.AsMMPsinMyanmarhave

beenfoundtoself-medicateanddelaytreatmentseekingduetostigmatization,lackoffinancial

resources,andlongdistancestohealthcenters,engagingwiththeminpreventionactivitiesis

particularlyimportant.

CAP-Malariaactivitiesengagedmobilegroupsnotonlyinplacesofwork,butintouchpoints

throughouttheirjourneytoandfromareasofemployment.Onesuchactivityinvolvedworking

withbusandtaxidrivers.CAP-Malariaprovideddriverswithtrainingaboutmalariaprevention,

treatmentandlocalservices;aswellaspromotionalmateriallikeCDs,DVDs,stickers,seat

coversandbrochureswithmalariamessages.Throughthisapproach,nearly20,000passengers

(5,000ofthemestimatedtobeMMPs)wereexposedtomalariamessageseachmonth[39].

TheRaksThaiFoundationandtheAmericanRefugeeCommittee(ARC)usedasimilarapproach

wheretheycreatedbilingualSBCmaterialsthatpromotedmalariahealth-seekingbehaviors.

Thesemessageswerewornbymotorcycledriversandusedasfabriccoversforboats.

Beyondprevention,CAP-Malariaactivitiesfocusedonexpandingaccesstotestingand

treatmentaswell.CAP-Malariaaccomplishedthisbydesigningactivitiesthatcoordinated

betweensedentarypopulationsandMMPsub-groupstheyinteractwith.Withthe

encouragementoftheMyanmarNationalMalariaControlProgram,CAP-Malariaworkedwith

employerstoidentifyandtrainnon-registeredprivatehealthproviders,locallyreferredtoas

‘quacks,’whowereoftenthefirstpeopleMMPsorvillagerswouldgotofortreatment.Using

thismodel,employerswereaskedtoidentifynearbyquacksorothervolunteers.CAP-Malaria

providedtrainingandquality-assuredrapid-diagnostictestsandACTstothoseselectedto

ensurecontinuousandqualitycoveragetocommunities.Theyalsorecruitedandtrained

mobilemalariaworkersandclinicsinremotecommunitiesandprovidedthemwiththesupplies

totestandtreatmalariacases.Mobileclinicswerescheduledonceortwiceamonth,

dependingonthespecificsub-group’smalariaprevalence.Byleveragingtheseestablished

21

socialnetworks,CAP-Malariawasnotonlyabletoreachtheirtargetaudiencebutalsoformed

partnershipswithleaderswhocouldhelpsustainmessagedelivery,monitorcasesandevaluate

programimpact[39,40,41].

SuccessesdetailedinCAP-Malaria’sfifthyearworkplanincludeadecreaseinincidence,from

22.3casesper1,000in2011to11.4in2014forCAP-Malaria’stargetareas[42].CAP-Malaria’s

work,consistentwiththeWHOstrategyforthesub-region,usedhumanmovementpatternsto

determinewheretoprovidetreatmentbeforeandaftertravel,aswellasinplaceswhere

MMPswork.

CaseStudy3:AmazonMalariaInitiative

Asshowninthepreviouscasestudy,anindividualcountry’spotentialtoeliminatemalariais

oftendependentonthesuccessofitsneighbors.TheAmazonMalariaInitiative’s(AMI)

illustratesthenecessityofstrengtheningcommunicationstrategiesandSBCimplementation

throughsystemsstrengtheningandregionalcoordination.

GeneralMalariaLandscape:Malariaisendemicin21CentralandSouthAmericancountries,

endangeringanestimated132millionpeople[38].With24%oftheregion’smalariacases,

Brazilbearsthehighestmalariaburden,followedbyPeru(19%)andColombia(10%)[43].

PlasmodiumvivaxmakesupthemajorityofmalariainfectioninSouthAmerica,although

Plasmodiumfalciparumcasesmakeupasignificantportionaswell.Since2010,malariacase

incidenceintheAmericashasfallenby31%.Mortalityhasbeenreducedby37%.Between2000

and2012,Belize,Ecuador,Guatemala,Honduras,Nicaragua,andSurinamereducedmalaria

incidencebyover75%.However,specialpopulationslikemigrantsandindigenousgroupsface

adisproportionatediseaseburdenandrepresentalargerproportionofcases.

Toaddressthis,aneleven-countryregionalprogramcalledAMIwasintroducedandsupported

byUSAID.AMIwaslaunchedin2001withafocusongeographicareasconsistingof88%of

LatinAmerica’sPlasmodiumfalciparuminfections.Participatingcountriesandtechnical

partnerscametogetherinacollaborativedecision-makingmodelwiththegoalofeliminating

malariainCentralandSouthAmerica.ThegroupwasmadeupofBrazil,Colombia,Ecuador,

Guyana,Peru,Suriname,Belize,Guatemala,Honduras,Nicaragua,andPanama(aswellas

formerparticipantsVenezuelaandBolivia).

RegionalMalariaSBCStrategyCoordinationandSupportInterventions:Strategydevelopment,coordination,resourcemobilization,systemsstrengtheningFormativeresearch:Countryassessmentsconsistingofin-depthinterviewswithNMCPsandvalidationof

approacheswithPAHO/WHO.

SBCapproaches:• Cross-bordercollaboration,keypopulationengagement,multi-sectoralengagement,technical

assistance

• Lessonslearnedaboutcollaborationandcollectiveworkplanningwillbenefitotherregionslookingfor

bestpractices.

22

SBCImplementation:AMI’sframeworkofsixinterventionsincludedantimalarialmedicine

resistance,diagnosticqualityassuranceandaccesstodiagnosis,antimalarialmedicinequality,

antimalarialmedicineaccessanduse,vectorcontrolandentomologyandcommunicationand

informationdissemination.LINKSMEDIAsupportedthedevelopment,adoptionand

implementationofAMISBCactivitiesfrom2013-2016.Responsibilitiesincludedcommunication

strategydevelopmentandcoordinatingSBCeffortsbetweenthePanAmericanHealth

Organization(PAHO),PMI,theAmazonNetworkfortheSurveillanceofAntimalarialDrug

Resistance(RAVREDA)andNMCPofficesineachcountry.

AMI’sstructurewasdesignedtocombineindependentorganizationsandtheirworkplans

underthedirectionofPAHO’sDirectingCouncil.Usingthismodel,eachorganizationdeveloped

workplansfortheirparticulardomain(laboratoryimprovement,policy,leadershipand

governance,systemsstrengthening,communicationetc.)beforecomingtogethertocombine

thoseplansunderasingle,alignedworkplan.Borderingcountriesmettwiceayearinpersonto

discussopportunitiesforintegrationandcoordination.TheAMImandateforeachgroupto

workwiththeotherscanbecreditedwithmuchofitssuccess.

UnderPAHO,LINKSMEDIAworkedtoincreasetheevidencebaseformalariaSBCbybuilding

countries’capacitytoshareexperiencesthroughpeer-reviewedliteratureandexchangingideas

atsemi-annualin-personmeetings.LINKSMEDIA’sportfolioalsoincludedassessingtheSBC

needsofthe11participatingNMCPsintheregion,facilitatingthedevelopmentofnationaland

regionalmalariacommunicationstrategies,creatingtoolsandguidanceformalariaresource

mobilization,coordinatingNMCPs,MOHs,donorsandimplementingpartnersunderPAHO’s

DirectingCouncil,andfosteringregionalsharingofbestpracticesandresources.

The2015-2020StrategicMalariaCommunicationGuideforCentralAmericaincludedregional

SBCsub-strategiestoaddressissuesliketargetingprogramstoatriskmobilepopulationsand

ensuringstakeholderbuy-in[44].Thestrategyincludedcommunicationobjectivesand

messagesforMMPs,includingtourist,indigenousandmigrantpopulations.Italsoadvocated

forimprovedcommunicationbetweenhealthserviceprovidersandindigenousandmigrant

populations,andencouragedimprovedcross-bordercoordinationandinformationsharingto

avoidmissingcasesanddoublecounting(especiallydataonresidentsofbordercountrieswho

travelfrequentlyandmayhavebeendiagnosedineithercountry).Thestrategysuggested

leveragingandestablishingregionalforumsandmeetingstocoordinateeffortsandcreate

communicationmaterialsformigrantpopulations.

InadditiontoregionalSBCstrategydevelopment,LINKSMEDIAworkedwithnational

representativesfromsixcountriestodevelopcountry-specificcommunicationstrategiesfor

Brazil,Colombia,Ecuador,Guyana,SurinameandPeru,severalofwhichincludedstrategies

focusedonspecific,localmigrantgroupsatriskformalaria.Tofacilitatecountryownership,

LINKSMediaprovidedtechnicalsupportthroughwebinars,materialsdevelopment,meetings,

andinternalmonitoringopportunities,suchasaskingcountrieswithhigherstaffcapacityto

superviseotherlower-capacityteams.

23

Regionalstrategydevelopmentandsystemsstrengtheningwaspairedwithworkatthenational

levelaswell.In2014,LINKSMEDIAworkedwithGuyana’sVectorControlServicesandPAHOto

developanationalstrategythatfocusedonminersandtheirrationaldruguse[45].Theyalso

workedwithVectorControlServicestodevelopSBCmaterialsforusebyhealthprovidersin

remotelocations.LINKSMEDIAalsocollaboratedwithSuriname’sBureauofPublicHealth

(BOG)andPAHOtocreateastrategytoimprovemalariamanagementamongartisanalmigrant

goldminersworkinginareasonSuriname’sborders(FrenchGuyanaandBrazil)[46].Messages

weredesignedaroundthegroup’sparticularcharacteristicsandbehaviors(e.g.,theywerenot

completingtheirtreatmenttosavedosesforfutureinstancesandlackedawarenessoffree

malariatestingandtreatment).Theteambasedtheirstrategyona2013KAPsurvey,which

foundthat“geographicinfluencesweremorepowerfulthanindividualbeliefsindetermining

theuseofhealthfacilitiesandpropertreatmentamongthispopulation.”TheSuriname

strategyalsofeaturedasub-strategyforthoseinroutinecontactwithminers(e.g.,

accompanyingspouses,sexworkersandcooks),audiencesthatshouldbeconsideredbyother

pre-eliminationcountriescommunicatingwithmobilepopulations.Inaddition,bothGuyana

andSurinameincludedadvocacymessagingtogovernmentdecision-makerstoadvocatefor

continuedsurveillance,plantocoordinatecommonissuesandsharedatathroughmeetings

withborderingcountries.

TheAMIcasestudydescribeshowtocombinesystemsstrengthening,strategydevelopment,

resourcemobilization,andregionalcoordinationtoeffectivelyfightmalariainaregionwith

highlystratifiedtransmission.AnintermediateperformanceevaluationofAMIactivitiesfound

thattheinitiativeplayedamajorroleinthedeclineofmalariaincidenceinLatinAmericaand

theCaribbean[47].Thisdeclinewasdescribedastheresultofimprovedtreatmentand

diagnosisofmalaria,theintroductionofITNs,moreefficientmanagementofnationalprograms

andworkwithhigh-riskpopulations.

ConclusionOverthepast50years,malariapreventionandcontrolhasbeendefinedlargelyintermsof

provisionofmedicalcommodities,insecticides,andclinicalguidanceoncasemanagement.

Morerecently,significantstrideshavebeenmadeinputtingpreventivetoolsincludingITNsin

thehandsofcommunitiesatrisk.Thishasincreasedthedegreetowhichthosewhosufferfrom

malariainfectionareabletoparticipateinandcontributetotheirownwell-being.Country-

wideSBCcampaigns,thehighvisibilityofmalariainfection,andresultingsocialunderstanding

andcommunitynormsevolvesastransmissionisfurtherreduced.Atthesametime,economies

ofscaleandcostsavingsinherentinpopulation-levelSBCactivities,suchasmass-media

campaignsandnationallyrepresentativehouseholdsurveymeasurementtools,willbe

renderedaninappropriatemeansofmeasuringandreachingincreasinglyhomogenousat-risk

groups.TheRBMAIMcallsforhuman-centeredapproachestomalariapreventionand

elimination.Thislandscapedocumentexploredanumberofwaystoensurethatontheroadto

globalmalariaeradication,provisionofmedicalcommoditiesandclinicalservicesare

adequatelypairedwithahuman-centeredSBCresponsewithinspecificmalariatransmission

strataandsuggestedanumberofoperationalresearchquestionsforfurtherexploration.

24

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