Helping to fight malaria with positive deviance volunteers

Wanweena Tangsathianraphap, External Communications Officer for the Asia region, visited Ratchaburi province in Thailand to report on Malaria Consortium’s Positive Deviance project.

At the community centre in Bor Wee village, Ratchaburi province in the western part of Thailand, a group of 14 positive deviance volunteers were conducting a role play on how to protect oneself from a mosquito bite. A mosquito net had been hung up and a volunteer acting as a mother was encouraging her children to sleep under it. It is simple thing to do, but can yield great results for malaria prevention if the behaviour is adopted by all villagers in the community.

The threat of malaria still exists in Bor Wee village. When Malaria Consortium’s team spoke to the children who participated in the latest positive deviance session, two thirds of them said they had contracted the disease more than once and thought that malaria was just a mild illness, similar to a common cold.

Dao Horla, one of the community health volunteers, shared her story with us: “My child once had a fever from malaria. I had to walk five kilometres to take her to see the doctor at the nearest clinic. At that time, I did not even know what had happened to my girl. She had very high fever and cried from pain. I was so afraid I might lose her.”

Dao and her youngest daughter
Dao and her youngest daughter

Dao’s house is located near a stream and is built in the typical hill-tribe style, on the side of a hill with an open door and window. “I did not realise that I have to use a mosquito net to protect my children. They love to play outside near the stream, and they did not always sleep under the mosquito net. But since I learnt about malaria, I make sure they sleep under the net every night. I do not want them to get malaria or any other mosquito-borne diseases again,” said Dao.  As a mother of five, she understood the pain and suffering children undergo because of malaria, and has now volunteered to learn more about the disease and to help raise awareness about malaria in her own community.

“My children no longer get malaria and I would like to tell my neighbours how to protect themselves and their families,” said Dao.  Her story is one of the several positive deviance tales that are being shared among the community members.

According to a report by the World Health Organization (WHO) and Department of Disease Control, Ministry of Public Health Thailand, the malaria incidence rates in parts of Thai-Myanmar borders are still high compared with the overall rates for Thailand. This high prevalence is due to the surrounding thick forest environment and the mobile population. With the natural borderline of Tanaosri mountain range, people in the area usually stay overnight in the forest either for work or to travel across the border to Myanmar. Over 80 percent of malaria patients live on this border. It is estimated that 70 percent of the patients diagnosed with malaria are adult males, who are likely to work in the forest.

Dao shares her story with the community
Dao shares her story with the community

Baan Huay Pak village is approximately 16 kilometres from the Thai-Myanmar border. Korwa Jorod, known by his community as Uncle Korwa, described his experiences of malaria to Malaria Consortium’s representatives.

“Most men in this area work in the forest and along the border. They usually come home late at night or during the next day. Sometimes they get sick. They are not careful about protecting themselves. I used to be the same,” said Korwa.

“I used to be careless and go to the forest without any protection from mosquitoes and, as a result, I kept getting malaria again and again. I didn’t think it was very serious until a local health organisation visited the village and told us about malaria. I then realised how dangerous the disease really is. My perception was drastically altered. So I joined the volunteer programme to learn more about malaria. I am so glad that I am now much better informed and also that I have a part in helping my community. Protecting people from mosquito bites is the best way to prevent malaria,” Korwa explained.

Uncle Korwa shows a picture from the IEC material which demonstrates how to protect oneself in the forest.

Apart from being a community health volunteer, Korwa is also the religious leader in the village, and is a member of the community river committee. His roles give him many opportunities to interact with villagers on a regular basis.

“I talk to the villagers like I’m their relative,” Korwa told Malaria Consortium. “Of course, not everyone will listen to me, but I will do my best in my role. One volunteer may not control the disease, but together we may create some changes. Importantly, I know I have the support of the other volunteers and the staff from Malaria Consortium and the Pattanarak Foundation. This encourages me. I feel that every life is worth living and I will do my best to save them.”

Both Korwa and Dao are part of the pilot activity on community mobilisation through positive deviance volunteers. Six villages in a high-risk area of Ratchaburi province were selected to apply this innovative approach on behaviour and social change.

Uncle PD
Uncle Korwa shares his lessons with the community

Funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria, the community mobilisation through positive deviance project is conducted by Malaria Consortium in close collaboration with the Pattanarak Foundation, a local non-profit organisation, as an attempt to improve malaria prevention methods in hard to reach and vulnerable communities. Since the project was launched in April 2014, more than 20 community health volunteers have been recruited and trained. Their work is vital to help bridge the gap between the community and the health authorities. This pilot in Thailand will provide learning about this approach and evidence of impact and, if successful, can be scaled up across the country.

Malaria Consortium’s behaviour change communication project

Monica Posada is Malaria Consortium’s behaviour change communication (BCC) technical specialist for the Asia region. She recently visited Cambodia in order to conduct research into behaviour change communication strategies at cross-border sites in the Greater Mekong Subregion (GMS).

Malaria Consortium has conducted a behaviour change communications (BCC) assessment project in Cambodia to assess how effective these strategies are when it comes to improving health conditions, particularly among vulnerable groups.

Behaviour change communication strategies are used to help prevent the spread of diseases by encouraging positive behaviour within a community. By assessing current BCC methods, the intention is to provide recommendations as to how this approach can be improved in the region, and rolled out on a larger scale.

The assessment included a review of BCC strategies and guidelines in Myanmar, Thailand, Cambodia and Laos, and investigated how these are being implemented and targeted toward vulnerable groups. In particular, the assessment focused on BCC interventions among migrant and mobile populations, who travel and work along key border sites where there is a threat of spreading the artemisinin resistant malaria parasite.

PD 4

A local family showing their hammocks and LLIN at their house in Battambang, Cambodia.

A research team conducted a seven day visit to the cross-border areas of Pailin and Battambang in order to conduct focus group discussions and in-depth interviews. More than 104 participants, including migrant populations, community leaders, community health workers, and NGO workers joined the study.

The interviews and discussions provided a chance to better understand the preventive and treatment-seeking behaviours of at-risk populations. For example, villagers were able to provide feedback on the quality and size of long lasting insecticidal nets and the barriers to treatment for malaria at the community healthcare centre.

The most interesting part of this study was to see that the chief of villages and village malaria workers had a considerable degree of trust among the local, migrant and mobile populations. The BCC approach, which relies on strong interpersonal communications and the discussion of best practices in preventing diseases, seems to be a very effective channel for health education.

Helping to eliminate the threat of dengue in Cambodia with Malaria Consortium

Vanney Keo is a Malaria Consortium field assistant, who has been working in Cambodia.

I have been working for Malaria Consortium on a Regional Integrated Vector Management Project in Cambodia, where we have been collaborating closely with the National Dengue Control Programme (NDCP). At a project closing event in the Mongkol Borey district of Cambodia, many community members thanked me for my role in sharing best practices on how to prevent dengue fever. I thought then that I would share my experiences working on this project.

The purpose of the project was to develop community-based methods to improve prevention, recognition and reporting of dengue. The positive deviance (PD) focus of the project involved identifying community members who, despite sharing similar living conditions and resources as the rest of the community, already demonstrated positive behaviours for preventing dengue. These individuals were encouraged to share what they did to preserve their health with the rest of the community by becoming PD volunteers.

At the start of the project I helped to select 16 PD volunteers who were both willing and able to share methods for preventing dengue. This meant four volunteers for each selected village throughout the Banteay Meanchey province. As well as speaking at meetings and seminars, the volunteers visited each household in their allocated village at least twice a month. One benefit of using volunteers from the community to help raise awareness of disease prevention behaviours is that they are recognised in that community and can help to galvanise support for educational events.

It was my responsibility to schedule community meetings so that PD volunteers were able to give seminars on preventing dengue. Their prevention methods include advising individuals to sleep under a mosquito net, even during the daytime; always disposing of containers and cans which can accumulate water; keeping children away from areas with high concentrations of mosquitoes like the forest; wearing long-sleeve clothes, particularly in high-risk areas; using guppy fish in water containers to limit the growth of mosquito larvae; and highlighting the importance of cleanliness.

I kept in regular contact with the volunteers to ensure that their methods were being picked up by the community. By coordinating with the village members on a regular basis, I acted as a bridge between the volunteers and health specialists from NDCP and Malaria Consortium, and helped to monitor the changes in the behaviour of community members.

On one occasion, I helped to organise an event where the villagers were encouraged to create posters explaining the dengue prevention methods they had been taught by the PD volunteers.

One of our seminars was attended by the majority of community members across all four villages (Khtum Reay Keut, Anlong Thngan Keut, Bat Trang Thum Keut, and Bat Trang Touch). Competitions were organised in order to increase community participation, and involved quizzes for the community’s children, which aimed at increasing their understanding of dengue and the threat of mosquitoes.

Here, a young girl says that she has learnt that dengue fever is transmitted by the bite of a tiger mosquito.

Positive Deviance volunteers also used the opportunity of cross-community events to give speeches, encouraging community members to continue spreading the messages after the closing ceremony. One positive deviance volunteer said, “Now the households of our community are very clean, and I’m really happy that you have all followed our suggestions”.

A positive deviance volunteers thanks community members and urges them to continue implementing preventive methods to protect themselves from dengue.
A positive deviance volunteers thanks community members and urges them to continue implementing preventive methods to protect themselves from dengue.

These events, and the participation of community members, required the approval of respected leaders within the villages. This meant I frequently met with the village chiefs in order to provide updates on the project and to address any concerns. By the end of the project, I believe that we had successfully broken a cycle of dengue as all of the villagers were maintaining good standards of cleanliness in their home, and were always sleeping under a net. I’m confident these methods will continue now that the project has ended.

The positive deviance volunteers at the end of the project.
The positive deviance volunteers at the end of the project.




My first week with Malaria Consortium: Positive Deviance in the Suan Phueng district of Thailand.

Pavan Singh works as an external communications volunteer at Malaria Consortium’s Bangkok office. As part of his six month placement, he visited a remote village in Thailand to get a first-hand account of Malaria Consortium’s Positive Deviance project.

As a GlaxoSmithKline (GSK) Pulse Volunteer, I joined Malaria Consortium’s Bangkok team at the start of July for a six month work placement. The PULSE Volunteer Partnership is GSK’s skills-based volunteering initiative. Through PULSE, selected employees are matched to a non-profit organisation for three or six months full-time, contributing their skills to help meet healthcare challenges.

Following orientation and training, I undertook a two-day field visit to learn more about Malaria Consortium’s Positive Deviance project being implemented in a small village in the Suan Phueng district of Ratchabury province in Thailand, close to the border with Myanmar. There is growing evidence of the emergence of artemisinin resistance along the Myanmar-Thailand border and significant efforts have been underway for a number of years to contain its spread. The transmission of a malaria parasite which is immune to the artemisinin vaccine could have catastrophic consequences in the fight against malaria.

Many migrant workers in this area of Thailand look for work during planting or harvesting seasons, and frequently cross borders with their families and stay for several months. For these communities, malaria is one of the most common diseases, and there is a risk of spreading a drug resistant parasite across borders.

Positive deviance involves identifying people who, despite sharing similar living conditions and resources with the rest of their community, are already demonstrating positive preventive and care-seeking behaviours. These individuals are encouraged to share those behaviours with the rest of their community. The strategy has been implemented in a number of countries to identify positive behaviours associated with newborn health, family planning, female genital mutilation and HIV/AIDS. Malaria Consortium is the first to implement the strategy for malaria control.

The pilot villages were identified based on the presence of mobile and migrant populations in high risk areas for malaria throughout Thailand. The men work in the rice fields until late, and the village is surrounded by forests. The risk of being infected by a malaria parasite-carrying mosquito is high, and there is a chance that an infected person could then spread the parasite.

I attended a community meeting which began at in the early evening and was attended by 25-30 villagers. Five positive deviance volunteers spoke and shared best practices to avoid being bitten by a mosquito, including advising to always sleep under a mosquito net, to always wear long-sleeved shirts and long trousers when working in a field, and to immediately go to the health centre for a blood test if suffering from malaria symptoms.

Villagers who work in the fields are particularly at risk of contracting malaria.
Villagers who work in the fields are particularly at risk of contracting malaria.

It was clear to me that the simple practices and solutions being shared by trusted members of a community made a big impact on the villagers. After each volunteer spoke, behaviour change specialists and project staff reinforced the key messages around malaria prevention and control. The meeting was conducted in English, then translated into Thai, and further translated into Karen, the local language, by Anusha from the Pattanarak Foundation, Malaria Consortium’s implementation partner on this project. This process was exhilarating to watch, and it was very rewarding to see life-saving messages being translated and successfully conveyed to people in the community.

Worth mentioning is that the language barrier is just one difficulty to be overcome when organising and implementing positive deviance activities. It is challenging to organise and motivate people to attend, especially in remote villages. Positive deviance volunteers have to conduct sessions sometimes at the convenience of the community, matching timings for as many members of the community as possible, organising a location, and making sure that the methods taught in seminars by volunteers are fully understood.

Community members attending the positive deviance meeting.
Community members attending the positive deviance meeting.

The following day we returned to the village for a feedback session. The objective was to consider further interactive tools for communication and to improve the quality of the meetings. As a result, we decided to provide further training to the positive deviance volunteers.

I have now been working with Malaria Consortium for just over a month, and my colleagues have returned to the village in Suan Phueng to provide further training to volunteers and improve integrated community healthcare and prevention techniques. It has been very interesting to see how Malaria Consortium projects work at community level and the challenges associated with disease prevention and control.

A new cross-border approach in the move to malaria elimination

The booth with its big banner catches your eye as you approach Phsar Prum, on the Cambodia border with Thailand. There are people there, clustered under the multi-language message about malaria and the colorful logos representing Malaria Consortium and our project partners. Once you pass through the checkpoint, a Malaria Consortium field assistant in a bright green jersey approaches, asking permission to talk with you about malaria, offering you a chance to be tested.

The team is good at what they do. The village chiefs, local health workers and the ‘Village and Mobile Malaria Workers’ are actively engaged and, though it’s only two weeks since the project launched, over 500 people have already been screened at checkpoints in Steung Treng, Rattanakiri and Pailin provinces.

“We explain very clearly what we are doing and why first, before they are asked to join,” says Malaria Consortium field assistant, Sokhoeun Chum. “At first some are scared about the finger prick, but when we explain, most agree to the test and are not worried about what we are going to do.”

All this activity is part of an innovative new study Malaria Consortium is leading focused on the special challenge Cambodia faces in identifying and treating migrants and other travelers, difficult-to-reach populations who may be at risk for malaria and transmission of drug-resistant parasites.

“It is the right thing to do in a right time for mobile and migrant people, and it is very important as a new approach for active case detection to do the screening at the cross borders,” adds Sophal Uth, field office coordinator, Malaria Consortium Pailin Field Office.

The goal? To develop a screening strategy that will help reduce the number of malaria parasites crossing Cambodia’s borders. Doing so could make a big contribution towards elimination of malaria and containment of drug resistance, goals of both Cambodia and the Greater Mekong Sub-Region. By locating check points in three different border provinces, this study presents a unique opportunity to compare and contrast their findings, enriching the strength of the recommendations that will be shared with the Cambodian National Programme for Parasitology, Entomology and Malaria Control (CNM) and others across the region next spring.

These early successes reflect careful planning, coordination and positive working relationships among individuals and organizations across Cambodia: the Ministry of Health and CNM; provincial government and health officials; police and immigration officers, village chiefs, village malaria workers, mobile malaria workers and local health workers; partner NGOs, like FHI360, Institut Pasteur du Cambodge and the London School of Hygiene & Tropical Medicine, as well as the project’s funder, the UK Department for International Development (UKaid).

Resistance in the fight against malaria

A growing public health risk originating in Asia, drug resistance, is threatening to undermine gains in malaria control

Significant progress has been made in recent years in the fight against malaria. Since 2000, mortality from malaria has decreased by over 25 percent globally. Scale-up of effective malaria interventions, including the use of artemisinin-based combination therapies – the most effective drug for treating the disease – have been instrumental to this success. However, growing resistance to artemisinins by the malaria parasite has been emerging in Southeast Asia and is threatening to reverse the gains that have been made to date. In this interview, Senior Technical Officer at Malaria Consortium, Dr Prudence Hamade, explains how dangerous a spread the spread of parasite resistance to anti-malarial drugs could be in Asia and beyond.

Q: Can you explain what drug-resistant malaria is and what the state of resistance is now in Southeast Asia?

A: Drug-resistant malaria refers to the strain of malaria parasites that have begun to show resistance to the drug currently being used to kill them. It occurs when a parasite is exposed to a specific drug, often over a long period of time, and successfully changes itself to avoid being killed. Increasingly over the last two or three years, we have noticed that artemisinin, the most effective drug we’ve ever had against malaria, is not working as well as it was in the early days, especially in Asia. It is used in combination with a partner drug, so the treatment is known as artemisinin-based combination therapy or ACT. The drugs clear the parasite from the blood very quickly, which in turn reduces the window for transmission of the parasite from one person to another. ACTs still cure the majority of people within 28 days, but in certain parts of Southeast Asia, there is more and more evidence that the parasite is surviving for longer, which indicates that resistance to artemisinin is on the rise.

Q: Where exactly are the problem areas?

A: The major hotspot for resistance to artemisinin is on the Thai-Cambodia border, where resistance was first detected in 2008. It has since been found elsewhere in Asia: on the Thai-Myanmar border and more recently in Vietnam. Although resistance in these areas is not at the levels we are witnessing along the Thai-Cambodia border, it is a clear indication that resistance to artemisinin is on the rise in the region.

Q: Why is Asia referred to as the hotspot for anti-malarial drug resistance?

Resistance to some of the most effective anti-malarial drugs we have used in the past first emerged in Southeast Asia: resistance to chloroquine for example was detected in the 1950s and Sulphadoxine-Pyrimethamine in the 1990s. Resistance to these drugs is now widespread throughout the world in many malaria endemic countries. Why Southeast Asia is the origin of this resistance is not completely clear but has been linked to the fact that artemisinin was introduced earlier there than elsewhere. Issues around the regulation of antimalarial drugs in the region and the use of monotherapies (where artemisinin is used alone rather than in combination treatments) have also been identified as likely contributors.

Q: The number of cases of malaria in Asia is much lower than in sub-Saharan Africa. Why then is artemisinin resistance in Asia such a grave public health concern?

A: If artemisinin was to stop working in Asia, it would mean that the number of cases of malaria in Asia would increase and become much more serious – because we won’t be able to reduce transmission or treat cases as effectively as before – and mortality will increase. The real worry is that this resistance could spread to Africa (where almost 600,000 people died from malaria in 2010), perhaps transferred by migrants, or emerging spontaneously. At the moment, we are still a long way from having another anti-malarial drug that is as effective or tolerated as well by patients as ACTs. It would then be highly likely that we would see an increase in morbidity and mortality from the disease.

Q: So how serious is the potential spread of resistance from Asia to Africa?

A: When resistance to chloroquine spread to Africa in the 80s and 90s, there were not adequate surveillance systems in place and it took a long time to detect. As a result there was an increase in the number of people dying from malaria. Pregnant women and young children in Africa are particularly vulnerable to malaria because they are the most likely to have either low or no immunity to the diseases, so if resistance to artemisinin were to spread to Africa now or in the next couple of years, the number of deaths among these groups in particular are likely to rise. It would also be more difficult to contain the spread of artemisinin resistance in Africa because of the widespread nature of the disease.

Q: What needs to be done to stop the spread of resistance in Asia?

A: The best case scenario would be to eliminate malaria from the region entirely. That would be extremely complicated but it could be possible. The first step to controlling the spread of resistance is to improve surveillance. We need good reporting systems in place because we need to know where the resistant malaria parasites are located in order to treat and eliminate the drug-resistant strains from those patients. That is the only way to stop the resistant strain spreading: to eliminate the resistant parasites as rapidly as possible by curing the patient quickly, thereby reducing the chances of those parasites being transmitted via mosquitoes to other people.

Q: So what is happening now?

A: The Bill & Melinda Gates Foundation funded the Containment Project, the first major initiative to contain artemisinin resistance in Southeast Asia. This project brought together regional governments and partners, including Malaria Consortium, to develop and implement a multi-pronged strategy to contain the resistance. Now, with support from the Global Fund and AusAid, partners in the region are trying to move beyond containing malaria and resistance, to eliminating malaria from the region altogether.