“Our main purpose is to educate communities about malaria – its effects, how it is transmitted and how to avoid it.” Mugoya Muzamir is one of over two thousand community members in Mbale who has been trained as part of the Mbale Malaria Control project.
Malaria is the most common cause of illness and death in children in Mbale district and, in 2011, at the start of the Mbale Malaria Control Project, the district had the highest malaria burden in Uganda. Now that Mugoya has been trained in malaria case management, it is his responsibility to communicate how to prevent malaria transmission to the communities throughout Mbale. One of the most effective ways of doing this, he has found, is through performance and drama.
Mugoya, and 24 other village health workers (VHTs) trained as part of the project, now travel from community to community, performing dramas that teach how to avoid getting malaria. When I met Mugoya, he told me this was an effective way of communicating to a wide range of people: “When you do something funny, many people will come.”
The method has been successful in conveying messages to people throughout Mbale. Community members told me their families had learnt the importance of sleeping under a mosquito net and that they now clear any stagnant water near their villages. The dramas also include messages of when to contact a VHT, and how to recognise a case of severe malaria.
“When you move round the communities, you notice there has been a change. We have seen that the number of malaria cases has fallen. Last month there was one case of malaria, whereas three months ago there were 27 cases of malaria in that month, so people are picking up on our messages.”
You can check out photos of the drama performance below:
The drama group begins by playing songs, all of them about preventing malaria, in order to attract a crowd.
The community starts to gather in anticipation of one of the drama performances.
One of the actors, who is playing a nurse, waits for her cue to join the performance.
Many children attend these events, and they are encouraged to take notes on how to prevent malaria transmission.
The performances use different characters and humour to keep the community engaged, while teaching them how to prevent the spread of malaria.
Mugoya Muzamir, one of the VHTs trained as part of the project, shows some of the messages they will be teaching in their performance: how to spot symptoms of malaria in pregnancy.
One of the core messages of the drama performances is conveying the importance of sleeping under mosquito nets. Here, the actors show how a net should be hung.
Community members, and in particular the young children, watch as the performers teach them how to hang a mosquito net before going to sleep.
The communities create murals and paintings demonstrating what they have learnt. This is a painting that was on display in the village, demonstrating mosquito net use, keeping stagnant water away from the village and showing the benefits of the boda boda hospital referral system.
The performance teaches the community about severe malaria, and how to contact a boda boda driver if someone is suffering from severe malaria.
Mugoya shows how to pay for a boda boda driver by completing a payment coupon, to be cashed in at the hospital.
The performances show community members how to spot the symptoms of severe malaria.
...And the performers also demonstrate how a child is treated for severe malaria, once they arrive at a district health centre.
A portrayal of family life during the performances also demonstrates preventive behaviour to audiences. Here, a family discusses keeping their house and village clean and getting rid of stagnant water.
Mugoya, acting in the role of a doctor, then emphasises how to prevent malaria being transmitted.
The performers act out various symptoms of severe malaria.
Finally, the drama group uses songs to educate people on how to identify, treat and prevent malaria.
VHTs and drama group members pose at the end of their latest performance.
Children make notes as the performance winds down.
Patrick Lee is Communications Assistant at Malaria Consortium in London.
“When the rainy season comes, our children fall sick because of the weather. It’s malaria, flu, cough – even measles. It affects us because they miss lessons, and they can’t always catch up when they come back.”
Mary is a teacher at Iyolwa Primary School in Tororo, eastern Uganda. She teaches maths, English and social studies to a class of around 80 students, most of whom are no more than 10 years old. Her students study hard but, like in many parts of the country, their education can be severely disrupted by malaria and other illnesses.
During my visit to check up on Comic Relief’s Operation Health project in the same district, I was fortunate enough to be able to observe an activity from one of our projects that tackles this issue head-on: the distribution of long lasting insecticidal nets that would provide protection for over a thousand children and their families.
Whilst malaria mortality and morbidity in Uganda is generally high, Tororo is the worst hit by the disease. On average, residents are exposed to one to two infectious mosquito bites per night, with malaria accounting for more than 40 percent of patient visits to many health facilities. Sleeping under a long lasting insecticide treated mosquito net is one of the best ways to prevent malaria, but unfortunately they are not always available, or if they are, people don’t know how to use them properly.
The Malaria Control Culture project in Tororo focuses on developing ‘routine’ net distributions, ensuring nets reach those that need them most and encouraging people to use them. At the health facility level, we provide nets for pregnant women (who are at an increased risk of contracting malaria) when they go for antenatal check-ups. We also help ensure good net coverage through annual distribution campaigns for school children in years one and four.
It was one of the school net distributions that I visited, arriving in time to enjoy a lively drama about malaria prevention performed by a group of village health workers and primary school pupils. While the drama was going on, Malaria Consortium staff were speaking with teachers about the logistics of the distribution, while parents and relations gathered in the shade to hear from district officials and other experts about how to use the nets.
“Today we are going to show you exactly what Malaria Consortium has done for the people in the village, and what good things are going on there,” said Saul, head village health team member (VHT) of the sub-county. “We are going to show you through song, and at the same time we are going to make a drama so you can see exactly what is happening.” He told me that he was there with other VHTs to teach the school children how to protect themselves and their families from malaria. This way, children not only bring home a net but can also pass along the lessons they have learnt on preventing malaria, he explained.
When the drama ended, children in Y1 and Y4 began to gather outside the school building, where teachers read out their names from class registers Abbo Kevin, mother of six year-old daughter Stella who received a net that day, told me: “I came to this school when I was younger, but I didn’t receive nets. This is the first time. Before, malaria was so high, but it is now decreasing because of the nets.”
Mary said she and the other teachers are also happy to see a drop in the number of absences: “Since the nets, it has changed. Many have been falling sick, but as of now the numbers have been reduced.”
Take a look at the photo gallery below to see some of the photos from the net distribution:
Students, teachers, parents and community health workers (VHTs) gather near Iyolwa Primary School for a drama performance that teaches children how to protect themselves and their families from malaria.
Students can sing along as the VHTs perform, ensuring that they remember key malaria prevention messages.
A student gets a prime view of the drama performance below.
Health messages can be found throughout the school grounds, encouraging students to stay healthy.
Abbo Kevin and her daughter Stella at Iyolwa Primary School. “I came to this school when I was younger, but I didn’t receive nets. This is the first time. Before, malaria was so high, but now it is going down because of the nets.”
Stella is six years old and in her first year at school. Through the Tororo project, Malaria Consortium distributes nets to children in years one and four.
Prior to the net distribution, Malaria Consortium’s Julian Jane Atim, Project Manager for the Tororo Project, briefs the VHTs on the events of the day.
Malaria Consortium’s Julius Lukwago, Technical Officer, shows parents how to properly take care of their nets.
And the school’s headmistress demonstrates how to hang the net.
As the net distribution begins, a teacher takes attendance by reading the names of her students off of a register.
Students at Iyolwa Primary School queue to receive LLINs.
Students queue to receive their nets.
Students gather in front of the Iyolwa school building.
Once the distribution has begun, Malaria Consortium and teachers at the school hand out nets to students.
Students approach one of the tables where nets are being handed out. Once they receive the nets, their names are recorded in a register.
Students in years one and four were chosen to receive the LLINs as part of an effort to increase overall coverage in Tororo district.
Students gather near the entrance of the school after the net distribution.
Students gather near the entrance of the school after the net distribution.
Mary teaches around 80 students at Iyolwa Primary School, focusing on maths, English and social studies.
“My children are from 8 to 10 years. When the rainy season comes, more of our children fall sick because of the weather. It affects us because they miss lessons, and because they don’t catch up [easily] when they come back. Since the nets, it has changed. Many have been falling sick, but as of now, the numbers have been falling.”
Ilya Jones is Communications Officer at Malaria Consortium in London.
Pregnant women are particularly susceptible to malaria partly because of their reduced immunity to the disease, but also because of their vulnerable social and economic status. Their unborn babies are also at high risk, with malaria potentially leading to spontaneous abortion and low birth weight. Babies born with low birth weight will often be weak and more likely to get sick. However, malaria in pregnancy is preventable. The World Health Organization recommends a combination of three interventions for the prevention and treatment of malaria in pregnancy: the use of long-lasting insecticidal nets, prompt diagnosis and effective treatment of malaria infections, and the administration of intermittent preventive treatment in pregnancy (IPTp).
It is this last method that we have been concerned with at Malaria Consortium. IPTp is low-cost, safe and generally acceptable to pregnant women, and can be provided at antenatal check-ups. However, despite generally high antenatal care (ANC) attendance, most countries in sub-Saharan Africa do not come close to meeting the targets set by organisations like Roll Back Malaria, which advocate for universal coverage. In Uganda, for example, current surveys suggest that only about a quarter of pregnant women receive two doses of IPTp (IPT2, the indicator commonly used to assess IPTp uptake). This suggests that many opportunities for the provision of IPTp are being missed.
We have coordinated a study conducted in 2014, which explored the barriers that continue to impede IPTp uptake in Uganda. This has involved carrying out in-depth interviews with pregnant women and mothers who attended ANC, health workers, district health officials and community leaders. Conducted through COMDIS-HSD, a research programme consortium funded by UK aid from the UK government, the study looked at both the supply side (i.e. the health system, including health workers) and demand side factors (i.e. women’s and communities’ perceptions).
The research concluded that, despite a range of minor concerns (for example with regard to taking IPTp on an empty stomach), women and communities have largely positive views of ANC and IPTp. Refusal rates of IPTp are low and given the high ANC attendance figures, the main obstacles to the provision of IPTp are therefore likely to be supply-side challenges. In the past, many health facilities struggled with frequent stock-outs of the drug used for IPTp, although this has been improving thanks to recent efforts from the Ministry of Health. Private facilities on the other hand have to buy their own supplies, which means stock-outs are still a problem.
Another major barrier to the provision of IPTp is health workers’ inadequate knowledge with regard to when and how to provide IPTp. This is compounded by the incoherent and out-of-date information provided in many policy documents and job aids that are supposed to guide health workers. Moreover, the policies in use are not in line with the most recent WHO policy recommendations for the provision of IPTp.
Malaria Consortium is about to implement a small-scale pilot intervention in collaboration with the Ministry of Health to address some of the key barriers to IPTp uptake in Uganda. The main focus of the intervention is to ensure adequate knowledge of IPTp guidelines among health workers. This will support the Ministry’s plans to roll out a country-wide classroom-based training programme on malaria in pregnancy, which will include updated IPTp guidelines that comply with current WHO recommendations.
However, it is unfortunately not feasible for everyone involved in ANC provision to attend traditional classroom training sessions. Therefore, in order to reinforce the guidelines and ensure all relevant health workers receive the necessary information, we will pilot the use of text messaging to communicate key messages. Following the classroom-based training, health workers providing ANC services at a number of health facilities in West Nile province will receive a series of text messages emphasising the importance of IPTp, explaining the new guidelines and the rationale behind the changes. This approach has recently been shown to be highly effective in communicating clinical recommendations to health workers in China, and we believe that the rapid spread of mobile technology in Africa means that the time is right to test this innovative solution in Uganda.
In order to assess the effect of the intervention, the pilot will also include health workers in a neighbouring district who will only receive the classroom-based malaria in pregnancy training. We will assess knowledge of IPTp at all facilities six months after the training. If text messaging works, we would expect to see better levels of knowledge among those health workers who attended the training and subsequently received the messages compared with those who only received the training. We would also expect that better knowledge of the IPTp guidelines will lead to fewer missed opportunities and hence an increase in IPTp coverage. The pilot is scheduled to start in May 2015 and evaluation results are expected to be available in 2016.
Christian Rassi is COMDIS-HSD Project Coordinator at Malaria Consortium
Community health workers, when trained and equipped to manage simple cases of pneumonia, diarrhoea and malaria in children under the age of five, can reduce child mortality caused by these three diseases by up to 60 percent.
Funded by the World Health Organization (WHO), the Rapid Access Expansion (RAcE 2015) project in Mozambique is a strategic alliance between Malaria Consortium and Save the Children, to support the Mozambican Ministry of Health’s community health programme. The project is focused on improving the quality of care provided by community health workers (locally known as Agentes Polivalentes Elementares or APEs) by strengthening their ability to correctly diagnose, treat and refer children with common diseases and by ensuring that they receive regular supervision to improve performance and correct errors.
In November, Malaria Consortium staff and Provincial Health Directorate authorities carried out supervision visits in Inhambane province, Mozambique, to assess the clinical skills of APEs. In Inhassoro district, we met Linda Noah, a health worker who had cycled 21km on her bike, carrying her seven-month old daughter and her APE kit on her back, to participate in a clinical supervision session. During this session, Linda provided care to three children, all under the age of five, while being observed by district health technicians.
“This was a first for me,” Linda said. “I have never had a clinical evaluation session like this. My supervisors observed my work and advised me right away on what I was doing right or wrong.”
This session made Linda aware of the challenges in correctly assessing danger signs and identifying those children that need an immediate transfer to a health centre.
“I enjoyed coming to this session. I faced many difficulties but I managed to fix them and I hope I will have even more of these kinds of opportunities with my supervisor to improve my work.”
Written by: Adolfo Guambe (Provincial Health Directorate, Inhambane) & Eder Ismael Zerefos (Malaria Consortium)
A Malaria Consortium está continuamente a apoiar o Programa de Revitalização dos APEs através do projecto RAcE
Os Agentes Polivalentes Elementares (APEs) são membros das comunidades, que promovem a saúde e realizam o diagnóstico e tratamento de casos simples de malária, pneumonia e diarreia em crianças menores de cinco anos, bem como identificam e referem adultos e crianças que necessitam de atenção médica para uma Unidade Sanitária. Os APEs, quando formados para prestar diagnóstico e tratamento de malária, pneumonia e diarreia ao nível da comunidade, podem reduzir a mortalidade infantil causada por estas três doenças em 60%.
A Direcção Provincial de Saúde de Inhambane, através do apoio dado pela Malaria Consortium na melhoria da qualidade dos serviços prestados pelos APEs, esta a assegurar que estes recebam supervisão regular e de qualidade para corrigir erros, melhorar o desempenho e fortalecer as suas capacidades.
Uma ronda de supervisão foi implementada em Novembro de 2014 na província de Inhambane, cujo objectivo principal foi de avaliar as competências clínicas dos APEs e prestar apoio para o aumento das suas capacidades técnicas em diagnóstico, tratamento e serviços de referência para as principais doenças infantis, nomeadamente a Malária, Pneumonia e Diarreia.
No distrito de Inhassoro, encontramos a APE Linda Noé da área de saúde de Macovane. Ela percorreu 21 km na sua bicicleta, durante 3 horas debaixo de um sol ardente próximo dos 40ºc, transportando o seu kit de trabalho de APE e sua filha de 7 meses as costas, para participar numa sessão de supervisão clinica. Nessa sessão, ela prestou atendimento a 3 crianças menores de 5 anos sob a observação de técnicos distritais, nomeadamente, os médicos chefes, coordenadores e supervisores directos dos APEs.
“É a primeira vez para mim; nunca participei numa sessão de avaliação clínica prática; normalmente, são avaliados os relatórios estatísticos; mas essa sessão foi realmente muito especial para mim, porque tinha os meus supervisores que olharam e que poderem me dizer precisamente o que estou a fazer correctamente ou de forma errada”.
Através dessa sessão, a Linda descobriu os seus desafios em avaliar correctamente os sinais de perigo e identificar as crianças que necessitam de transferência imediata para um centro de saúde.
“Gostei de ter vindo fazer essa avaliação clinica, porque tinha muitas dificuldades mas consegui corrigir e espero ter mais oportunidades junto do meu supervisor para melhorar a meu trabalho de APE”.
Elaborado por: Adolfo Guambe (Direcção Provincial de Saúde, Inhambane) & Eder Ismael Zerefos (Malaria Consortium)
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’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.
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.
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.
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.
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.
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.
In recent years, there has been a rapid proliferation of mobile phone applications. There seems to be one for everything, from daily reminders to complex navigation. But while most of us don’t think of phone applications as lifesaving tools, in some remote communities where healthcare access is limited, that is exactly what they are.
In many remote villages in Mozambique, community health workers are the first point of contact when a child gets sick. They are trained to diagnose and treat children under five years for some of the deadliest conditions – pneumonia being chief among them – and provide referrals to health facilities for severe conditions.
Community health workers, or Agentes Polivalentes Elementares (APEs) as they are known locally, have been highly effective at bringing healthcare closer to people living in the poorest and most remote communities. However, they face a number of challenges carrying out their work. They often lack the tools necessary to properly assess symptoms, diagnose and treat childhood illnesses and have had limited contact with their supervisors.
Malaria Consortium has been testing the utility of mobile phone applications as a means to improve the motivation and confidence of community health workers who face these obstacles every day.
How are the phones used?
APEs are given a smartphone that comes preloaded with an app called ‘inSCALE APE CommCare’. This application helps them carry out their daily work.
Firstly, this app acts as an interactive job aid, guiding them through all steps of diagnosis, treatment and referral. For pneumonia, the app asks a series of questions regarding symptoms and uses a special counter that helps to assess the respiratory rate of the child. If the child is found to have pneumonia symptoms, the app provides educational messages and treatment instructions for both APE and caregiver. Recommendations for follow-up visits or referrals are given based on the diagnosis and vaccination status of the patient.
Patient data, including diagnosis and vaccination status, is stored on the phone along with weekly aggregated data and medicine stock levels, all of which are sent to the APE’s supervisor. This is then collated into statistics at the provincial and district levels that provide real-time data available to health officials. After submitting the data, the APEs receive feedback messages thanking them for their work.
Communication with supervisors and peers is also significantly improved through the phones. Each APE receives a monthly automated credit allowance for making calls – an initiative that bridges the gap between health workers and their supervisors, ensuring closer coordination and improved performance. Periodic motivational messages also can help increase a sense of collective identity and purpose.
Has it been successful?
The results have been encouraging. A process evaluation was carried out in Mozambique, which showed that 68 percent of APEs always use CommCare in their work. Respondents reported that the application helped them remember the symptoms to look for.
The three most favoured aspects of the inSCALE APE CommCare app were the job aid for newborns, children and pregnant women; improved respiratory rate timer; and treatment and dosing instructions. Mobile phones were also found to improve the community standing and legitimacy of the health workers.
At the heart of the application’s success was its user-centred design. The Mozambique Ministry of Health and the community health workers themselves were heavily involved in each step of the design process, ensuring that the app remained easy-to-use and intuitive. However, most APEs and supervisors were unaccustomed to using smart phones, so introductory sessions were held in addition to the existing CommCare training. This allowed for efficient use of the phone and its software.
You can learn more about the CommCare app by watching the demonstration video below:
*Malaria Consortium’s inSCALE project is funded by the Bill & Melinda Gates Foundation and carried out in partnership with the London School of Hygiene and Tropical Medicine and University College London.
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.
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”.
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.
Dr Jonathan Jiya is the programme manager of Malaria Consortium’s RAcE project in Nigeria. He recently met with senior leaders of communities in Niger state to discuss the implementation of a project which aims to provide healthcare for 150,000 children under five by 2016.
Malaria Consortium’s Rapid Access Expansion (RAcE) project, funded by the World Health Organization (WHO) and the Canadian Department of Foreign Affairs, Trade & Development (DFATD) aims to improve the community-level management of childhood malaria, pneumonia and diarrhoea in Niger state, Nigeria. In rural areas of Niger state, there is a lack of healthcare services required to treat these conditions, which are the biggest killers of children under five.
The project builds upon existing community-based health interventions, such as integrated community case management (iCCM), and involves working with a number of Nigerian organisations, including the Centre for Communications Programs Nigeria (CCPN) and the Federation of Muslim Women Association Nigeria (FOMWAN). Malaria Consortium is supporting the Ministry of Health in Niger state to implement iCCM activities in six local government areas (LGAs).
As the project leader for RAcE, I recently met with influential leaders, including senior community leaders and other stakeholders across the six LGAs, in order to mobilise resources and begin implementing iCCM activities. The LGA representatives welcomed the proposed meetings – there were never fewer than 40 people at each one. Discussions focused on the value of iCCM, on reasons why a programme like RAcE is necessary and on how best to select members of each community to take part in the project.
Community leaders and other key stakeholders were briefed on proposed iCCM strategies. As part of the project, Malaria Consortium will train over 1,700 community oriented resource persons (CORPs) and will consequently help to provide basic healthcare by 2016 to over 150,000 children in hard to reach areas of the six selected LGAs. CORPs will be trained to identify and treat the diseases, and will serve as both an access point and a form of continuity of care to existing healthcare systems.
The community leaders I met were asked to select responsible and well-respected members of their communities to be nominated as CORP volunteers. As one objective of the project is to build trust and cooperation between health systems and community members, the input of leaders in selecting role-models from the community is essential. Respected members of the community are in a strong position to influence others and to encourage behaviour changes which can prevent the spread of illnesses.
The second in command to the Emir in Lapai emirate, The Shaba Lapai, welcomed the opportunity to be consulted, saying, “This is the type of project we want. It will save the lives of our children and because the participation of community leaders has been recognised, we will support the project in any way we can for it to succeed”. He went on to say that the community will “support CORPs training and ensure that the community health committees function optimally for progress and abide by the given criteria for selection of CORPs”.
Hajiya Hauwa Usman, a participant at one of the forums, said: “Pneumonia, diarrhoea and malaria bring so much pain to mothers and families each year, especially during the rainy season. Malaria Consortium’s RAcE project will reduce this suffering and help children in their communities.” Mallam Garba Hussaini, an Islamic cleric agreed, stating, “We are appreciative of the effort of the state government and RAcE in selecting our communities to benefit from this project”.
The community forums also provided a chance to clear up logistical issues, such as the problem of a lack of storage facilities for the drugs that are being provided. In this instance, the concerns were addressed by promising the provision of portable storage facilities for each CORP. The most positive outcome of the meetings, however, was seeing that community leaders were appreciative of the opportunity to be included in the planning and implementation of RAcE.
Fernando Bambo is Malaria Consortium’s Communications and Advocacy Coordinator in Mozambique
One of the most interesting aspects of working at Malaria Consortium for me is tracking its progression over time. It was in December 2005 that I joined the organisation, as Deputy Coordinator of the demand creation component of the project for Sustainable Distribution Systems of LLINs, funded by the UK Government.
This innovative project, initially implemented in Inhambane province in Mozambique and subsequently expanded to Nampula and Cabo Delgado, rested on three pillars. These were:
1) The free distribution of LLINs to pregnant women at public antenatal care clinics;
2) Support for the commercial sector to develop a market for mosquito nets that were affordable for all socio-economic groups;
3) Demand creation for mosquito nets through communication activities, as well as the promotion of proper nets’ use and care.
The communication component had a huge impact on creating demand for mosquito nets in both the public and private sectors. At the time, LLINs were still a novelty in Mozambique, and we all had a lot to learn in almost all areas of implementation. One of our achievements was the development of a communication strategy to promote LLINs using the COMBI approach (Communication for Behavioural Impact) whose principles have since been incorporated in the National Communication Strategy and Advocacy for Malaria (2013-2017).
COMBI was the strategy that gave rise to the popular interactive radio programme ‘MozzzKito.’ In addition to MozzzKito, we also developed a new tool, the “net hat”: this was an exercise and games worksheet specifically designed for primary school children to help them learn about malaria in a fun way. The ‘hat’ consisted of a poster with six learning exercises and games, including brain teasers, and “malariamática” (math on malaria). With support from teachers, children solved the exercises in the classroom and afterwards folded the poster into a ‘hat’ with the message – “I am protected, sleeping under a net.” This symbolised the participation of children in the fight against malaria.
Upon leaving the classroom, the children went out onto the street in groups showing their hats, and interacting with the community about malaria. At home, the children read the poster aloud to their parents, and in the end, the parents signed a paper that indicated that they had seen the poster. Finally the children took the “hat” back to school and gave it to the teacher.
Even today, I still think of those earlier projects and look at how far we have come as an organisation. Since I first joined, each project has built on experiences from the last – in this way we have improved our work and generated new ideas. Currently, Malaria Consortium is working on the Malaria Prevention and Control Project – a project that I am a part of. The project aims at engaging communities in defeating malaria through school activities, radio programmes, and capacity building of community-based organisations in conducting behaviour change communication activities. The lessons learned and the accumulated experiences all contribute to better and healthier lives.
Quem diria, mas o tempo passa rápido. Foi em Dezembro de 2005 que ingressei na Malaria Consortium, como Coordenador Adjunto da área de Comunicação para a Criação da demanda do Projecto de Desenvolvimento de Sistemas Sustentáveis para a Distribuição Gratuita de Redes Mosquiteiras Tratadas com Insecticida de Longa Duração (REMTILD), Financiado pelo Departamento Britânico para o Desenvolvimento Internacional (DFID).
Este projecto inovador, inicialmente implementado em Inhambane e posteriormente expandido para as províncias de Nampula e Cabo Delgado, assentava em 3 pilares, nomeadamente:
1) A distribuição gratuita de REMTILDs para mulheres grávidas na Consulta Pré – Natal (CPN);
2) Apoio ao sector comercial para o desenvolvimento de um mercado de redes mosquiteiras para que as mesmas estejam a preços acessíveis a todos grupos sócio – económicos e;
3) Comunicação para a criação da demanda e uso correcto de redes mosquiteiras.
A área de comunicação na qual trabalho até hoje, tinha a enorme responsabilidade de contribuir para a criação da demanda para o sector público e o sector privado. Lembro – me que na altura, as REMTILD ainda eram uma novidade em Moçambique, e todos tínhamos muito a aprender em
quase todas as áreas de implementação. Uma das realizações de realce foi o desenvolvimento da estratégia de comunicação para a promoção das REMTILD, a estratégia COMBI (Communication for Behavioral Impact) cujas ideias estão incorporadas na Estratégia Nacional de Comunicação e
Advocacia da Malária (2013 – 2017).
Foi a estratégia COMBI que deu origem ao popular programa interactivo de rádio “MozzzKito”. A par do MozzzKito, também desenvolvemos o “Chapéu de Rede Mosquiteira” material que foi produzido para trabalhar a temática da malária com as crianças do ensino primário. O “Chapéu” consistia num cartaz com 6 exercícios didácticos e interactivos sobre a prevenção da malária, dentre os quais, quebra cabeça, passatempo, malariamática (matemática
sobre a malária). Com apoio dos professores, as crianças resolviam os exercícios na sala de aulas, e após completarem a actividade, dobravam o cartaz e elaboravam um chapéu ficando
na parte frontal, a seguinte mensagem “Debaixo da Rede Durmo Protegido” simbolizando a participação das crianças na luta contra a malária.
Ao saírem da sala da escola, em grupos organizados, na rua, as crianças levavam o seu chapéu na cabeça criando agitação na comunidade com perguntas surgindo e sendo respondidas sobre o motivo do esforço. Em casa, as crianças liam a informação do cartaz em voz alta diante dos pais, e no fim, os pais assinavam o cartaz indicando que a leitura do cartaz foi feita. Finalmente a criança levava o “chapéu” de volta para a escola e entregava ao professor/a”.
Actualmente, a Malaria Consortium implementa dentre outras intervenções, o Projecto de Prevenção e Controlo da Malária do qual faço parte. O projecto envolve as actividades escolares, programas de radio, e envolvimento de estruturas comunitárias em actividades de comunicação para a mudança de comportamento para a prevenção da malária. As lições apreendidas e a experiência acumulada contribuem para melhor qualidade das actividades.