“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.
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.
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.
Effective health care starts at home and in the community. Leila Noisette, Malaria Consortium’s Advocacy Officer in Uganda, explains how Malaria Consortium works with communities, providing training and tools that they can use to improve their own health and that of their children
Though close to Kampala – the capital city of Uganda – and close to a major highway, Kiboga District is essentially rural and the main means of income are from crops and livestock. Most of the local residents rely on subsistence agriculture. Malaria has been a major cause of child mortality here and has affected the productivity of adults working in the fields.
Adera Nakato, a young grandmother explained that falling sick from malaria used to be common in the area: “I could hardly work for money and had limited food for my children. I used to buy nets but they were not effective because they were not treated; it gave us false confidence and we continued to suffer from malaria.”
Three years ago, Malaria Consortium distributed long-lasting insecticidal nets in the area. Adera received nets through the distribution for her family:
“Ever since we started using them, none of us here has suffered from malaria fever,” she told us.
Every household in four districts of mid-western Uganda benefited from the net distribution, a universal coverage campaign undertaken by Malaria Consortium through the Pioneer project funded by Comic Relief.
Tumusiime Mildred, a 32 year old mother of five children also benefited from the distribution of nets: “What can I say about the nets? It is just evident when you look at my children playing. They look happy and healthy.”
Mildred’s husband is a teacher but she had to stop work after a complication during the birth of her youngest child. She explains that nets have helped to reduce the amount of money her family have to spend on health care: “Treating the whole family was costly. Now, we no longer frequent hospitals due to malaria. My last born is two years old and she has never suffered from malaria yet. When the older ones get sick, they are taken to Ssunna, the village health team member, and they get better in a few days,” Mildred adds.
Ssunna is one of a number of community members who have been trained by Malaria Consortium to act as village health team members (VHTs), providing basic health care to young children in the community. He learnt to diagnose and treat malaria, as well as other leading causes of child death including pneumonia and diarrhoea in children under the age of five.
“I am glad that I am here to serve my community as a VHT,” Ssunna explains.
As well as diagnosis and treatment, VHTs also actively work with communities to share information about disease prevention and basic sanitary measures that families can follow to stay healthy. Ssunna received training to conduct community dialogues. The dialogues, part of a community outreach initiative supported by Malaria Consortium and the District Health Authorities, encourage communities to express their views and share experiences related to health, sanitation and hygiene. “With the village chairperson, we organise community dialogues every month where we discuss prevention of diseases such as malaria. These dialogues have yielded good results. In fact I can now spend a whole month without seeing a child suffering from malaria, diarrhoea or pneumonia.”
Catherine Nassiwa, a senior nursing officer, is the Malaria Focal Person in Kiboga District Health Team. A lot has improved as a result of the partnership between the district health team and Malaria Consortium, she explains: “Awareness of malaria has increased… sanitation, hygiene and care-seeking behaviour have improved, which, combined with the use of nets has reduced the morbidity in the district. Thanks to reduced expenditure for treatment, families can invest their money elsewhere. The relationship between community members and health workers has also improved. This has built health workers confidence and increased community members trust in the public health services.”
As the Pioneer project draws to a close, Ssunna talks about the lasting impact the project will have on the area. He hopes that, with support from active residents like himself, the community will continue taking care of their health without relying on support from partners.
“I am looking at a strategy to continue working with the community without waiting for support form Malaria Consortium.”