Role of Communication in Malaria Control in Africa
In April 2000, 50 malaria-afflicted African countries signed the Abuja Declaration, and agreed to achieve the following targets by 2005:
Since then, the Roll Back Malaria (RBM) partnership has focused attention on resource mobilization, policy change, research, and health system strengthening. Relatively less attention has been paid to malaria communication. Yet, there is general agreement that, if we are to meet the Abuja targets, communication is key.
This concept paper summarizes some of the communication challenges RBM has experienced in Africa and poses some ways in which strategic communication can help propel countries closer to the Abuja targets.
The Problem of Malaria: Malaria is endemic to the poorest countries in the world, causing 400 to 900 million clinical cases and up to 2.7 million deaths each year (Breman, 2001). More than 90% of malaria deaths occur in Sub-Saharan Africa, resulting in an estimated 3,000 deaths each day. Almost all the deaths are among children younger than 5. Other high-risk groups include women during pregnancy, non-immune travelers, refugees and other displaced persons, and people of all ages living in areas of unstable malaria transmission (WHO & UNICEF, 2003).
In highly endemic countries, malaria poses a serious danger to pregnant women and their unborn children. Malaria in pregnancy causes maternal anemia, miscarriage, and low birth weight. In endemic countries, It is the leading cause of maternal mortality and one of the primary causes of neonatal deaths (Breman et al, 2001; WHO & UNICEF, 2003).
Malaria is caused by infection with one of four species of Plasmodium: Plasmodium falciparum, P. vivax, P. ovale, and P. malariae. Plasmodium falciparum causes the most serious disease and is responsible for over 95% of infections in sub-Saharan Africa. Malaria parasites are transmitted through the bite of an infected Anopheles mosquito. Malarious mosquitoes bite between sunset and sunrise, usually during the night.
Over the last two decades, morbidity and mortality from malaria have been increasing due to deteriorating health systems, growing drug and insecticide resistance, periodic changes in weather patterns, civil unrest, human migration, and population displacement (WHO & UNICEF, 2003).
RBM Communication Challenges: Strategically designed communication can play a key role in taking RBM to scale. Communication strategies are generally called for whenever there is a need to change awareness, knowledge, attitudes, social norms, skills, or expectations. Certainly, the RBM strategies call for all of these.
Experience in Africa, where malaria communication has typically lagged behind other RBM efforts, highlights communication challenges at individual, family, community, health delivery, and policy levels. Some of the common communication challenges experienced in Africa are described below. While many of these challenges could be partially answered through other types of interventions—service delivery, policy, monitoring and evaluation, or systems strengthening—all demand a communication response. Challenges are presented for each of the four RBM strategies; as well as a few that cut across all four strategies.
To meet the Abuja RBM targets, communication needs to be fully integrated into the broad spectrum of malaria interventions and not seen as an isolated intervention, an after-thought or an add-on. With adequate time and resources, strategically designed communication can play an important role in scaling up prevention and control efforts at the individual/household, community, health delivery, decentralized and national levels.
Malaria communication should be integrated with other health education and communication efforts. Malaria control programs need to balance malaria-focused and integrated communication approaches. For example, after initial introduction through focused communications, malaria control in pregnancy should become an integral part of reproductive and maternal health communication. Likewise, information and education about home management of malaria in children should become part of integrated management of childhood illnesses (IMCI) communication.
Communication efforts should be strategically designed from an audience perspective to address the social and contextual environment as well as individual behaviors and knowledge. The coordinated use of interpersonal communication, community mobilization, advocacy and mass media has been effective in a variety of other public health agendas. Integrating strategic communication approaches and service delivery can enhance the utilization of services and improve client compliance. In fact, the integration of community-based distribution of antimalarials and malaria information and education has been documented to reduce under-five mortality by 41% in one Ethiopian program (Marsh & Kachur, 2002; WHO & UNICEF, 2003).
As with HIV/AIDS, malaria communication will be more effective when a multi-sectoral approach is adopted. Labour, agriculture, education, and gender are all affected by and can play significant roles in malaria control. For example, in places such as Kenya where most school children purchase their own drugs for the treatment of fevers, schools present an excellent venue for teaching children about appropriate and effective malaria treatment (Marsh and Kachur, 2002). Likewise, in places like Uganda, where workers miss an estimated 42 work days each year due to malaria, employers often welcome workplace prevention programs (FUE, 2002).
Communication is essential to advocacy, communicating policy changes, home-based management, improving the quality of health care, creating demand for malaria services and products, changing household practices, and mobilizing communities for malaria control.
Advocating for Malaria Prevention and Control Particularly in the areas of malaria in pregnancy, home management, drug policy, epidemic preparedness, and prevention, there is a need in many countries to introduce policies and programs that are technically sound and feasible. In order to do this, it is essential to reach out to policymakers and other influential people and win their active support for RBM-recommended malaria control strategies. This will require evidence-based and compelling arguments that speak to the interests, concerns and needs of this unique audience.
Effective advocacy among influential individuals and groups can also help address some of the underlying societal and environmental factors that influence individuals’ ability to take action, either in terms of prevention or treatment (eg. exempting ITNs from import taxes; reclassifying anti-malarial drugs so they can be legally dispensed by patent drug vendors and community-based workers, and organizing rotating funds for purchasing ITNs).
Religious, health, political, commercial, traditional, and community leaders, through their positions of power and respect, can make malaria a public issue and support recommended prevention and control practices, helping to overcome barriers to adoption, acting as role models, and changing community norms around treatment seeking and prevention. Advocacy efforts can equip these influential individuals with malaria information and create opportunities for them to address their constituencies, whether through mass media or group forums.
Carefully planned advocacy campaigns can help to make Malaria Control Programmes more effective. Through advocacy, Ministries can be convinced to reposition Malaria Control Programmes so they are better able to influence policy, provide effective guidance for malaria control strategies, and monitor and evaluate implementation. Within Malaria Control Programmes, advocacy can convince medical experts of the need for strategic communication, and appreciation for the communication process can improve time and resource allocations for malaria communication, and can improve the status of health educators.
Many countries are adopting new malaria treatment policies. New guidelines need to be communicated to health providers and drug vendors in both the formal and informal sectors. The public also needs to be informed and educated about changes in malaria treatment policies, thus preventing public fears and backlash against new anti-malarial drugs. Well-developed communication strategies can also improve acceptance of and compliance with drug regimens, especially combination therapies, at all levels of official and unofficial healthcare systems, the private sector, and the community.
Information, education and communication for health providers, clients, and influencers is also essential to effectively introduce new initiatives such as home management by community-based providers or patent drug vendors, and IPT for antenatal clients.
Equipping providers—facility, community-based, and non-formal vendors–with interpersonal communication skills and malaria information so they can effectively interact with their clients is essential. Too often, providers lack guidelines and other job aids, client education materials, and/or the interpersonal skills to do this. While logistics and technical training and supervision are essential ingredients to the safe and effective delivery of malaria-related services, so are the communication tools that support service delivery. It is through effective communication that service providers can best influence treatment compliance and effectiveness.
Communication programs can also contribute to a reduction in anti-malarial drug resistance by changing health workers’ and drug vendors’ prescription practices. This may entail short orientation courses for health workers and simple job aids that serve as reminders of treatment schedules for various age groups.
Providing malaria treatment through community-based providers and selling subsidized ITNs through a voucher system will not automatically increase appropriate treatment or ITN use unless such initiatives are coupled with active communication. This may take the form of branding and media promotion; referrals through health services; community mobilization activities; or a combination of the three. Demand creation involves more than informing people about products or services. It involves understanding the audience’s socio-psychological environment and designing messages and materials that inform, educate, and motivate audiences within that context.
Communication through a variety of channels is the best way to change individual and community attitudes and practices that act as barriers to effective malaria control. Through multi-channel communication, including interpersonal, community, electronic and print media, malaria programs can:
By stimulating community dialogue about malaria, communities can assess their own malaria situation and come up with relevant solutions. Communities can be mobilized to establish drug revolving funds; organize periodic net re-treatment; to organize transportation for children with complicated malaria, and select community members for training as drug distributors. Through community education and dialogue, ITN use, IPT, and immediate appropriate treatment of malaria can become social norms. Communities can also take a more active role in regulating the activities of service providers, whether community-based volunteers, non-formal vendors, or health workers.
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