Illustrative Communication Strategy for Prevention and ... - Jhpiego

ILLUSTRATIVECOMMUNICATIONSTRATEGYforPrevention and Control ofMalaria during PregnancyDeveloped byJohns Hopkins Bloomberg School of Public HealthCenter for Communication Programs

List of AbbreviationsANCIECIMCIIPTITNMOHPRASPTBAUNICEFWHOAntenatal CareInformation, Education and CommunicationIntegrated Management Of Childhood IllnessIntermittent Preventive TreatmentInsecticide Treated NetMinistry of HealthParticipatory Rapid AppraisalSulfadoxine-pyrimethamine (Fansidar)Traditional Birth AttendantUnited Nations Children’s FundWorld Health Organization

TABLE OF CONTENTSBACKGROUND............................................................................................................................. 1Strategy Design Process .............................................................................................................. 1Points of Strategic Integration..................................................................................................... 2COMMUNICATION STRATEGY FOR CONTROL OF MALARIA DURING PREGNANCY 3Priority Problems, Their Causes, and Factors that Exacerbate or Diminish Them ..................... 3Communication Strategy Overview ............................................................................................ 4Assumption and Recommendation: The Service Delivery/Communication Link ...................... 5STRATEGY OUTLINE: MALARIA DURING PREGNANCY ................................................... 6MONITORING AND EVALUATION PLAN ............................................................................. 10

BACKGROUNDMalaria among pregnant women contributes to maternal anemia, low birth weight and infantdeaths; it is the single most common cause of spontaneous abortion in many African countries.In response to this serious health problem, the Abuja Declaration for the initiative “Roll BackMalaria” in Africa was launched with a strategy to ensure pregnant women prevent malariathrough the use of intermittent preventive treatment (IPT) with an effective anti-malarial drug andregular use of insecticide-treated bed nets (ITNs).Effective communication is the basis of behavior change for all stakeholders – women, theirfamilies, community leaders, program managers and service providers. This document brieflyoutlines a generic communication strategy that supports the prevention and control of malariaduring pregnancy. It illustrates a step-by-step process to define the communication strategy andexamples of possible priority problems and how to address them. A country-specificcommunication strategy should be developed with local stakeholders and the localcommunication specialists, taking into consideration updated national malaria policy andguidelines.Strategy Design ProcessA three-step process can be used to develop a communication strategy:1. Develop a working group of stakeholders who can guide the process of strategicdevelopment. These should be program managers, IEC and technical experts, serviceproviders and community people, including decision makers and expectant mothers.2. Conduct a literature review of work that has already been carried out on malariaduring pregnancy to better understand important components such as: recognition ofmalaria, decision-making, treatment practices, treatment sources, compliance withtreatment, caretakers’ sources of information, availability and accessibility toeffective prevention and control drugs and ITNs, community perception about formalhealth services, and relevant MOH policies. Program managers should examine theliterature review to identify gaps in providers’ knowledge and to address these gaps.A special focus should be placed on helping providers and the community toovercome any obstacles to behavior change in implementing correct action.3. Carry out qualitative research to fill in the gaps. This research can take the form offocus group discussions with expectant mothers, women aged 35 and above and menand community leaders. Key informant interviews with community drug vendors,traditional birth attendants, and qualified health workers can also provider invaluableinformation on important issues to address. The qualitative research will providemore detail about what people do, why they do it and the obstacles to behaviorchange.The working group of stakeholders can then review the literature and formative research findings,and develop a communication strategy based on those findings. The strategy presented here is anillustrative strategy that could be the results of such a workshop.1

Points of Strategic IntegrationPossible results from the formative research are:1. Underlying problems Women are unable to access the resources they need to take action Service providers and clients are unaware of treatment guidelines Communication between clients and providers is not always optimal and can beimprovedBy understanding the challenges, program managers can craft training, supervision, andcommunication materials that address malaria during pregnancy effectively.2. AudiencesTo effectively address the issue of malaria during pregnancy, there are four principalaudiences: policy makers and program managers, community decision makers (men,mothers-in-law, and opinion leaders), young and expectant mothers and service providers.Policy makers and program managers must facilitate access to effective preventive andcontrol measures. Men and community opinion leaders must understand that families andconstituencies need resources to protect pregnant women. Young and expectant mothers needto understand how to take care of themselves during pregnancy, how to care for their youngchildren, and how to advocate for the resources they need. Service providers need to have abetter understanding of counseling, as well as preventive and treatment guidelines forpregnant women.3. Media and mobilisationMedia and mobilisation strategies are often similar in their approach. Both strategies call for:a logo to identify sources of quality malaria information and services; use of newsletters toimprove provider compliance; radio programs, information sheets and posters to summarizetreatment guidelines; and meetings with in-charges and orientations to improve supportsupervision.2

COMMUNICATION STRATEGY FOR CONTROL OF MALARIADURING PREGNANCYPriority Problems, Their Causes, and Factors that Exacerbate or DiminishThemThe following is an example of possible formative research results. The literature review, andqualitative research will provide the specific information for each country to identify its priorityproblems and how to address them.Examples of priority problems that lead to inadequate prevention and control of malaria duringpregnancy are:1. Poor provider compliance with national malaria guidelines• Problem: Service providers offering antenatal services at public and private health facilitiesdo not comply with malaria guidelines.• Causes: Lack of provider compliance is due to inadequate dissemination of the NationalGuidelines for Malaria during pregnancy; lack of orientation to guidelines; inability of someproviders to understand guidelines; non-availability of guidelines in a language easilyunderstood by the providers; lack of clear information for health workers on how to provideIPT; few discussions between health workers and pregnant women about malaria, side effectsof SP, and SP schedule; failure to include private sector in strategy.• Factors that exacerbate the problem: Desire to reserve SP for treatment of those who aresick, rather than those who do not have symptoms of malaria• Factors that diminish the problem: National Guidelines for Malaria during pregnancy areavailable. The structure is in place (decentralized system) for effective guidelinedissemination and quality support supervision.2. Pregnant women not preventing or treating malaria correctly• Problem: Pregnant women are not preventing and treating malaria correctly.• Causes: Pregnant women are not taking steps to prevent or treat malaria because they havenot been made aware that the placenta can harbor malaria parasites without the womanhaving any physical symptoms. They are not aware of the seriousness of fever duringpregnancy; they believe fever is a normal sign of pregnancy; sometimes there are nosymptoms of malaria; they are not able to recognize the symptoms of malaria; they attributelow birth weight or miscarriages to witchcraft or infidelity, not malaria; they fear thatchloroquine and SP are dangerous to pregnancy.• Factors that exacerbate the problem: Malaria tests are not available; malaria is especiallydangerous during a first pregnancy, yet younger women are less likely to get antenatal care;women do not have the financial resources to either pay for malaria drugs, or ITNs.• Factors that diminish the problem: Communities are aware that malaria is dangerous; thereare organized structures within communities that can be used to raise awareness.3. Pregnant women lack power, authority, and resources• Problem: Pregnant women do not make decisions for themselves regarding health care andoften lack authority over resources such as funds for transport to attend antenatal care.3

• Causes: Decisions are made jointly by husbands and in-laws who do not recognize theseriousness of malaria during pregnancy; women do not control resources.• Factors that exacerbate the problem: Young women, primigravidae, who are the mostseriously affected by malaria are often the women with the least authority and resources.• Factors that diminish the problem: Women who are educated or have work outside thehome may have control over some resources and be willing to seek care.4. SP is not acceptable to many pregnant women.• Problem: For a variety of reasons, many women do not want to or cannot take SP.• Causes: The unacceptability of SP to some women is due to a belief that Fansidar isdangerous during pregnancy; sensitivity to the presence of sulfur in the drug and SP sideeffects; the feeling that SP is too strong- and bitter-tasting; and the fact that the woman doesnot see any results from taking SP since she doesn’t have any malaria symptoms.• Factors that exacerbate the problem: Rumors in the community and the newness of theintervention, so that there is not a lot of experience with IPT using SP and its effectiveness.• Factors that diminish the problem: Many women have taken SP and have remained healthyand given birth to healthy babies.5. Pregnant women are not using ITNs• Problem: Pregnant women are not using ITNs.• Causes: Pregnant women are not using ITNs because ITNs are not widely available; somesay ITNs choke them; some rooms are overcrowded, there is not an easy way to hang them;they are not affordable to many; women fear that insecticide is dangerous.• Factors that exacerbate the problem: Continued high tariffs and taxes on imported,insecticide-treated nets, making them more expensive• Factors that diminish the problem: More countries beginning to manufacture local netsand community groups organizing to re-dip nets at minimal cost.Communication Strategy OverviewAfter examining all of the priority problems, the working group will decide which are the mostimportant and develop a communication strategy that addresses these. For example, if we choosethe first two priority problems: service providers are not complying with malaria duringpregnancy guidelines, and pregnant women are not preventing and treating malaria adequately,we can develop four important elements in the strategy:1. Creating a symbol that identifies providers and facilities offering correct information andservices for malaria prevention and treatment for pregnant women. (This symbol can alsoidentify sources of information and treatment for children under the age of five.)2. Building a sense of urgency among leaders and men and persuading them through radio,print, and interpersonal channels to advocate for, support and provide the resources necessaryto pregnant women for quality, focused antenatal care including intermittent preventivetreatment with an effective anti-malarial drug and use of an insecticide-treated net. Also, theyshould support prompt and proper treatment of pregnant women with fever.3. Improving the quality of information and training provided to health care providersthrough effective dissemination of simplified treatment guidelines and job-aids.4

4. Motivating pregnant women to seek IPT and use ITNs through group education sessions,radio, point of service materials and community-based interventions.Assumption and Recommendation: The Service Delivery/CommunicationLinkThe assumption underlying this strategy is that the service delivery, policy, management,logistics, and supply interventions that are necessary complements to any successfulcommunication strategy will be in place. No malaria communication program can succeed ifwell-articulated national protocols and service delivery guidelines are not adequatelydisseminated and understood; if the right drugs are not available at the right time; and if serviceproviders are not adequately trained.Recognizing the crucial importance of these complementary service delivery issues, the managersof the communication program must closely coordinate with their service delivery counterparts.Advocacy-related communication will be crucial to ensuring that the necessary services are inplace. Communication programs should be synchronized with services. That is: when aneffective anti-malarial drug (e.g. SP), is fully available and district health workers trained toprovide IPT, appropriate communication interventions should accompany or follow close behind.5

STRATEGY OUTLINEMALARIA DURING PREGNANCYPriority Problem I: Service providers offering antenatal services atpublic and private health facilities do not comply with guidelines forprevention and control of malaria during pregnancy.Primary Audience:Service providers offering ANC services at public and private health facilitiesSecondary Audience:District training and supervision teams, plus health teams (core orientation teams)Tertiary Audience:Central/coordination officers (MOH officers, regional officers)Communication Objective:Primary audience:By year XXXX, increase to 80% the proportion of ANC providers in public and privatefacilities in the country who correctly follow the guidelines for preventing and managingmalaria during pregnancy.Motivating factors for service providers:Decide what are motivating factors for providers:If you follow the MOH guidelines for prevention and control of malaria during pregnancy,Your workload will be reduced because there will be fewer cases of severe anemia,stillbirths, and miscarriages resulting from malaria during pregnancy.You will have better pregnancy outcomesYou will be recognized as providing quality care, etc.Support points:The international literature review and qualitative research highlight points, which provide keymessages for the provider. These can be more focused in each country with local data.• The government has put in updated guidelines for preventing and managing malaria duringpregnancy• Malaria during pregnancy causes anemia, low birth weight, miscarriages, and stillbirths. Mostmiscarriages and stillbirths are due to malaria during pregnancy.• Pregnant women are more likely than non-pregnant women to have malaria because theirresistance is low.• Many pregnant women who feel and look well carry malaria parasites.6

• A single dose of three SP tablets given at least two times—once at the first regularlyscheduled ANC visit after quickening (no sooner than 16 weeks) and at each regularlyscheduled visit thereafter (at least 1 month apart). SP is available from healthcare workersand shops or clinics bearing the malaria symbol.• SP is a very safe and effective drug that works against malaria during pregnancy. SP does notharm the mother or the child.• Many pregnant women have taken SP during pregnancy with no ill effects (support this pointwith testimonies).• For effective management of malaria, pregnant women with fever should be treated with—(use the directives from the national guidelines).• The best way to protect oneself from mosquito bites is to sleep under ITNs.Desired action responses from service providers:• I will follow the national guidelines for giving IPT to prevent malaria, and I will treat allpregnant women with fever with the recommended regimen in the national guidelines.• I will encourage pregnant women to sleep under ITNs to prevent mosquito bites.Tools to support mobilization activities:• Simplified guidelines for malaria treatment in pregnancy for both public- and privatesectorservice providers. These will be translated into some vernacular languages forcommunity-based health workers.• Laminated one-page, two-sided job-aids for community providers, one side in English orFrench, the other in the local language. The sheet will give a brief and easy-to-followexplanation of how to administer SP as a preventive measure and how to treat those womenwho have fever or other signs of malaria.• Combined orientation meetings for malaria and focused antenatal care. The central levelwill prepare guidelines and conduct meetings for training core district orientation teams. Coredistrict orientation teams then will use the same simplified guidelines to orient both privateand public service providers. This training can be combined with training for focusedantenatal care to ensure a quality service. Furthermore, this combination can be moreefficient, saving time and money for training.• Posters containing IPT schedule to be displayed in health facilities.• Weekly radio programs for health workers offering technical updates on prevention andcontrol of malaria during pregnancy and other quality of care issues such as focused antenatalcare for health workers (primary audience) and women (secondary audience).• Simplified flipcharts with dosage information on one side and messages for clients on theother.• T-shirts, badges, and stickers with the malaria symbol and slogan for malaria duringpregnancy.• Special focus on prevention and control of malaria during pregnancy in quarterly newsletterfor health workers.7

STRATEGY OUTLINEMALARIA DURING PREGNANCYPriority Problem II: Pregnant women are not preventing andtreating malaria correctly.Primary Audience:Women aged 18-25 living in malaria endemic areasSecondary Audience:Extended family (husbands, in-laws, mothers) and health workersTertiary Audience:Community and opinion leaders, TBAs (elderly women), and satisfied users of IPT.Communication Objectives:Primary Audience:Increase to 50% the proportion of women aged 18-25 who are aware of the dangers ofmalaria during pregnancy and intend to use an ITN and follow the recommended dosageof IPT during pregnancy.Secondary Audience:By the year XXXX, increase to 60% the proportion of extended family members andhealth workers who support and encourage women to seek correct malaria prevention andtreatment during pregnancy.Tertiary Audience:By the year XXXX, increase to 60% the proportion of community leaders who will speakwith others about the benefits of IPT.Motivating factors for mothers (primary audience):If you receive IPT during pregnancy to prevent malaria and regularly use an ITN, then you willbe a healthy mother and have a healthy babySupport points:The international literature review and qualitative research highlight points, which provide keymessages for the woman, her family and community leaders. These can be more focused in eachcountry with local data.• Malaria during pregnancy is dangerous to you and your baby and can lead to miscarriages,stillbirths, and weak babies• Sometimes malaria has no signs in pregnancy, so every pregnant mother must take preventivemeasures using SP and ITNs.• Any fever during pregnancy should be considered serious. It could be a sign of malaria.8

• To prevent malaria, ITNs are an essential protection against mosquito bites. Every pregnantwoman should sleep under an insecticide-treated mosquito net• Malaria germs hide in the body causing anemia. When women become pregnant, these germscause malaria.• To prevent malaria, pregnant women should visit the clinic for an antenatal care visit and getIPT at the recommended dosage. (Use the national guidelines protocol.)• Pregnant women with fever should be treated according to national treatment guidelines.• Many pregnant women have taken SP during pregnancy with no ill effects (support this pointwith testimonies).• SP is safe and effective in preventing malaria during pregnancy• SP is available in health facilities and drug shops labeled with the malaria symbol.Desired action response from women:I intend to go for IPT and get treated for fever when I am pregnant so that I can be healthy andhave a healthy baby, and I will encourage other pregnant women to do the same. Also, I willsleep under an insecticide-treated net.Tools to support mobilization activities:• Incorporate messages about malaria control in pregnancy into existing health radioprograms• Radio spots with messages about the dangers of malaria during pregnancy, use of ITNs andIPT during pregnancy will be produced in all major languages and broadcast on a variety ofstations.• Leaflets will be produced in local languages to explain about malaria during pregnancy andhow it should be treated and prevented and distributed to all waiting clients at health facilities• Posters placed strategically in the community will encourage pregnant women to requestIPT, get immediate treatment for fever, and to sleep under ITNs.• Bags/satchels with the malaria symbol for women to "pack in" for ANC visits and hospitaldelivery.• Drama/songs. Scripts will be written centrally and translated and performed at the districtand sub-district levels by local music dance and drama performers.• Integrated Reproductive Health Days at health facilities. During these special events,health workers will offer antenatal checkups, IPT, ITN sales and distribution, immunization,growth monitoring, Vitamin A supplementation, nutrition-related activities, and healtheducation for mothers.• Newsletters. An issue of the quarterly newsletter will be dedicated to malaria duringpregnancy and focused antenatal care• Video. One TV/video series will be devoted to malaria during pregnancy. This program willbe made available in vernacular languages and will be shown on television, at video clubsand during community video shows.• The Malaria symbol will identify sources of IPT and fever/malaria treatment for pregnantwomen as well as malaria home management for children.• A booklet with simplified information about malaria during pregnancy will be produced forcommunity leaders.• Calendars. Each year, the Malaria Control Program produces a calendar. One calendar willfocus on malaria in pregnancy.9

MONITORING AND EVALUATION PLANAn appropriate monitoring and evaluation plan should be developed to document that plannedactivities are carried out in a timely manner and that they have their desired effect, achieving thecommunication objectives.10