Kamden Hoffmann
Nan Lewicky
Michael Toso
Publication Date
May 1, 2015

Insight Health (Hoffmann), Health Communication Capacity Collaborative (HC3) (Lewicky, Toso)


"The purpose of this desk review is to identify promising SBCC practices related to malaria case management at both community and service provider levels in the four focus countries: Zambia, Ethiopia, Rwanda and Senegal."

This Health Communication Capacity Collaborative (HC3) desk review was undertaken in 2014 to better understand: 1) failure to use standard social and behaviour change communication (SBCC) malaria indicators in project design and evaluation and 2) a lack of focus on service providers as the focus audience of SBCC interventions. The introduction of the review describes a strategic SBCC approach: "a formative assessment, which identifies the important barriers and motivators to behavior change, followed by the design and implementation of a comprehensive set of interventions to support and encourage positive behaviors."

It then reviews impact indicators designed to look at the differences that a strategy might have made in the overall programme environment. "An example of an impact indicator for malaria case management could be: the proportion of children under five years old with fever in the last two weeks for whom advice or treatment was sought. Typical data sources can include:

  • Population-based household surveys, such as the Demographic and Health Survey (DHS), the Malaria Indicator Survey (MIS) or the Multiple Indicator Cluster Survey (MICS).
  • Smaller sub-national surveys, particularly in areas where malaria communications were targeted."

The methods for the study include a qualitative analysis and a desk review of research, country-level documents, international publications, and project reports. The qualitative analysis of experiences and perceptions from the field in all four countries was done through interviewing using a semi-structured questionnaire: Participants for key informant interviews (KIIs) included members of the appropriate government departments, such as units within the Ministry of Health (MOH) and bilateral and non-governmental organisation (NGO) implementing partners and staff.

SBCC in this study is explained as: "SBCC for malaria case management in communities involves encouraging prompt care seeking behavior for those with fever, convincing people that it is important to test for malaria before medicating, and that if medicating for simple malaria with the recommended artemisinin-combination therapy (ACT), to take the full regimen as instructed. Among service providers, behaviors like clinical diagnosis (diagnosing based on symptoms, not based on blood results of rapid diagnostic tests or microscopy) and presumptive treatment with ACTs for those with fever must be addressed."

Results are detailed by country and include descriptions of malaria operations plan studies and projects. Some communication-related observations and recommendations include:

  • Ethiopia
    • the use of radio as a channel to promote health messages regarding the importance of adherence to therapies.
    • advocacy for health education workers (HEWs) to carry out specific training on communicating treatment instructions. 
    • training of mother coordinators to teach neighbour-group mothers to recognise symptoms, e.g., the "Teaching Mothers to Provide Home Treatment of Malaria in Tigray, Ethiopia".
    • information, education, communication (IEC) materials and counseling cards for health workers (problems included poor distribution and a lack of attention to ethnically sensitive messages).
  • Rwanda
    • a national, integrated SBCC strategy to harmonise the communication activities and messages for health sector interventions.
    • interpersonal communication through leadership and social moblisation of community health workers (CHWs), care groups, local authorities, religious leaders, and opinion leaders to educate families.
    • IEC materials.
    • a distance learning radio programme aimed at building the capacity of CHWs in integrated community case management (ICCM).
    • community mobilisation, social behaviour change, care groups, and improved counseling, as well as capacity building and mobilisation of CHWs, care groups, local authorities, religious leaders, and opinion leaders to educate families. For example, the Kabeho Mwana programme, in which key "innovations" were noted as: "The Project’s unique community-based health information system and its system of local rapid assessments allow for measurement in changes in behavior on a quarterly basis to make rapid adjustments if appropriate progress is not happening…..The use of peers to educate in the care groups and among volunteers is empowering, and allows for immediate application of what they have learned….'Cascade approach' to training: senior project staff members are trained, they then train the junior project staff members, who then train the volunteers….Simplicity of the messages, the availability of indicators to monitor progress in the implementation of the messages, and the monitoring and evaluation (M&E) methods for monitoring progress….Strong presence of supervisory staff in the field to directly observe progress.”
  • Senegal
    • a national strategy that included the programme Xeex Sibbiru (“Let’s beat malaria” in Wolof) spreading messages through business and sports personalities, the media and religious leaders.
    • promising practices such as adequate BCC materials for CHWs.
    • local theatre for transmitting messaging on harmful traditional practices.
    • communication campaigns combined with home visits.
    • village elders' involvment for ownership of  BBC campaigns.
    • village care groups trained in signs and symptoms recognition and assisting the health worker in case detection and encouraging treatment compliance.
  • Zambia
    • the campaigns evaluated: the Safe Love Campaign and the Mothers Alive Campaign, with television and radio reaching people, but print material not reaching rural areas.
    • civil service organisations working with communities to establish goals and action plans, design activities, conduct monthly self-monitoring, and use public presentation of the data/progress toward goals to motivate everyone in a community to participate.
    • radio programming, community dramas, and community health information cards to increase public awareness.
    • paid facilitators to teach messages to care groups every two weeks.
    • refresher training for CHWs and birth attendants on malaria, nutrition, immunisations, and safe motherhood/neonatal care.

The summary and recommendations sections include the following:

  • Evidence of impact was available in several studies (more such studies are needed) that showed impact of SBCC interventions on malaria case management and child mortality and on changes in care-seeking behaviour, and uptake of ACTs). In SBCC intervention component measurement, particularly multi-channel, multi-level interventions, there was difficulty in attributing results to a specific intervention. Recommendations suggest including SBCC at the inception of programme design and evaluation design.
  • There is a lack of involvement of trained social scientists in programme design and evaluation, though that involvement does not guarantee solutions to measurement issues. Using inquiry to inform design is recommended, along with testing promising practices, such as:
    • "Advocacy and capacity building among MOH and country programs to include extensive planning, training, and M&E planning in SBCC for malaria case management.
    • Alignment and integration of SBCC and malaria case management planning, from the Malaria Operational Planning stages through program implementation and evaluation, including key participants in social science and malaria prevention and control.
    • Emphasizing the focus on producing SBCC evidence of the same scientific standard and rigor which is produced for other public health interventions."
  • Evidence was found for the effectiveness of the care group approach, particularly those led by MOH and CHWs, so as to reduce dependence on NGOs. A results table on page 22 lists project findings on care groups by country, and a chart on page 23 lists suggests recommendations for the introduction and scale-up of this model.
  • Evaluation of impact of SBCC was recommended. "This review has listed a number of SBCC programs implemented at different levels (community, regional, national) and paired them with appropriate methods of evaluation." A chart on page 24 details design approaches for evaluating field work including:
    • Stepped wedge design, wait list case/control, comparative effectiveness trials
    • Propensity analysis scoring
    • LiST tool (Lives Saved Tool)
    • Randomized Control Trial.

Health Communicator Capacity Collaborative (HC3), September 4 2015. Image credit/caption: Cover photo: A field worker collects a blood sample for malaria testing from a child in northern Zambia. © 2012 Timothy Shields, Courtesy of Photoshare