STOP MALARIA PROJECT
Submitted by:
Submitted by
November, 2012
Contact:
Basil Tushabe
Executive Director, CDFU,
Plot 58, Kibira Road (Kamwokya), P.O. Box 8734, Kampala
Telephone: 0312-263941/2, Fax: 0312-263943
Email:
ABBREVIATIONS
ANC: Antenatal Care
BCC:Behaviour Change Communication
CDFU: Communication for Development Foundation Uganda
CCP: Centre for Communication Programs
DHI: District Health Inspector
DHO: District Health Officer
DHT:District Health Team
DOTS:Direct Observed Treatment
FGD: Focus Group Discussion
HA:Health Assistant
HFI:Health Facility In Charge
IDI:Infectious Diseases Institute
IPTp:Intermittent Preventive Treatment in Pregnancy
JHU:Johns Hopkins University
KII: Key Informant Interviews
LLIN: Long Lasting Insecticide Treated Nets
MC:Malaria Consortium
MFP: Malaria Focal Person
MoH:Ministry of Health
OPD: Out Patients Department
PHC: Primary Health Care
PMI:Presidential Malaria Initiative
PS:Primary School
SMP: Stop Malaria Project
USAID:United States Agency for International Development
Table of contents
Executive summary......
CHAPTER 1......
1.1 INTRODUCTION AND BACKGROUND......
1.2 Overview of Coverage of Key Messages on Malaria Prevention and Treatment
1.3The Documentation
CHAPTER 2......
DOCUMENTATION METHODS AND APPROACH......
2.1Study Design......
2.2Study Area / Geographical scope......
2.3Population......
2.4Sampling Procedure......
2.5 Data Collection Tools and Methods......
2.6Data Processing and Analysis......
CHAPTER 3......
FINDINGS......
3.1Knowledge Levels on Malaria Prevention and Treatment,......
3.3 Technical Support for Health Assistants......
3.4Logistical Support...... 24.
3.5Benefits of integrating Malaria Prevention and Treatment Intervention...
3.6 Success Stories/Best Practice......
3.7 Suggestions and Recommendations......
GENERAL CONCLUSIONS......
4.3Technical and Logistical Support to Health Assistants......
4.4 Benefits of integrating Malaria Prevention and Treatment Intervention...
GENERAL RECOMMENDATIONS......
Appendix 1: Ministry of Health Structure that facilitates......
Appendix 2:SAMPLE SIZE SELECTION......
Appendix 3:Interview Guides Key Informants......
Appendix 4 (a) FOCUS GROUP DISCUSSION GUIDE: PUPILS......
Appendix 4 (b) FOCUS GROUP DISCUSSION GUIDE: PARENTS......
Appendix 4 (C) FOCUS GROUP DISCUSSION GUIDE:......
Appendix 4 (d) FOCUS GROUP DISCUSSION GUIDE: PREGNANT WOMEN
1
Executive Summary
Introduction
This report presents findings from the documentation of the malaria prevention and treatment community mobilization interventions conducted in six pilot districts of Hoima, Kibaale (Mid – West Region); Kaberamaido, Soroti (Teso Region) as well as Mukono, Rakai (Central Regions). In addition, information was also collected in two control districts namely Wakiso (Central Region) and Serere (Teso Region). The documentation focused on key thematic areas that include: use of Long Lasting Insecticide Treated mosquito Nets (LLINs); uptake ofIntermittent Preventive Treatment in Pregnancy (IPTp) among pregnant women; early treatment seeking behaviour within 24 hours on onset of malaria signs and symptoms. In addition, issues of male involvement were also addressed.
Methods
The documentation employed qualitative methods of data collection. Key Informant interviews were conducted with district officials, school teachers & administrators, Health Assistants (HAs), health facility in-charges and leaders of community listenership groups. Focus group discussions were alsoheld with parents, pupils, pregnant women and listenership groups. A total of 79 Key Informant interviews and 67 FGDs were conducted.
Results
District officials in pilot districts where HAs’ interventions are implemented, reported that the general communities including school children had improved knowledge on malaria prevention and treatment in the three key SMP intervention areas. In the control districts, officials reported that communities had more knowledge on other malaria control interventions, for instance slashing bushes and draining stagnant water, compared to the three key SMP intervention areas. This knowledge had been mainly provided by Village Health Teams, (VHTs).
Focus Group Discussion (FGD)participants from the pilot districts had more knowledgeon the three key SMPmalaria prevention and treatment components compared to those in the control districts. This is becausethe HAs have been actively engaged in capacity building activities supported by the Stop Malaria Project (SMP). The HAs also worked in collaboration with the VHTs,to mobilize and sensitizegrass root communities, which ultimately created high levels of knowledge and awareness on malaria control.
In regard to attitudes and practices district officials in the pilot districts also reported great improvement towards malaria control in schools, health facilities and grass root communities. They attributed this to continuous mobilisation and sensitization by HAs, working in collaboration with VHTs. In the control districts, district officials mostly reported on improvement in other malaria control interventions like clearing bushes, and removing stagnant water other than consistent use of LLINs, uptake of IPTp and early treatment seeking behaviour.
FGD participants in pilot districts reported that they had improved their attitudes and practices on malaria prevention and treatment. Pupils reported that HAs had imparted to them knowledge and skills on malaria control interventions during the health/malaria club activities. Parents of most of the pupils in the malaria clubs reported that their children had helped to promote best practices in malaria control at home and in the neighbourhood. Pregnant women reported that they had obtained information on malaria control from the health workers including HAs. Some pregnant women also reported that the health workers had provided them with LLINs as well as fansider, which they were using and taking respectively as directed by them. In addition, men and community listenership groups acknowledged that HAs had contributed to change in attitudes and practices related to malaria control. Men also reported that they were actively involved in malaria control practices that focused on the three key SMP interventions
In the control districts, the pupils reported that they didn’t have malaria clubs to promote messages on key SMP intervention areas. In addition, FGD respondents also reported more improved attitudes and practices in other malaria control interventions, other than the three SMP intervention areas, though some also reported use of LLINs and IPTp uptake.
Conclusion and Recommendations
In the pilot districts, most of the HAs have contributed to positive attitudinal and behavioural change in the three key SMPinterventions as reflected by the reports from districts officials, respective focus groups as well as observations made by the documentation team in respective districts.For instance, pupils in the pilot districts demonstrated improved information and skills inthe SMP intervention areas, compared to their counterparts in control districts, where they did not have malaria clubs. Pupils in the pilot districts exhibited positive change in malaria control as reflected in their success stories, poems, drama/skits, board games and debates. In addition, in control districts,the change in attitudes and behaviours was mainly towards other malaria control interventions other than consistent use of LLINs, IPTp and early treatment seeking behaviour.
Nevertheless, SMP needs to increase collaboration with the District Management Teams,for sustainability of BCC interventions through participatory development of integrated work plans and budgets, participation in review meetings, as well as conducting joint support supervision.
SMP alsoneeds to continue to work with HAs in the pilotdistricts to consolidate the SMP key intervention areas that they started implementing in the past one year, It is this regard that SMP in collaboration with District Management Teams SMP needs to continue to support HAs integrate the three key SMP interventions, as they continue towork closely with pupils in malaria clubs, communities (including the community listenership groups and their leaders) as well as staff at the Health Facilities.
SMP needs to ensure that male involvement is at the core of planning, implementation and monitoring of all the key intervention areas, since males influence greatly attitude and behaviourchangetowardsmalariacontrolinterventions This can be done through community dialogue meetings with the men.
CHAPTER 1
INTRODUCTION AND BACKGROUND
1.1 Introduction
The Stop Malaria Project (SMP) is a five-year program (2008-2013) of development assistance funded by the Presidential Malaria Initiative (PMI) and United States Agency for International Development (USAID). SMP is comprised of a consortium of partner organizations led by the Johns Hopkins UniversityCentre for Communications Programs (JHU/CCP). Other partners include Malaria Consortium (MC), the Infectious Diseases Institute (IDI) and Communication for Development Foundation Uganda (CDFU). The overall goal of the project is to assist the Government of Uganda to reach its goal of reducing malaria-related mortality. During the five years, the project will work towards reaching 85% coverage of pupils less than five years of age and pregnant women in the thirty four partner districts, with proven preventive and therapeutic interventions:
•Artemisinin-based Combination Therapy (ACT) for treatment of uncomplicated malaria,
•Intermittent Presumptive Treatment (IPT) of malaria in pregnancy, and
•Long-lasting insecticide treated nets (LLINs).
In line with the project objective of building community capacity to respond to malaria, the project focuses on improving community knowledge, perceptions and behaviours on malaria by strengthening the knowledge and skills through the health assistants.
CDFU is the lead partner in the implementation of the community mobilization interventions in the respective ten pilot districts of Mukono, Masaka, Rakai (Central Region); Amuria, Kaberamaido, Katakwi, Soroti (Teso Region) and Buliisa, Hoima, Kibaale (Mid West Region).The focus is on empowering individuals, households and communities to prevent/reduce malaria related mortality and morbidity, using an integrated approach for community engagement that utilizes the Ministry of Health (MoH) structure which directly interfaces with the grass roots communities. The point of interface in the MoH structure is the Health Assistant linking with Village Health Teams at Heath Centre I and Grassroots Communities.
(Refer to Appendix 1: Ministry of Health Structure that facilitates Grassroots Community Engagement at the District Level).
The Community Mobilization component of SMP focuses on the promotion of four key messages including: proper and consistent use ofLLINs; increased uptake of IPTp; early treatment seeking behaviour within 24 hours on the onset of signs and symptoms of malaria and male involvement in malaria prevention and treatment services.
1.2 Overview of Implementation of Behaviour Change Communication (BCC) – Malaria
Control Inteventions
The Community Mobilization component commenced in the third year of the project (October 2010), with the aim of supporting district structures to promote malaria control in the grassroots communities. Health Assistants were identified as a critical structure that interfaced with the grassroots communities. It was in this regard that an assessment was conducted to find out whether Health Assistants were actively engaged with communities. The findings from the assessment revealed that the HAs were actively involved in Health Promotion activities in the communities. In addition, it was also found out that HAs had limited information on the three key SMP intervention areas. It was on this basis that SMP held various planning and review meetings with respective DHTs and One hundred and Twenty Two (122) HAs in ten selected pilot districts to provide guidance on implementation of the SMP – BCC malaria control interventions as well as capacity building for the HAs. During these meetings it was emphasized that HAs integrate BCC malaria control interventions during their work at the health facilities and communities. Key community structures including primary schools, community leaders, community groups (VHTs, savings and credit groups as well as women’s groups) were identified as the most appropriate communication channels for the intervention.
a) Health Facility Interventions
The HAs developed an integrated plan, together with the Heath Facility staff, to ensure that Health Education on malaria controlwas conducted at the Out Patients’ Department (OPD) and Antenatal Care Units (ANC), on a regular basis. SMP provided job aids on malaria control in various languages of the respective districts. The target audience at the OPD was the general community, while at the ANC pregnant women and their partners were the target population. The HAs and health facility staff used the job aids, as educational materials, to facilitate discussions at both the OPD and ANC, and as much as possible also encouraged interpersonal discussions.
SMP also providedthe health facilities with monitoring tools including record keeping books, that the HAs and the health workers used to document the malaria control topics covered and the number of people reached.
b) Primary School Interventions
The HAs were each assigned with identification of five primary schools in which they could integrate malaria control interventions, in routine school activities. The respective HAs sensitized various primary schools on the importance of malaria control and sought for possibilities of partnerships for initiating and strengthening malaria control interventions among the pupils, focusing on integration of the key SMP intervention areas. The HAs collaborated with schools that showed keen interest in integrating the key SMP intervention areas. The HAs initially sought to integrate the interventions within existing health clubs, but the majority of the schools preferred to have a specific malaria club to ensure that maximum advocacy for the key SMP intervention areaswas conducted among the school population.
The malaria clubs compriseof a representation of two pupils (a girl and a boy) from each class., who are committed and interested in actively participating in malaria control interventions in general and the key SMP intervention areas in particular. The pupils in the malaria clubs engage in child friendly strategies including development of skits, poems, songs, board games to empower them assimilate and also be effective communication channels that promoted the SMP intervention areas. In addition, they also participate in health education at assemblies, using the job aids as well. The pupils are empowered with information and skills to promote and engage in malaria control activities in schools, home and neighbourhoods.
The head teachers are the key contact persons, who subsequently with the support of the HAs also engage the school staff in integrating messages on the SMP key intervention areas in their lesson plans. Various channels of communication are used in the primary schools, to promote the key SMP intervention areas among the school population, including formation of malaria clubs and talking compounds. The HAs also supported the pupils to understand and interpret the malaria messages in the “talking compounds”which SMP in collaboration with DHTs, initiated in the respective primary schools. The pupils were empowered with information and skills to promote and engage in malaria control activities in schools, home and neighbourhoods.
SMP provided the schools with record keeping books for monitoring the malaria control activities. The focus of data recording was on the malaria control topics covered and the number of pupils and school staff reached.
c) Grassroots Communities’ Interventions
The HAs worked with community leaders to identify already existing community groups, which they constituted as community listenership groups. The listenership groups included members of VHTs, Savings and Credit Cooperative Groups and Women’s Groups. The HAs integrated key SMP intervention areas, in the routine work of the respective groups, highlighting the importance ofboth prevention and early treatment seeking behaviour. The community listenership groups participated in listening to the malaria radio programs that were being aired by SMP and subsequently they would analyse and discuss information. The HA would clarify on issues that were not clear and thereafter together with the group would develop an action plan on how to disseminate the key messages presented during the radio program to the rest of the community. The action plans facilitated monitoring of progress of dissemination of key radio messages.
For all the above BCC – Malaria Control interventions, the HAs, provided regular monthly reports to SMP, through the District Health Inspector, on progress of activities. In addition, the SMP staff, in collaboration with DHTs conducted support supervisory visits in health facilities, schools and communities on a quarterly basis.
1.3Documentation of the Community Mobilization interventions integrated by HAs
This report highlights the background, methodology, key findings, conclusions and recommendations in relation to documentation of community mobilization interventions integrated by HAs. The report provides comparative documentation between six pilot districts of Hoima, Kibaale (Mid – West Region); Kaberamaido, Soroti (Teso Region) and Mukono, Rakai (Central Regions,) and two control districts namely Wakiso (Central Region) and Serere (Teso Region), where CDFU has not yet integrated the key SMP intervention components in the communities,implemented by HAs.
Key issues that prompted the need for this comparative documentation included the need tohave evidence based information on community mobilization interventions by HAs in selected pilot intervention and control districts, so as to guide the upcoming SMP planning process for year five.
1.3.1Operational Definitions
(i)Pilot Districts
These comprise of the six selected intervention districts, where the key SMP malaria control community mobilization interventions have been integrated in the scope of work of the HAs.
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(ii)Control Districts
These comprise of the two selected districts, where key SMP malaria control community mobilization interventions have not been integrated in the scope of work of the HAs.
Aim and Objectives of the Documentation
1.3.2Aim
The main aim of the documentation was to collect information on community mobilization interventions focusing on the three key SMP malaria control components, integrated in the scope of work of HAs, so as to provide evidence based input for the SMP planning process in year five.