Malaria Behavior Change Communication (BCC) Indicator …€¦ · officers at National Malaria Control Programs, as well as by representatives of donor agencies that fund malaria

Malaria BCC Indicator Reference Guide

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Malaria Behavior Change Communication (BCC) Indicator Reference Guide

February 2014


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Copyright© 2014 Roll Back Malaria Partnership

The Roll Back Malaria Partnership (RBM) is the global frame-work for coordinated action against malaria. Founded in 1998 by UNICEF, WHO, UNDP, and the World Bank and strengthened by the expertise, resources, and commitment of more than 500 partner organizations, RBM is a public-private partnership that facilitates the incubation of new ideas, lends support to innovative approaches, promotes high-level political commit-ment, and keeps malaria high on the global agenda by en-abling, harmonizing, and amplifying partner-driven advocacy initiatives. RBM provides policy guidance and secures financial and technical support for control efforts in countries and monitors progress towards universal goals. The RBM Secre-tariat is hosted by the World Health Organization in Geneva, Switzerland.

The geographical designations employed in this publication do not represent or imply any opinion or judgment on the part of the Roll Back Malaria Partnership on the legal status of any country, territory, city or area, on its governmental or state authorities, or on the delimitation of its frontiers. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the Roll Back Malaria Partnership in preference to others of a similar nature that are not mentioned or represented.This document may be freely reviewed, quoted, reproduced and translated, in part or in full, provided that the source is acknowledged.

The authors are grateful to all of the organizations and individ-ual photographers who granted permission for their photos to be used in this publication. Photo credits are on the inside back cover. Permission to reproduce any of these photos can only be granted by the original owners.

Cover explanation:

In the top picture, a data collector is conducting a household malaria survey. The bottom pictures represent various types of behavior change communication activities for malaria (L to R): a health worker counseling a pregnant woman and her husband on malaria in pregnancy in Uganda, a malaria educa-tion radio show in Cambodia and a home visit by a community health worker in Senegal.

Cover photo credits:

Top picture – Sarah Hoibak/Mentor Initiative, Uganda

Left – Stop Malaria Project, Uganda

Center - Moeun Chhean Nariddh/Containment, http://malaria-containment.wordpress.com/page/2/

Bottom: Diana Mrazikova/NetWorks Project, Courtesy of Pho-toshare. Senegal


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Table of ContentsAcronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Rationale for Measuring these Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

How to Use this Document . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

General Notes on Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

Data sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Gender implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Sample size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Core Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Targeted Behaviors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

1. Proportion of people who practice the recommended behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Reach/Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

2. Proportion of people who recall hearing or seeing any malaria message within the last 6 months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Knowledge and Awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

3. Proportion of people who name mosquitoes as the cause of malaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 4. Proportion of people who know the main symptom of malaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 5. Proportion of people who know the treatment for malaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 6. Proportion of people who know preventive measures for malaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Risk and Efficacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

7. Proportion of people who perceive they are at risk from malaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 8. Proportion of people who feel that consequences of malaria are serious . . . . . . . . . . . . . . . . . . . . . . . . . 29 9. Proportion of people who believe that the recommended practice or product will reduce their risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 10. Proportion of people who are confident in their ability to perform a specific malaria-related behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Supplemental Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Norms and Attitudes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

11. Proportion of people with a favorable attitude toward the product, practice or service . . . . . . . . . . . 36 12. Proportion of people who believe the majority of their friends and community members currently practice the behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43


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Experimental Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

13. Proportion of people who have encouraged friends or relatives to adopt the specific practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 14. Bed net care and repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 48 15. Non-adoption (subjective/objective) of recommended malaria interventions . . . . . . . . . . . . . . . . . . . . 53 16. Proportion of members of the household who sleep outside the house, by month . . . . . . . . . . . . . . . 57

Upcoming Activities Requiring Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

1. Seasonal Malaria Chemoprevention (SMC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 2. Larviciding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 3. Intermittent Screening and Treatment (IST) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 4. Mass Drug Administration (MDA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 5. Outbreak Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 6. Reactive/Active Case Detection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Process Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Reporting guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Annex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

Survey questionnaires . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Resource documents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Theory Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71


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Acronyms

ACT Artemisinin Combination Therapy

AED Academy for Educational Development

AIDS Acquired Immunodeficiency Syndrome

ANC Antenatal Care

BCC Behavior Change Communication

CHW Community Health Worker

DHS Demographic and Health Survey

FHI 360 Family Health International

HIV Human Immunodeficiency Virus

iCCM integrated community case management

IEC Information Education Communication

IPTp Intermittent Preventive Treatment

IRS Indoor Residual Spraying

IST Intermittent Screening and Treatment

ITN Insecticide Treated Net

JHU•CCP Johns Hopkins University Center for Communication Programs

LLIN Long Lasting Insecticide Treated Net

M&E Monitoring and Evaluation

MDA Mass Drug Administration

MERG Monitoring and Evaluation Reference Group

MICS Multiple Indicator Cluster Survey

MIS Malaria Indicator Survey

PMI President’s Malaria Initiative

RBM Roll Back Malaria

RDT Rapid Diagnostic Test

SMC Seasonal Malaria Chemoprevention

SP Sulfadoxine/Pyrimethamine

UNICEF United Nations Children’s Fund

USAID United States Agency for International Development

WHO World Health Organization


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IntroductionBehavior Change Communication (BCC) has been a critical component of malaria prevention and control strategies. Most programs, however, have not been rigorously evaluated, either due to a lack of funding for such evaluations and/or due to lack of clarity about best practices for measuring the contribution of BCC for malaria prevention and control. In the past decade, malaria funding has increased exponentially and implementation of malaria control activities including long-lasting insecticide treated bed net (LLIN) distribution; malaria case management; prevention of malaria in pregnancy; and indoor residual spraying are rapidly being scaled up in an attempt to meet ambitious global malaria objectives. Behavior change communication activities and campaigns should provide support to malaria scale up activities, to ensure their effectiveness and to support overall improvements in populations’ knowledge, attitudes and practices in malaria prevention and management. Significant resources have been budgeted to implement BCC activities and campaigns. Evidence, however, is limited as to the comparative effectiveness of materials, activities, and messages as well as to the overall effectiveness of communications on behavior change.

Objective: The proposed Malaria BCC Indicator Reference Guide aims to support Ministries of Health, donor agencies and implementing partners involved in malaria prevention and control to evaluate the effectiveness of malaria BCC interventions and to measure levels of behavior change for malaria prevention and case management at the country level. The indicators are also useful for monitoring and designing malaria BCC interventions.

Intended beneficiaries: This document is intended for use by communication and monitoring and evaluation officers at National Malaria Control Programs, as well as by representatives of donor agencies that fund malaria prevention and control, and by communication/BCC officers within implementing partner agencies.

About the authors: These indicators were based on the collection of Behavior Change Communication indicators within the Family Planning and Reproductive Health Online Indicators Database, developed by the University of North Carolina Population Center under the Measure Evaluation Population and Reproductive Health associate award from USAID in 2009-2011. They have been selected and adapted for the malaria context, by a group of malaria BCC experts, including Hannah Koenker, Jessica Butts, Angela Acosta, Martin Alilio, Marc Boulay, Debra Prosnitz, Hibist Astatke, Susan Zimicki, Joe Keating, and Janita Bhana.

The indicator guide builds on the work and contributions of many people. Particular thanks go to the following individuals for their contributions to the planning and review of this document: Zandra Andre, Kirsten Bose, Beatie Divine, Samantha Herrera, Nan Lewicky, Thad Pennas, Emily Ricotta, Douglas Storey, Kirsten Unfried, Jennifer Yourkavitch and Matt Lynch.


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Rationale for measuring these indicators These indicators were selected based on findings from existing literature that have examined determinants of behavior in malaria, HIV and family planning, and from the four commonly used theories of communication and behavior change:

• ReasonedAction/PlannedBehavior,whichfocusesprimarilyoncognitiveorrationalprocessesarounddecision-making;

• SocialLearning,whichfocusesonhowpeoplelearntobehavebyobservingothers;

• DiffusionofInnovations,whichfocusesonthestructureofthesocialenvironmentandhowthisinfluences access to information and behavioral response; and

• ExtendedParallelProcessingorFearManagement,whichfocusesonhowcognitionandemotionworktogether to motivate behavior.

These theories, and decades of research in health communication for HIV/AIDS, Family Planning, and other health areas, have shown that knowledge is not the only determinant of behavior. Factors such as exposure to messages, perception of risk, self-efficacy, response efficacy, and social norms play a key role in health decision making. For malaria specifically, exposure to messages, perception of risk, self-efficacy, response efficacy, and knowledge of malaria transmission and symptoms have been shown to be associated with preventive behaviors [1-19, Boulay 2014 in review]. Indicators measuring these aspects have been included as Core Indicators. These indicators enable an explanation of the relationships between exposure, awareness, susceptibility, severity and behavior.

Social norms play a significant role in HIV/AIDS and Family Planning behaviors, but have not yet been shown to be associated with malaria behaviors. These indicators are included in this Reference Guide as Supplemental Indicators to encourage research in this area. Finally, intention and context-specific indicators are included as Experimental Indicators to promote research to assess their utility in predicting malaria preventive behaviors. Supplemental and Experimental Indicators are included to provide more contextual information to better understand behavioral determinants and to encourage research in certain areas.

These indicators were developed and chosen by a working group composed of President’s Malaria Initiative (PMI) partners with extensive experience in monitoring and evaluating BCC activities, including malaria BCC activities. Survey questionnaires from 15 partners were examined and questions were grouped into theoretical construct areas, such as efficacy, threat, norms, attitudes and knowledge. Indicators were distilled from the list and discussed and refined over a period of three years.


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Four Commonly-Used Theories ofCommunication and Behavior Change

Attitude

Subjective Norm

Intention Behavior

Perceived Behavioral Control

Figure 2. The Theory of Planned Behavior focuses mainly on cognitive or rational processes around decision-making

Perc

ent

of a

dopt

ion

Time

100%

Figure 4. The Diffusion of Innovations Theory describes the structure of the social environment and how this influences access to information and the adoption of new behaviors over time.

Environment

Person

Behavior

AgeGenderEthnicity

PersonalitySocioeconomics

Knowledge

Modifying Factors Individual Beliefs Action

Individual behaviors


Percieved susceptibility

to and severity of disease

Perceived benefits

Perceived barriers

Perceived self-efficacy

Percieved threat

Figure 3. Social Learning Theory focuses on how people learn by observing others

Figure 5. The Health Belief Model illustrates the importance of beliefs about the risks, benefits, barriers and self-efficacy in behavior change

Figure 1. The Extended Parallel Processing Model focuses on how emotion and cognition work together to motivate behavior

Highly motivated to take

protective action

High Efficacy(Able to respond

effectively)

EFFICACY DETERMINES REACTION

Low Efficacy(Unable to respond

effectively )

High Threat(Vulnerable to Serious Harm)

Low Threat(Invulnerable,Trivial Threat)

Low motivation, may be some

protective action

Denial, defensiveness,

avoidance

No Response


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How to use this documentThis document is to be used as a reference guide for measuring the effectiveness of malaria BCC interventions. The indicators outlined below are to serve as a template for the collection, analysis and interpretation of data that can be used to evaluate the effectiveness of BCC interventions. The questions provided serve as a guide and can be adapted to suit the local context and questionnaire into which they are incorporated. This document outlines the recommended indicators required for tracking (Core Indicators), as well as optional indicators (Supplemental and Experimental). Implementers are invited to include the Supplemental and Experimental indicators in their data collection activities and provide feedback to the Roll Back Malaria Communication Community of Practice to help contribute to the continual refinement of malaria BCC indicators.

General notes on indicatorsSome of the indicators presented in this Reference Guide are standard indicators recommended by Roll Back Malaria (RBM) and included in the RBM Household Survey Indicators for Malaria Control. These indicators – mostly related to practicing targeted behaviors - have clear definitions and data collection tools. This Reference Guide also presents indicators which are not included in the RBM guidance. For each indicator, the indicator formulation is presented and any additional indicators noted. Also outlined are the purpose, indicator definition, numerator and denominator, measurement of the indicator, interpretations, strengths and limitations. Gender implications are included where they are especially important for the indicator. A general description of gender implications, relevant for all indicators, is included below. Relevant references to complementary documents and resources are included for each group of indicators.

Data SourcesData for measuring these indicators will typically be collected through population-based household surveys. Ideally, these surveys will be nationally representative surveys such as the Demographic and Health Survey (DHS), the Malaria Indicator Survey (MIS), or the Multiple Indicator Cluster Survey (MICS). These data could also be collected in smaller sub-national surveys, particularly in areas where malaria communications were targeted. It is acknowledged that adding questions to large population-based household surveys such as those mentioned requires planning and negotiation. The indicators and questions presented below (some of which are not included in the DHS, MIS or MICS) should be selected as needed and their inclusion into these surveys should be discussed at the earliest planning stages of these surveys. Implementers should use the questions as a guide, adapting them to suit the local context and the program being monitored. Implementers should note that there may be cost considerations related to adding questions to an existing questionnaire (increased sample size (see below), training of enumerators); hence the suggestion for early planning and consultation is emphasized.

DefinitionsIn general, these indicators represent measurement of individuals, not households. Even if questions are asked as part of the household questionnaire, the responses represent the individual providing them, not all household members. If the target audience is a segment of the general population (e.g., pregnant women or children under 5 years of age) the survey questions must be asked of this specific sub-population (e.g., did the child under 5 years of age sleep under a bed net last night?). If the intended target group is health care workers or community leaders, these populations will have to be sampled separately as they are not included in population-based household surveys (unless their households are randomly selected as part of the sampling).

mailto:http://www.rollbackmalaria.org/mechanisms/cwg.html

mailto:http://www.rollbackmalaria.org/mechanisms/cwg.html

http://www.rbm.who.int/toolbox/tool_HouseholdSurveyIndicatorsForMalariaControl.html


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Gender implications The indicators presented in this Reference Guide should be disaggregated by sex when possible so that any gender differences between boys, girls, or women and men, can be ascertained. For example, disaggregation of data can provide information on differing treatment-seeking behavior for males and females, or gender differences in bed net use within a household.

Sex-disaggregated data may reveal differences in knowledge and self-efficacy between men and women, or different avenues by which men and women access information.

Gender refers to the socially constructed roles, behaviors, activities, and attributes that a given society considers appropriate for men and women, and the relationships between men and women in a given society. Gender may, therefore, contribute to making people more or less susceptible to malaria infection, may affect prevention and health seeking behaviors, and likely contributes to varied means of access to communication materials and information.

Sex-disaggregated data are a crucial first step for program implementers to examine gender-differentials. Gender should be considered in the design of both messages and communication channels to ensure that interventions and programs have the greatest impact. Gender differences may require tailoring of messages and materials in order to effectively reach both males and females.

Sample SizeFor smaller surveys, implementers need to ensure an adequate sample size to provide enough power for disaggregated data analysis for specific target populations (e.g., pregnant women) if the sub-population is targeted. Given the importance of a large enough sample size to draw meaningful interpretations from the data, it is highly encouraged that the incorporation of these questions into existing surveys be discussed at the earliest stages of planning so that adequate resources are allocated.

TerminologyIn this document, ‘respondents’ refers to the people selected for participation in the survey. Respondents will be selected based on the survey sampling methodology but should represent the target population of the malaria program. ‘Target population’ refers to the group for whom the intervention was intended.

For ease of reference, the generic term ‘bed nets’ is used in this document (unless specifically noted). For specific country contexts, implementers can modify this terminology, substituting insecticide treated nets (ITNs) or Long Lasting Insecticide Treated Nets (LLINs), as appropriate.


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Core IndicatorsThe indicators below represent the Core Indicators of the Reference Guide. Core Indicators measure targeted behaviors; reach or exposure; knowledge and awareness; and self-efficacy and risk. It is highly recommended that questions required for the measurement of these indicators be added to population-based household surveys so that these indicators can be compared over time and the effectiveness of BCC programs assessed.

Targeted BehaviorsThe following indicator measures whether respondents are practicing the targeted behaviors. Behaviors include use of insecticide treated bed nets, Intermittent Preventive Treatment (IPTp) for pregnant women, timely treatment for children less than 5 years of age with fever, and Indoor Residual Spraying (IRS) of structures.

1. Proportion of people who practice the recommended behavior

Purpose:

These are the core population-based indicators for measuring malaria prevention and control. BCC programs aim to influence activities such as bed net use – especially for children under 5 years of age and pregnant women, timely treatment for malaria – especially for children under 5 years of age with fever, completion of IPTp during pregnancy, and IRS of structures.

Definition:

Among those in the target population surveyed, the indicator is defined as the proportion of respondents who practice the recommended behavior. ‘Target population’ is defined as the intended population for the program. ‘Behavior’ refers to the desired result the program is trying to achieve among members of the target population.

The indicators included below are drawn from the June 2013 document ‘Household Survey Indicators for Malaria Control’ and are chosen to measure bed net use, uptake of IPTp, timely treatment for children under 5 years of age with a fever, and indoor residual spraying.

1. Proportion of population that slept under an ITN1 the previous night

2. Proportion of households sprayed with IRS within the last 12 months

3. Proportion of women who received 3 or more doses of IPTp2 during ANC visits during their last pregnancy

4. Proportion of children under five years old with fever in the last two weeks for whom advice or treatment was sought

Detailed information on measuring these indicators, including the numerators and denominators, is available from the Household Survey Indicators for Malaria Control.3

1 The RBM 2013 guidance uses the term ‘ITN’ to cover both LLINs and conventionally-treated nets (see page 15)2 The RBM 2013 guidance is based on the latest WHO guidance on IPTp. As IPTp policies differ by country, this indicator may be modified to reflect the country context. 3 http://www.rollbackmalaria.org/toolbox/tool_HouseholdSurveyIndicatorsForMalariaControl.html



http://www.rollbackmalaria.org/toolbox/docs/rbmtoolbox/tool_HouseholdSurveyIndicatorsForMalariaControl.pdf

http://www.rollbackmalaria.org/toolbox/tool_HouseholdSurveyIndicatorsForMalariaControl.html


12

Measurement: See standard RBM guidance for indicator definitions, including numerator and denominator construction. Questions from the Malaria Indicator Survey (MIS) are provided below for reference.

Question No Question Responses Code

BED NET USE

Q101

Did anyone sleep under this

mosquito net last night?

YES

NO

NOT SURE

1

2

99

Q102

Who slept under this mosquito net last night?

RECORD THE PERSON’S NAME AND NUMBER FROM THE HOUSEHOLD SCHEDULE.

NAME

LINE NUMBER

INDOOR RESIDUAL SPRAYING

Q103

At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?

YES

NO

DON’T KNOW

1

2

99

PREGNANCY AND INTERMITTENT PREVENTIVE TREATMENT

Q104When you were pregnant with (NAME), did you see anyone for antenatal care for this pregnancy?

YES

NO

1

2

Q105

During this pregnancy, did you take any drugs in order to prevent you from getting malaria?

YES

NO

DON’T KNOW

1

2

99

Q106

What drugs did you take?

RECORD ALL MENTIONED.

IF TYPE OF DRUG IS NOT DETERMINED, SHOW TYPICAL ANTIMALARIAL DRUGS TO RESPONDENT.

SP/FANSIDAR

CHLOROQUINE

OTHER (SPECIFY):

DON’T KNOW

1

2

3

99


13


Q107How many times did you take (SP/Fansidar) during this pregnancy?

TIMES

FEVER IN CHILDREN

Q108

Has (NAME) been ill with a fever at any time in the last 2 weeks?

YES

NO

DON’T KNOW

1

2

99

Q109Did you seek advice or treatment for the illness from any source?

YES

NO

1

2


14


Q110

Where did you seek advice or treatment

Anywhere else?

PROBE TO IDENTIFY EACH TYPE OF SOURCE

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE

PUBLIC SECTOR

GOVT HOSPITAL

GOVT HEALTH CENTER

GOVT HEALTH POST

MOBILE CLINIC

FIELDWORKER

OTHER PUBLIC SECTOR (SPECIFY): __________________

PRIVATE MEDICAL CENTER

PVT. HOSPITAL/CLINIC

PHARMACY

PVT. DOCTOR

MOBILE CLINIC

FIELDWORKER

OTHER PVT MEDICAL (SPECIFY):

___________________________

OTHER SOURCE

SHOP

TRADITIONAL PRACTITIONER

MARKET

OTHER (SPECIFY): ____________

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

88

Q111

How many days after the fever began did you first seek treatment for (NAME)?

SAME DAY

NEXT DAY

TWO DAYS AFTER FEVER

THREE OR MORE DAYS AFTER FEVER

DON’T KNOW

1

2

3

4

99


15

Interpretation:Behavior change is a lengthy process and it may take several years of program implementation before actual changes occur. While responses can be triangulated against service statistics (for treatment seeking and IPTp) and observation (such as hanging of bed nets), responses are subject to individuals’ self-report. Responses may be influenced by response bias if respondents are familiar with the behavior and respond in the ‘correct’ way as opposed to responding according to their true actions.

Strengths• Thehouseholdnetrostercanbeusedtocollectdataforindicatorsmeasuringtheuseofbednets.The

household roster is applicable for all household members, pregnant women, and children under 5 years of age.

• Presenceofanetistypicallyverifiedattimeofinterview.

• ThequestionsforthemeasurementofthesefourcoreindicatorscanbeaddedtoanynonDHS/MIS/MICS sample survey of households, both large nationally representative survey or smaller surveys representative of a sub-national area (e.g. region, district, or project area).

Limitations• NotallITNsfoundinthehouseholdarefitforuse.

• Womenmaynotrecallthenameofthedrugtheytookduringpregnancyforpreventionofmalaria.

• Thetimeframeof12monthsforthemeasurementofIRSmaybesubjecttorecallbias.

References: Roll Back Malaria Monitoring and Evaluation Reference Group (RBM MERG). Household Survey Indicators for Malaria Control, June 2013.

Reach/Exposure

The following indicator measures the reach of behavior change communication messages. This indicator can be adapted to measure the proportion of people hearing a specific message and can also be modified to ascertain the channels through which people are receiving messages.

2. Proportion of people who recall hearing or seeing any malaria message within the last 6 months

Additional indicators:• Proportionofpeoplewhorecallhearingorseeinganymalariamessagewithinthelast6months

• Proportionofpeoplewhorecallhearingorseeingspecificmalariamessages(reportedbyeachspecificmessage)

• Proportionofpeoplewhorecallhearingorseeingamessagethroughcommunicationchannel‘X’(reported by each specific communication channel)




16

PurposeExposure of the target population to communication messages is the primary outcome of BCC. Exposure is the critical first step to increasing knowledge of the products, practices, or services in question that may influence an individual to adopt a particular behavior (or change a behavior). The target populations’ ability to recall messages about malaria is an indicator of how widely malaria communications have penetrated the target audience. Survey questions can then go further to ask about recall of specific messages and the channels through which the communications were received.

Definition This indicator is defined as the proportion of respondents who recall any malaria message that they have either seen or heard in the past six months. Respondents are asked about the type of messages they saw or heard, as well as about specific campaign messages. The additional indicators provide more precision – with regard to the specific messages seen or heard and the communication channel through which the message was transmitted.

Numerator: Number of respondents who recall hearing or seeing any malaria message during the last 6 months

• Number of respondent who recall hearing or seeing ‘X’ malaria message

• Number of respondents who recall hearing or seeing any message through communication channel ‘X’

Measurement:The questions required for calculating these indicators have become a part of the standard household questionnaire module for the MIS. These data could also be collected in smaller sub-national surveys, particularly in areas where malaria communications were targeted.

The numerator is obtained by asking the respondent if s/he has seen or heard any messages about malaria within the past six months. In cases where the survey is being conducted more than six months after the BCC campaign, the timeframe can be adjusted accordingly. Implementers must note, however, that an extended timeframe between the BCC campaign and the survey will introduce more recall bias into the measurement. In cases where the BCC campaign has taken place within a timeframe shorter than six months, the survey question can be altered accordingly.

The numerators for the additional indicators are obtained by asking follow-up questions to those respondents who replied in the affirmative that s/he had seen or heard a malaria message in the specified time period. The first follow-up question asks what specific messages the respondent has seen or heard and the second question asks where the message was seen or heard. To mitigate potential response bias, the survey enumerator should avoid asking: “Did you hear/see X message?” (Yes / No). Alternatively, depending upon the content of the communication campaign, the survey can ask the respondent to complete a catch phrase or jingle associated with the campaign. This method works well for radio, television, or even community events. For more visual campaigns using billboards, posters, or other printed materials, the enumerator can ask respondents to identify a familiar logo or image associated with a campaign. The survey can include questions on as many specific messages as are applicable. Optimally, responses will be unprompted but may include a probe (i.e., “Is there anything else?”) to ensure the respondent has fully considered the question.

The denominator for all indicators is measured by the total number of survey respondents. An alternative denominator for the additional indicators could be the “Number of respondents who recall hearing or seeing any malaria message,” if there is a desire to know the message or channel that resonated most with the target population that recall hearing or seeing any message.

Additional questions can be included in the measurement tool to provide more details and contextual information, such as:


17

• Access to radio/television and frequency of use (access to a radio and television are included in the MIS and in the DHS but only the DHS Women’s Questionnaire includes questions about the frequency of radio and television use)

• Understanding of a specific message or jingle (e.g., is the message about using bed nets, seeking prompt treatment for fever, recognizing danger signs of malaria); this question should be asked in an open-ended (i.e., unprompted) way

The survey may also include a communication channel not used in the communication campaign to gauge the extent of social desirability bias inherent in the responses. Social desirability bias occurs when the respondent tries to give the socially correct answer or one s/he feels will please the interviewer, rather than a true response. This check is particularly useful in an environment with relatively few communication channels.

Measurement Method:


Q201

In the past 6 months, have you seen or heard any messages about

malaria?

YES

NO

1

2

Q202

Where did you hear or see the messages or information?

Anywhere else?

GOV.T CLINIC/HOSPITAL

COMMUNITY HEALTH WORKER

FRIENDS/FAMILY

WORKPLACE

DRAMA GROUPS

PEER EDUCATORS

POSTER/BILLBOARDS

TELEVISION

RADIO

NEWSPAPER

OTHER (SPECIFY): ______________

DON’T KNOW

1

2

3

4

5

6

7

8

9

10

88

99


18


Q203

What messages about malaria did you hear or see?

Is there anything else?

MALARIA IS DANGEROUS

MALARIA CAN KILL

MOSQUITOES SPREAD MALARIA

SLEEPING UNDER A MOSQUITO NET IS IMPORTANT

WHO SHOULD SLEEP UNDER A MOSQUITO NET

SEEK TREATMENT FOR FEVER

SEEK TREATMENT FOR FEVER PROMPTLY (WITHIN 24 HOURS)

IMPORTANCE OF HOUSE SPRAYING

NOT PLASTERING WALLS AFTER SPRAYING

ENVIRONMENTAL SANITATION ACTIVITIES

OTHER (SPECIFY): ______________

DON’T KNOW

1

2

3

4

5

6

7

8

9

10

88

99

Q204

Can you complete the following phrase: “Take cover under the net every…”?

[Respondent reply: “…day every night”]

YES

NO

DON’T KNOW

1

2

99


19


Q205

Where did you hear or see this phrase? RADIO

TELEVISION

POSTER

COMMUNITY EVENT

HEALTH CARE WORKER

FRIEND/NEIGHBOR/FAMILY MEMBER

OTHER (SPECIFY): ______________

DON’T KNOW

1

2

3

4

5

6

88

99

Q206

Do you recognize any of these logos/pictures?

[Interviewer shows 3 images including the logo that has been used in the communication campaign; the other 2 are made up]

YES

NO

1

2

Q207

Where did you hear or see this image? RADIO

TELEVISION

POSTER

COMMUNITY EVENT

HEALTH CARE WORKER

FRIEND/NEIGHBOR/FAMILY MEMBER

OTHER (SPECIFY): ______________

DON’T KNOW

1

2

3

4

5

6

88

99


20

Interpretation:This indicator provides a measure of the reach and penetration of general malaria communications in a target audience. The additional indicators provide information on the relative strength of specific messages in reaching the target audience and the most effective means through which the audience received messages.

Strengths• Responsescanbetailoredtothecampaignsandmessagesrelevanttothearea

• Limitednumberofquestionsrequiredforconstructionofindicators

• Useofcomplete-the-phraseand/orrecognize-the-logohelpstomitigatesocialdesirabilitybias

Limitations• Subjecttobias/confoundingwithuseofprobing(probing/promptingstylesmaynotbeuniformacross

interviewers)

• Subjecttorecallbiaswithasix-monthlook-backperiod;wouldnotcapturecommunicationcampaignsimplemented prior to the past six-month period without risking further bias

• Theprimaryindicator(recallofanymalariamessageinlastsixmonths)doesnotprovidesufficientdetail to inform programmatic decisions; additional indicators are required for more meaningful information

Knowledge & AwarenessThe following questions measure knowledge and awareness of target populations. Malaria BCC has focused on increasing populations’ knowledge and awareness about malaria prevention and control methods and malaria treatment. These indicators measure the level of knowledge regarding the cause of malaria, the main symptom of malaria, the correct treatment for malaria, and preventive measures. These indicators can be measured separately or can be combined to create a composite indicator.

PurposeBetter knowledge of malaria (cause, symptoms, treatment, and preventive measures) is a foundational step toward changing behavior, such as increasing the use of insecticide-treated nets or care-seeking practices, especially for caretakers. Members of the target population who know how to prevent getting malaria by avoiding the primary causes, who can recognize the first signs of infection, and who know how to treat cases, are generally more likely to engage in the behaviors that will protect themselves.

Prompt and effective treatment is a key element in successful malaria control because of the rapid onset of illness and severe health outcomes related to Plasmodium falciparum malaria, especially among children and non-immune populations

Definition These indicators are defined by the proportion of people surveyed who know the cause, main symptom, treatment and preventive measures for malaria. The indicators are broken down by aspect with the numerator measuring the various prevention and control components while the denominator remains the number of people who were surveyed.


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3. Proportion of people who name mosquitoes as the cause of malaria

Numerator: Number of respondents who name mosquitoes/mosquito bites as the cause of malaria

Denominator: Number of respondents surveyed

Additional indicator 3a.: Proportion of people who name only mosquitoes as the cause of malaria

4. Proportion of people who know the main symptom of malaria

Numerator: Number of respondents who know that the main sign/symptom of malaria is fever


5. Proportion of people who know the treatment for malaria

Numerator: Number of respondents who know that the appropriate treatment for malaria is ACTs4


6. Proportion of people who know preventive measures for malariaNumerator: Number of respondents who know that the primary preventive measures for malaria include using bed nets, taking preventive medication during pregnancy, taking seasonal prophylaxis, or having your house sprayed with insecticide


Additional indicator: Proportion of respondents who know the danger signs and symptoms of severe malaria

MeasurementThe numerator for these indicators is obtained by asking respondents a series of questions about the causes, signs/symptoms, treatment, and preventive measures for malaria.

For indicator 3 ‘cause of malaria’, the respondent is asked about the causes of malaria and the enumerator marks the responses mentioned. The options in the questionnaire must include mosquitoes or mosquito bites. Other options should be context-specific common misunderstandings about the cause of malaria. The respondent is counted in the numerator if they mention mosquitoes or mosquito bites as the cause of malaria.

With regard to Additional Indicator 3a, recent analysis has shown that in some areas, respondents who believe that only mosquitoes cause malaria may be more likely to sleep under bed nets. For Additional Indicator 3a, respondents are counted in the numerator if they cite only mosquitoes as the cause of malaria (and do not cite any incorrect causes of malaria). Implementers can measure Additional Indicator 3a if it is deemed useful for the program.

For indicator 4 ‘symptoms of malaria’, the respondent is asked to name the main signs or symptoms of malaria. Responses should be unprompted (i.e., spontaneous) to minimize bias, but the interviewer should probe respondents to ensure they have the opportunity to provide multiple responses. A typical probe would be, “Is there anything else that is a sign of malaria?” To be counted in the numerator, the respondent must identify fever among their responses.

4 Depending on the country context


22

For indicator 5 ‘treatment for malaria’, the respondent is asked to name the most effective medication used to treat malaria. Responses should be unprompted (i.e., spontaneous) to minimize bias, but the interviewer should probe respondents to ensure they have the opportunity to provide multiple responses. Only one response is required of the respondent. The respondent is counted in the numerator if s/he cites artemisinin combination therapy (ACTs) as the most effective treatment, but country-specific context should be applied to this measure. For example, a local name for ACT is an acceptable response. Countries in which a substantial proportion of infections are caused by Plasmodium Vivax should consider chloroquine or ACTs acceptable.

For indicator 6 ‘prevention of malaria’, the respondent is asked to name one or more preventive measures for malaria. The options in the questionnaire must include the relevant preventive measures implemented in the community; these may include using bed nets, taking preventive medication during pregnancy, taking seasonal prophylaxis, or having the house sprayed with insecticide. If any of these preventive measures are not implemented in the target community (e.g., seasonal prophylaxis), it should not be included as an option. Other options should include false preventive measures for malaria including cutting grass, keeping the house surroundings clean, and avoiding drinking dirty water. The respondent is only counted in the numerator if they name at least one of the relevant preventive interventions and none of the incorrect behaviors.

An additional indicator that can be included is knowledge of the signs and symptoms of severe malaria. The numerator for this indicator would be obtained by asking the respondent to name danger signs for malaria. Respondents should only be counted if they are able to name at least one clinical feature based on the WHO guidelines: impaired consciousness, prostration/extreme weakness, convulsions, respiratory distress, circulatory collapse/shock, acute kidney injury, clinical jaundice, and abnormal bleeding. Responses should be unprompted (i.e., spontaneous) to minimize bias, but the interviewer should probe respondents to ensure they have the opportunity to provide multiple responses.

Measurement Method:


Q301

What do you think is the cause of malaria?

Anything else?

RECORD ALL MENTIONED

MOSQUITO BITES

EATING IMMATURE SUGARCANE

EATING COLD FOOD

EATING OTHER DIRTY FOOD

DRINKING DIRTY WATER

GETTING SOAKED WITH RAIN

COLD OR CHANGING WEATHER

WITCHCRAFT

OTHER (SPECIFY): __________

DON’T KNOW

1

2

3

4

5

6

7

8

88

99


23


Q302

What signs or symptoms would lead you to think that a person has malaria?

Anything else?


FEVER

FEELING COLD

HEADACHE

NAUSEA AND VOMITING

DIARRHEA

DIZZINESS

LOSS OF APPETITE

BODY ACHE OR JOINT PAIN

PALE EYES

SALTY TASTING PALMS

FEELING WEAK

REFUSING TO EAT OR DRINK


DON’T KNOW

1

2

3

4

5

6

7

8

9

10

11

12

88

99

Q303

What is the most effective medication used to treat malaria?

Anything else?


SP/FANSIDAR

CHLOROQUINE

QUININE

NEW MALARIA DRUG/ACT

ASPIRIN, PANADOL, PARACETOMOL


DON’T KNOW

1

2

3

4

5

88

99


24


Q304

How can someone protect themselves against malaria?

Anything else?


SLEEP UNDER A MOSQUITO NET

SLEEP UNDER A INSECTICIDE-TREATED MOSQUITO NET

USE MOSQUITO REPELLANT

AVOID MOSQUITO BITES

TAKE PREVENTIVE MEDICATION

SPRAY HOUSE WITH INSECTICIDE

USE MOSQUITO COILS

CUT THE GRASS AROUND THE HOUSE

FILL IN PUDDLES (STAGNANT WATER)

KEEP HOUSE SURROUNDINGS CLEAN

BURN LEAVES

DON’T DRINK DIRTY WATER

DON’T EAT BAD FOOD

PUT MOSQUITO SCREENS ON THE WINDOWS

DON’T GET SOAKED WITH RAIN


DON’T KNOW

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

88

99


25


Q305

What are the main danger signs of malaria?

Anything else?


SEIZURE / CONVULSIONS

FAINTING

ANY FEVER

HIGH FEVER

STIFF NECK

FEELING WEAK

NOT ACTIVE

CHILLS/SHIVERING

NOT ABLE TO EAT

VOMITING

CRYING ALL THE TIME

RESTLESS

DIARRHOEA


DON’T KNOW

1

2

3

4

5

6

7

8

9

10

11

12

13

99

InterpretationThis indicator provides a measure of the most basic knowledge of selected audience members about the cause, symptoms, treatment, and prevention of malaria. Based on the individual components of the indicators, a composite indicator can be constructed to measure the proportion of people who know the cause of, symptoms of, treatment for or preventive measures for malaria (Global Fund Toolkit Indicator).

Strengths• Relativelyfewquestionsarerequiredtomeasureeachknowledgeindicator

• Providesusefulformativedatatodeterminetargetaudience’sknowledgeneeds.

Limitations• Subjecttobias/confoundingwithuseofprobing(probing/promptingstylesmaynotbeuniformacross

interviewers)


26

• Difficulttolinkknowledgetoanyspecificinformation/communicationcampaignwithoutreferencingactual campaign messages.

References

Global Fund Monitoring and Evaluation Toolkit, Part 4 – Malaria, November 2011, http://www.theglobalfund.org/en/me/documents/toolkit/

Management of Severe Malaria, WHO 2012, http://apps.who.int/iris/bitstream/10665/79317/1/9789241548526_eng.pdf

Risk and EfficacyThe following indicators measure the perceived risk from malaria, perceived consequences of malaria, the perceived effect of certain products and services in reducing risk, and perceived self confidence in conducting a specific malaria-related behavior.

The Risk Perception Attitude Framework (Rimal and Real, 2008) describes the interaction between cognitive and emotional factors in decision-making of individuals. This model is also known as the Extended Parallel Processing Model – the parallel consideration of rationality and emotion. Fear may motivate action but too much fear can be inhibitive. There are two components to the model – fear or threat (the emotion component) and efficacy (the rational/cognitive component).

The fear component has two parts: severity and susceptibility. Severity refers to how serious people believe the threat (malaria) to be. Susceptibility refers to the belief that the disease or threat can actually happen to them.

The second component of the model is efficacy – or confidence in one’s ability to control or manage the threat or risk perceived. Efficacy is composed of three parts: response efficacy, self-efficacy, and barriers. Response efficacy refers to a perception that a proposed action or solution will actually control the threat. In the case of malaria – a person’s belief that bed nets serve as good protection against malaria is an example of response efficacy. Self-efficacy is a measure of self confidence that a person can perform an action to control the threat. Self-efficacy can refer to a person’s confidence in correctly and consistently using a bed net to prevent malaria. The last part of efficacy, barriers, refers to perceptions of factors which may hinder someone from practicing the behavior to reduce the threat.

Research has shown that individuals can have the knowledge and skills, positive beliefs, attitudes, and intentions toward a specific behavior, yet they avoid engaging in the recommended behavior. A trigger to motivate action is needed. Much research has shown that perceived threat is a powerful trigger to action (Witte, 1992 and 1998). Evaluators can expect desirable behavioral responses when people have strong risk perceptions coupled with strong beliefs of self-efficacy toward the recommended response.

7. Proportion of people who perceive they are at risk from malaria

8. Proportion of people who feel that consequences of malaria are serious

PurposeThe purpose of these indicators is to measure the respondent’s perceived risk of malaria. The perceived risk can be analyzed and interpreted in line with the respondent’s behavior and future intentions. ‘Risk perception’ is defined as a person’s beliefs about the likelihood of experiencing negative or harmful consequences from malaria. This definition comprises two distinct dimensions: (a) susceptibility to a threat, and (b) severity of that threat. Douglas (1985) defines risk as the likelihood of a specific event occurring multiplied by the magnitude of consequences associated with that event.

http://www.theglobalfund.org/en/me/documents/toolkit/


http://apps.who.int/iris/bitstream/10665/79317/1/9789241548526_eng.pdf



27

Definition:Indicator 7 measures the perceived susceptibility to the threat of malaria while indicator 8 measures the respondents’ perceived severity of the malaria. Susceptibility and severity are measured by a variety of questions, with the mean score indicating perceived risk and perceived consequences.

Indicator 7:

Numerator: Number of respondents who perceive they are at high risk of malaria (people with a mean score >0)


Indicator 8:

Numerator: Number of respondents who perceive the consequences of malaria are serious (people with a mean score of >0)


Measurement Method:

I am going to ask you about a series of actions you could take, and I would like you to tell me how confident you are that you could actually do that action successfully. For each action, please tell me if you think you definitely could, probably could, probably could not or definitely could not do each action successfully. INTERVIEWER: DO NOT READ “DON’T KNOW” / “UNCERTAIN” RESPONSE AND ONLY USE IF RESPONDENT IS NOT ABLE TO PROVIDE ANOTHER ANSWER.

Strongly Disagree

Somewhat Disagree

Somewhat Agree

Strongly Agree

Don’t Know / Uncertain

Q401I don’t worry about malaria because it can be easily treated

1 2 3 4 99

Q402 (Inv)

During the rainy season, I worry almost every day that someone in my family will get malaria

1 2 3 4 99

Q403

My children are so healthy that they would be able to recover from a case of malaria

1 2 3 4

Q404

People in this community only get malaria during rainy season

1 2 3 4 99


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Strongly Disagree

Somewhat Disagree

Somewhat Agree

Strongly Agree

Don’t Know / Uncertain

Q405People only get malaria when there are lots of mosquitoes

1 2 3 4 99

Q406 Only weak children can die from malaria 1 2 3 4 99

Q407

(Inv)

Nearly every year, someone in this community gets a serious case of malaria

1 2 3 4 99

Q408

I cannot remember the last time someone I know became dangerously sick with malaria

1 2 3 4 99

Q409Every case of malaria can potentially lead to death

1 2 3 4 99

Q410

When my child has a fever, I almost always worry that it might be malaria

1 2 3 4 99

Q411

(Inv)

When someone I know gets malaria, I usually expect them to completely recover in a few days

1 2 3 4 99

Q412

(Inv)

When my child has a fever, I usually wait a couple of days before going to a health provider

1 2 3 4 99

These questions can be adapted or dropped if the intervention focuses on a different sub-population (e.g. pregnant women) or does not focus on a sub-population, as in the case of an intervention which is aimed at all household members.


29

To calculate the susceptibility indicator (Indicator 7), a mean score for questions 401 to 408 is calculated for each individual (questions 402 and 407 must be inverted). The Likert Scales are converted such that “strongly disagree” is coded as -2 and “strongly agree” is coded as +2. “Don’t know/Uncertain” is not offered as an option but if the respondent is conflicted about an answer, this option can be used. Enumerators should be trained, however, not to mention this as an option, and only select it if the respondent does not want to answer.

Individuals with a negative mean score (<0) are categorized as ‘low perceived risk’ and those with a positive mean score (>0) are categorized as ‘high perceived risk’. The total proportion of individuals that perceive they are at risk from malaria can then be easily obtained.

To calculate the severity indicator (Indicator 8), a mean score for questions 409 to 412 is calculated for each individual (question 411 and 412 are inverted). Individuals with a positive mean score (>0) are categorized as ‘high perceived severity’ and those with a negative mean score (<0) are categorized as ‘low perceived severity’. The total proportion of individuals that perceived malaria as serious can then be calculated.

Interpretation:Evaluators may expect undesirable behavioral responses when people have strong risk perceptions but they doubt their ability to enact a recommended response (e.g., obtaining sulfadoxine/pyrimethamine (SP) from the clinic during antenatal care (ANC)), and/or they doubt the recommended response will work to avert the threat (e.g., strong rumors circulate in some countries that IRS and/or LLINs reduce fertility). Therefore, evaluators must measure perceptions of efficacy (Indicator 9) when they assess perceptions of risk, so that program staff can devise the best communication messages.

Strengths• Questionsprovidedaboverelatetoindicatorsonbothsusceptibilityandseverity

• Theuseofreversecodeditemswillreducebiasbypreventingrespondentsfallingintoaresponsepattern

• ASTATADo-fileisavailabletoguidedataanalysisandinterpretation

Weaknesses• Useofinversionsmayposechallengesduringdataanalysis.Analystsshouldbeclearwhichquestions

are to be inverted and how the results are to be interpreted.

9. Proportion of people who believe that the recommended practice or product will reduce their risk

Purpose: This indicator measures response efficacy – the belief that an intervention or solution will control the threat. Within the Stages of Change Continuum (FHI, 2004), before behavior change can occur, people must first be knowledgeable about the change that needs to happen and believe that they will personally benefit from adopting the behavior. Response efficacy combined with self-efficacy (Indicator 10) can be good predictors of behavior change.

Definition:This indicator is defined as the proportion of the target population surveyed who believe that the recommended practice or product will reduce their personal risk for adverse health outcomes. ‘Practice’ refers


30

to the desired behavior the program is trying to promote among members of the target population. Examples include: complying with IRS spray team instructions, sleeping under a bed net, or attending ANC. Examples of recommended ‘products’ (which accompany recommended practices) include SP for IPT during pregnancy, ACTs for treating malaria, or bed nets.

Numerator: Number of respondents who believe a behavior or practice will reduce their risk of malaria

Denominator: Total number of respondents surveyed

Measurement Method:

Response Efficacy Questions

Strongly Agree

Somewhat Agree

Somewhat Disagree

Strongly Disagree

Don’t Know/ Uncertain

INDOOR RESIDUAL SPRAYING (IRS)

Q501

I have noticed fewer mosquitoes around since our homes were sprayed with IRS

1 2 3 4 99

Q502

(Inv)

The liquid used to spray the walls is often too diluted to kill many mosquitoes

1 2 3 4 99

Q503

Re-plastering the walls of a house after they have been sprayed will make the spray less effective at killing mosquitoes

1 2 3 4 99

BED NET USE

Q504

(Inv)

My chances of getting malaria are the same whether or not I sleep under a bed net

1 2 3 4 99

Q505

(Inv)

Many people who sleep under a bed net still get malaria

1 2 3 4 99

Q506

I have noticed my family gets sick less often since we began sleeping under nets

1 2 3 4 99

INTERMITTENT PREVENTION TREATMENT IN PREGNANCY (IPTp)


31


Strongly Agree

Somewhat Agree

Somewhat Disagree

Strongly Disagree


Q507

The medicine given to pregnant women to prevent malaria works well to keep the mother healthy

1 2 3 4 99

Q508

(Inv)

Pregnant women are still at risk for malaria even if they take the medicine that is meant to keep them from getting malaria

1 2 3 4 99

Q509

The medicine given to pregnant women to prevent malaria works well to keep her baby healthy when it is born

1 2 3 4 99

DIAGNOSIS

Q510

(Inv)

The health care provider is better than the test at diagnosing malaria, so I rely on the provider to tell me whether the fever is caused by malaria

1 2 3 4 99

Q511

(Inv)

Even if the malaria test says that the fever was not caused by malaria, I would will still seek out malaria treatment from a health provider because I don’t believe the result

1 2 3 4 99

Q512

The malaria tests are a good way to know if someone really has malaria or not.

1 2 3 4 99

TREATMENT

Q513 ACTs* work quickly to treat malaria 1 2 3 4 99


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Strongly Agree

Somewhat Agree

Somewhat Disagree

Strongly Disagree


Q514

It’s important to take the entire course of malaria medicine to make sure the disease will be fully cured

1 2 3 4 99

Q515

(Inv)

All the malaria medicines work equally well at treating malaria

1 2 3 4

* Adjust according to country context

To calculate the proportion of people who believe a recommended practice or product will reduce their risk of malaria, a mean score is calculated (questions 502, 504, 505, 508, 510, 511, and 515 must be inverted). The Likert Scales are converted such that ‘strongly disagree’ is coded as -2 and ‘strongly agree’ is coded as +2. “Don’t know/Uncertain” is not offered as an option but if the respondent is conflicted about an answer, this option can be used. Enumerators should be trained, however, to encourage respondents to choose a response within one of the other categories.

For IRS, a mean score greater than zero for questions 501, 502 (inverted) and 503 represents someone who perceives IRS to be protective against malaria. With regard to bed nets, a mean score of greater than zero for questions 504 (inverted), 505 (inverted) and 506 indicates that a respondent feel bed nets protect him/her from malaria. With regard to IPTp, a mean score greater than zero for questions 507, 508 (inverted) and 509 indicates a belief that preventive treatment during pregnancy is effective. A mean score greater than zero for questions 510 (inverted), 511 and 512 indicates that the respondent believes in the efficacy of diagnostics. With regard to treatment, a mean score greater than zero for questions 513, 514 and 515 (inverted) represents someone who perceives ACTs (or other relevant treatment) as efficacious in treating malaria.

Interpretation:The separation of questions into components related to IRS, bed net use, IPTp, diagnosis, and treatment enables researchers to compute a global mean for this indicator, while also maintaining the ability to analyze component-specific metrics. These component-specific metrics can provide more detail than a composite indicator, which may be more programmatically useful for adjusting and refining interventions.

Strengths

• Questions provided above relate to components covering prevention (IRS, bed nets, IPTp), diagnosis, and treatment.

• The use of inversions will reduce bias by preventing respondents from falling into a response pattern.

• A STATA Do-file is available to guide data analysis and interpretation

Weaknesses

• Use of inversions may pose challenges during data analysis. Analysts should be clear which questions are to be inverted and how the results are to be interpreted.


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References: FHI. Monitoring HIV/AIDS Programs: A Facilitator’s Training Guide. Module 6: Monitoring and Evaluating Behavior Change Communication Programs. 2004.

10. Proportion of people who are confident in their ability to perform a specific malaria-related behavior

Purpose:Self-efficacy belief is defined as an individual’s self confidence to perform a specific behavior. This type of belief may be particularly salient for bed net-related behaviors such as net hanging and net retreatment. Self-efficacy beliefs are different than beliefs about the response efficacy of a particular type of prevention or treatment. However, these beliefs are related, since belief in the effectiveness of the action will encourage adoption of the behavior.

Key behavior change theories and models recognize the importance of perceived self-efficacy in the adoption and sustained practice of a behavior. Bandura (2004) notes that belief in personal efficacy play a central role in personal change; he asserts that self-efficacy is the foundation of human motivation and action.

Definition:This indicator measures perceived self-efficacy: the conviction that one can successfully accomplish the behavior required to produce a particular outcome. This indicator measures self confidence in various components, outlined in the table for measurement methods.

Numerator: Number of respondents who cite being confident in their ability to perform a specific malaria-related behavior


Measurement Method:


Definitely Could

Probably Could

Probably Could Not

Definitely Could Not

Don’t Know/

Uncertain

PROTECTION OF SELF AND FAMILY

Q601 Easily protect yourself from getting malaria 1 2 3 4 99

Q602 Easily protect your children from getting malaria 1 2 3 4 99


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Q603Easily take care of family members if they contract malaria

1 2 3 4 99

BED NET USE

Q604Obtain enough bed nets to cover all of the sleeping spaces in your household

1 2 3 4 99

Q605Sleep under a bed net for the entire night when there are lots of mosquitoes

1 2 3 4 99

Q606Sleep under a bed net for the entire night when there are few mosquitoes

1 2 3 4 99

MALARIA DETECTION

Q607 Know if a fever is a sign of malaria or something else 1 2 3 4 99

Q608 Know if a child has a typical or serious case of malaria 1 2 3 4 99

Q609Know if I need to rush to the clinic or not when my child is sick

1 2 3 4 99

SEEK DIAGNOSIS

Q610Request a diagnostic test at the clinic when I think my child might have malaria

1 2 3 4 99

Q611Find money to take the child to the clinic when malaria is suspected

1 2 3 4 99


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Q612 Find someone I trust to tell me whether my child has malaria 1 2 3 4 99

SEEK TREATMENT

Q613Get the appropriate treatment for my child when s/he has malaria

1 2 3 4 99

Q614Make sure my child takes the full dose of medicine that s/he is prescribed

1 2 3 4 99

Q615Find resources to travel with my child to the clinic within 24 hours when he/she is very sick

1 2 3 4 99

SEEK PREVENTIVE TREATMENT

Q616 Go to ANC visit as soon as I think I might be pregnant 1 2 3 4 99

Q617 Go to at least 4* ANC appointments at the clinic 1 2 3 4 99

Q618 Take the SP at each of my ANC visits 1 2 3 4 99


Q619Move all my furniture out of my house to prepare the house for spraying

1 2 3 4 99

Q620Not replaster or repaint the walls after the spraying, for 6 months/one year**

1 2 3 4 99

Q621Continue to use my bed net after the house has been sprayed

1 2 3 4 99

*depending on the national policy

** will depend on insecticide used


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The Likert Scales are converted such that ‘definitely could’ is coded as +2 and ‘definitely could not’ is coded as -2. ‘Don’t know/Uncertain’ is not offered as an option but if the respondent is conflicted about an answer, this option can be used. Enumerators should be trained, however, to encourage respondents to choose a response within one of the other categories. For the various components of the indicator as a whole, a mean score greater than zero represents high perceived self-efficacy while a mean score less than zero represents low perceived self-efficacy.

Interpretation:Questions about perceived self-efficacy should be precise and refer to specific circumstances. For example, perceived self-efficacy at finding resources to take a child with fever to the clinic may depend on the particular context. Therefore, a question that is not context-specific may be a poor measure of self-efficacy.

StrengthsQuestions provided above relate to components covering prevention (IRS, bed nets, IPTp), diagnosis, and treatment.

The indicator can be measured as a composite of all the components or separately, per component. Component-specific metrics can provide useful information on areas in which target populations feel more or less self-efficacious; this information could be useful to inform malaria BCC programs.

WeaknessesThe inclusions of several questions per component into an established household survey may be difficult to negotiate. As such, implementers may be limited in the number of questions they can include to measure each component, thereby affecting the validity if analyzed by component

There is a risk of social desirability bias with regard to confidence as the enumerator is not asking for proof of confidence. The respondent may be tempted to note that s/he is confident in her/his ability to perform the activity to please the enumerator.

Supplemental IndicatorsSocial norms play a significant role in public health behaviors but have not yet been shown to be associated with malaria behaviors. These indicators are included in this Reference Guide as Supplemental Indicators to encourage research in this area. This group of indicators may be more useful in certain contexts than in others and while there are reasons to believe that they are useful as determinants of behavior, there is not yet enough solid evidence. Implementers are encouraged to use these indicators, adapting as necessary, and to provide feedback, which can inform future editions of this Indicator Reference Guide.

Norms and Attitudes

11. Proportion of people with a favorable attitude toward the product, practice or service

Purpose: Attitudes influence all types of social behavior with people acting in ways consistent with beliefs about whether a behavior will lead to certain outcomes. Communication programs often address the specific beliefs and values that encourage or discourage a particular practice or behavior. In some societies, for example, men believe they have the right to determine when their partners should go to the clinic for ANC. Mass media


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programs can begin to alter behaviors if they portray those behaviors as socially unacceptable (thereby modifying norms).

Attitude change (and reinforcement) is one of the ways in which communications programs indirectly influence health behavior. Target populations who change or strengthen their attitude because of exposure to the messages of a communication program are more likely to engage in the desired behavior (Fishbein and Ajzen, 1975).

The questions below provide guidance on how to gauge attitudes towards malaria-related components. Questions to gauge the personal attitudes of the respondent are included, as well as questions to gauge the perception of behaviors practiced by others in the community.

It is not expected that all these questions are included into an existing survey; rather, implementers should choose the most relevant questions based on what the country or program has identified as potential barriers or determinants in other research. Questions can be adapted to the country context or replaced with more appropriate questions.

Implementers with access to a statistician should consider constructing scales so that a predictive index can be developed. More guidance on constructing a predictive index will be forthcoming in future revisions of this Reference Guide.

Definition:‘Favorable attitude’ is defined as a person’s positive assessment of a behavior or related construct (such as a specific product or source of service). The assessment is expressed by statements from the respondent that relate the behavior with a positive value held by the respondent.

Numerator: The number of respondents with a mean score of greater than zero for a product, practice or service


Measurement:Enumerators measure attitude by asking respondents how strongly they agree or disagree with these statements, usually in terms of the four-point (Likert-type) scale.

The statements must all correspond to the same behavior, product, or issue. Respondents express their values in terms of the expected outcome of the behavior, expected benefit or harm, or positive and negative attributes of the behavior or product.


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Measurement Method:

Strongly Agree

Somewhat Agree

Somewhat Disagree

Strongly Disagree

Don’t Know/

Uncertain

INTERMITTENT PREVENTIVE TREATMENT (IPTp)

Q701

Once a woman thinks she may be pregnant, she should see a health provider as soon as possible

1 2 3 4 98

Q702Pregnant women often feel sick when they take medicine on an empty stomach

1 2 3 4 99

Q703

(Inv)

Even if a woman thinks she may be pregnant, she should wait a few months to know for certain before she sees a health provider

1 2 3 4 99

Q704

Health care providers will only give a pregnant woman medicine if they know for certain that it is not harmful to her or to her baby

1 2 3 4 99

Q705

(Inv)

A pregnant woman needs permission from her husband or other family to go to ANC

1 2 3 4 99

Q706

A pregnant women must seek several doses of medicine to protect herself from malaria during pregnancy

1 2 3 4 99

Q707

(Inv)

A pregnant women is at no more risk of malaria than any other member of the community

1 2 3 4 99

BED NETS

Q708

(Inv)

More expensive bed nets are more effective than less expensive or free bed nets

1 2 3 4 99


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Strongly Agree

Somewhat Agree

Somewhat Disagree

Strongly Disagree

Don’t Know/

Uncertain

Q709

(Inv)

Bed nets only prevent mosquito bites when used with certain types of beds

1 2 3 4 99

Q710

(Inv)

It only takes a few months for a bed net to get too many holes to stop mosquitoes

1 2 3 4 99

Q711

(Inv)

The insecticide on bed nets can be dangerous to people who sleep under them

1 2 3 4 99

Q712

(Inv)

It is difficult to sleep well under a bed net when the weather is warm

1 2 3 4 99

Q713Sleeping under a bed net is a good way to get privacy in a crowded house

1 2 3 4 99

Q714Many people will choose not to sleep under a bed net if they don’t like its color

1 2 3 4 99

Q715It is easier to get a good night’s sleep when you sleep under a bed net

1 2 3 4 99

Q716 I mainly use a bed net to avoid malaria 1 2 3 4 99

Q717

(Inv)

I mainly use a bed net to avoid pests that can bite me while I sleep

1 2 3 4 99

Q718 It is good that people use mosquito nets 1 2 3 4 99

Q719Pregnant women should sleep under a mosquito net every night

1 2 3 4 99

Q720Children under five years old should sleep under a mosquito net every night

1 2 3 4 99


40

Strongly Agree

Somewhat Agree

Somewhat Disagree

Strongly Disagree

Don’t Know/

Uncertain

Q721

(Inv)

It is only necessary to use mosquito nets during rainy seasons

1 2 3 4 99

Q722

(Inv)

To sleep under a mosquito net makes me feel like I am suffocating

1 2 3 4 99

DIAGNOSIS AND TREATMENT

Q723

The health provider is always the best person to talk to when you think your child may have malaria

1 2 3 4 99

Q724

(Inv)

It is easy to tell whether a fever is malaria or not 1 2 3 4 99

Q725

A person should only take malaria medicine if a health provider says that a fever really is malaria

1 2 3 4 99

Q726

(Inv)

Sometimes, parents will know that a child has malaria even if a health provider’s test says that he or she does not have malaria

1 2 3 4 99

Q727

(Inv)

Many people will go to a second health provider for malaria medicine if the first provider says that the fever is not due to malaria

1 2 3 4 99

Q728

(Inv)

People don’t need to get a test to know if they have malaria 1 2 3 4 99

Q729

The best place to seek treatment for a fever in children under 5 years of age is in a public health facility*

1 2 3 4 99


41

Strongly Agree

Somewhat Agree

Somewhat Disagree

Strongly Disagree

Don’t Know/

Uncertain

Q730

The best place to seek treatment for a fever in children under 5 years of age is in a private clinic

1 2 3 4 99

Q731

The best place to seek treatment for a fever in children under 5 years of age is in NGO or mission facility

1 2 3 4 99

Q732

(Inv)

When I am given medicine to treat malaria, I save up some medicine for someone else in the family who might need it

1 2 3 4 99

Q733 I trust that the medicines I am given will cure malaria 1 2 3 4 99

Q734

To handle fever in children under 5 years of age, the provider(s) where I sought treatment were very knowledgeable

1 2 3 4 99

Q735I think modern medicine works better than traditional medicine

1 2 3 4 99

Q736

(Inv)

Overall, I am not very satisfied with the care I received at the place I sought treatment

1 2 3 4 99


Q737It is not dangerous for someone to touch the walls after they have been sprayed

1 2 3 4 99

Q738Once a house’s walls are sprayed, the odor from the spray can last many days.

1 2 3 4 99

Q739

Most families have an easy time carrying their possessions outside so that the walls can be sprayed

1 2 3 4 99


42

Strongly Agree

Somewhat Agree

Somewhat Disagree

Strongly Disagree

Don’t Know/

Uncertain

Q740

(Inv)

Many people develop rashes on their skin after the walls inside their houses are sprayed

1 2 3 4 99

Q741

(Inv)

The liquid used to spray the walls is often too diluted to kill many mosquitoes

1 2 3 4 99

Q742

(Inv)

Most families would be worried about leaving all of their possessions outside of their house while their walls are being sprayed

1 2 3 4 99

Q743

(Inv)

It can be embarrassing to leave all of your possessions outside of your house where other people in the community can look at them

1 2 3 4 99

Q744

Spraying the inside walls of a house to kill mosquitoes does not cause any health problems for the people living in the house

1 2 3 4 99

Q745

The government would not spray the inside walls of a house if it was not an effective way to prevent malaria

1 2 3 4 99

* For contexts in which integrated community case management (iCCM) is being implemented, the following should also be included as an option: “The best place to seek treatment for a fever in children under 5 years of age is from a community health worker.”

To calculate a respondent’s attitude, a mean score for questions 701 to 745 is calculated for that respondent (questions 703, 705, 707-712, 717, 721, 722, 724, 726 – 728, 732, 736, 740 – 743 must be inverted). The Likert Scales are converted such as ‘strongly disagrees’ is coded as -2 and ‘strongly agree’ is coded as +2. ‘Don’t know/Uncertain’ is not offered as an option but if the respondent is conflicted about an answer, this option can be used. Enumerators should be trained, however, not to mention this as an option, and only select it if the respondent does not want to answer. Any answer of ‘don’t know’ is not included in the calculation of the mean.

Individuals with a positive mean score (> 0) are categorized as having a positive attitude to the product, practice or service while individuals with a negative mean score (<0) are categorized as having an unfavorable attitude to the product, practice or service.

InterpretationThe separation of questions into components related to IPTp, bed nets, diagnosis and treatment, and IRS enables researchers to compute a global mean for this indicator, as well as component-specific metrics. These


43

component-specific metrics can provide useful information on attitudes towards practices and products, which are important to program managers as they design or refine their interventions.

Gender implicationsMeasures of gender-related factors can be taken into account and questions adapted accordingly. For example, gender considerations could include:

Bed net use: “If there are not enough nets for every child in the house, boys should be given bed nets first.”

Treatment: “If my child is sick with a fever, I must consult my husband/partner before taking the child for testing and treatment,” and “It is more important for sons to be treated for malaria quickly than it is for daughters so that they (sons) can continue with school.”

General: “The man of the house should decide who receives a bed net or treatment for malaria.”

Strengths • ThisindicatorandcorrespondingquestionsareincludedintheReferenceGuidetoallowcountriesto

collect and analyze data to determine if useful findings emerge.

• Questionsarebroadandcanbeadaptedtothecountrycontext.

• Countriescanaskquestionsrelatingtoallorsomeofthecomponentsoutlinedabove.

Weaknesses• Attitudesrepresentvaluejudgmentsandaredifficulttomeasureinastandardizedway.

• Thesequestionswillhavetoundergovalidationtoensuretheycapturetherequiredinformation.

12. Proportion of people that believe the majority of their friends and community members currently practice the behavior

Purpose: The Social Learning Theory states that people learn by observing what others do. People observe the consequences of others’ actions (either benefit or punishment), evaluate the relevance and importance of those consequences for their own lives and then rehearse the behavior and attempt to reproduce the action themselves.

Communication strategies are critical for initiating and building momentum for behavior change. As individual behavior is strongly influenced by peers and the community at large, mass media campaigns are important for challenging deeply held beliefs and customs regarding certain health practices, and creating a need or demand for changes in health behavior. Even if real behavior change has not yet occurred, when program implementers influence the public’s perception to believe change is occurring or has occurred (which in turn affects the attitude toward the practice), it creates the necessary momentum and supportive environment to impact actual change. This indicator measures the persuasion of communications strategies in influencing the perception of people in the intended audience that their friends, family, and other fellow community members are adopting the recommended behavior and that adherence to that behavior is increasing, decreasing, or staying the same.


44

Definition:‘Believe’ is defined as what the intended respondents understand, discern, or recognize to be true based largely on personal experience or anecdotal evidence.

‘Behavior’ refers to the desired result the program is trying to achieve among members of the target population. Examples include: sleeping under a bed net, using first-line drugs for treating malaria, or going early to ANC.

Numerator: Number of respondents who believe that their friends and community members are practicing the recommended behavior


Measurement Method:


Q801

Generally, in how many households in your community do people sleep under a bed net

ALL HOUSEHOLDS

MOST HOUSEHOLDS

MORE THAN HALF

FEWER THAN HALF

HARDLY ANY HOUSEHOLDS

DON’T KNOW

1

2

3

4

5

99

Q802

Generally, how many women in your community receive at least 4 checkups*

from a health provider when they are pregnant

ALL WOMEN

MOST WOMEN

MORE THAN HALF OF THE WOMEN

FEWER THAN HALF OF THE WOMEN

HARDLY ANY WOMEN

DON’T KNOW

1

2

3

4

5

99


45


Q803

Generally, how many children in your community visit a health provider on the same day that they develop a fever

ALL CHILDREN

MOST CHILDREN

MORE THAN HALF OF THE CHILDREN

FEWER THAN HALF OF THE CHILDREN

HARDLY ANY CHILDREN

DON’T KNOW

1

2

3

4

5

99

* should be adapted based on country IPTp policy

This indicator is calculated as the proportion of respondents who think that ‘at least half’ or more (codes 1, 2 and 3 above) of their community practice the behavior in question. Codes 1, 2 and 3 are grouped into a single category. Codes 4 and 5 are grouped into another category. ‘Don’t know/Uncertain’ is not offered as an option but if the respondent is conflicted about an answer, this option can be used. Enumerators should be trained, however, to encourage respondents to choose a response within one of the other categories.

Interpretation:As much as communication planners take steps to avoid rumors, sometimes misconceptions and negative publicity develop and gain traction, sharply influencing the public’s perception about the popularity of a particular behavior and possibly exaggerating it. Evaluators must be prepared to deal with this possible outcome and swiftly and efficiently implement ‘damage control’ to reverse public perception and attitudes.

The components on bed net use, IPTp and health seeking behavior for children with fever are to be interpreted as stand-alone components.

Strengths• Thecomponentsmeasuredinthisindicatorarestandalonebutcouldalsobecompiledintoan

aggregate score to reflect how people perceive the health behaviors of people in the communities.

• Relativelyfewquestionsarerequiredtomeasurethisindicator.

Weaknesses• Thisindicatorisbasedonpersonalperceptionsandmaynotreflecttherealityofcommunity

practices. As such, the data should be interpreted in the context of the questions asked and should be triangulated with other findings from the survey which relate to actual bed net use, IPTp uptake and health seeking behavior.

References: Seidel R. 2005. Behavior Change Perspectives and Communication Guidelines on Six Child Survival Interventions. A joint publication of AED and JHU/CCP with support from UNICEF.

FHI. Monitoring HIV/AIDS Programs: A Facilitator’s Training Guide. Module 6: Monitoring and Evaluating Behavior Change Communication Programs. 2004.


46

Experimental IndicatorsExperimental Indicators are included in this Reference Guide to promote research to assess their utility in predicting malaria preventive behaviors. Supplemental (above) and Experimental indicators are included to provide more contextual information to better understand behavioral determinants and will encourage research in certain areas. The main constructs being measured in this category are social support, bed net maintenance, perceived barriers to prevention and treatment, and household member sleeping arrangements.

13. Proportion of people who have encouraged friends or relatives to adopt the specific practice

Purpose: The Diffusions of Innovations Theory of behavior notes that people choose to act based on how they perceive the action in the context of their daily lives, what they see other people doing and how people talk about and share information about the action. New ideas come from opinion leaders within the community or from outside the community but they are adopted or rejected within the social networks of people who share common interests and values. This indicator aims to identify opinion leaders who may have influenced the behavior of people with regard to malaria interventions.

Studies have found that sustained behavior change is higher among individuals who not only receive benefits but also tell others about them. Personal advocacy reinforces one’s own behavior, while, at the same time, creating a social environment that reinforces others’ behavior or influences others to change their behavior (Kincaid, 2000; Kincaid et al., 1999). One can, however, successfully adopt and sustain a behavior without publicly advocating it to others.

Mass media programs can be designed to remind current users that benefits or changes in their lives relate to the practice in question. Programs can also encourage satisfied users to talk to their friends or to have their friends come with them for services. This indicator helps assess the degree to which a behavior has become a new social or community norm, as active encouragement/discouragement by a broad range of family and community members goes beyond perceived changes in social norms and becomes active social support for the practice. The goal of these interventions is to confirm individual behavior change through advocacy of use to others and to establish the behavior in question as an established social norm everyone can follow.

Definition:‘Encouraged’ refers to speaking positively about the practice to other people. ‘Friends and relatives’ are self-defined by the respondent. ‘Adopt the specific practice’ refers to the behavior that the communication campaign is attempting to change. Numerator: Number of respondents who have encouraged adoption of a specific practice


Measurement Method:


47


901

Have you ever encouraged anyone to [use a bed net/use ACTs/get an RDT/accept spraying/attend ANC]?

YES

NO

DON’T KNOW

1

2

99

902

Who did you encourage? FRIEND

OTHER FAMILY MEMBER (SPECIFY):

SPOUSE

CHILD

1

2

3

4

903

Has anyone encouraged you to [use a bed net/use ACTs/get an RDT/accept spraying/attend ANC]?

YES

NO

DON’T KNOW

1

2

99

904

Who encouraged you? SPOUSE

CHILD

OTHER HOUSEHOLD MEMBER (SPECIFY): _______________________

FRIEND

COMMUNITY LEADER

RELIGIOUS LEADER

COMMUNITY HEALTH WORKER

OTHER (SPECIFY): _________________

1

2

3

4

5

6

7

88

Interpretation:Because the data is based entirely on self-reporting, the respondent may wish to please or impress the evaluator by stating that s/he has encouraged something s/he believes is considered positive (e.g., using a bed net, taking SP for IPTp).

In order to mitigate bias social desirability bias, the questionnaire could include some questions to assess social desirability. The Crowne and Marlow Social Desirability Scale [20] or shorter versions of the scale [21] are useful in assessing whether respondents are responding truthfully or are misrepresenting themselves in order manage the enumerator’s perceptions of them.


48

The Social Desirability Scale can be adapted to specific country contexts. The data analysts can compare the Social Desirability Score and a key variable of interest, such as bed net use or correct health seeking behavior. Analysts can then control for high social desirability in multivariate analyses. Examples of questions on a (13 question) short-version of the Crowne – Marlowe scale [21] include:

• IsometimesfeelresentfulwhenIdon’tgetmyway

• TherehavebeentimeswhenIwasquitejealousofthegoodfortuneofothers

• Iamsometimesirritatedbypeoplewhoaskfavorsofme

• TherehavebeenoccasionswhenItookadvantageofsomeone

• Isometimestrytogetevenratherthanforgiveandforget

• IamalwayswillingtoadmitwhenImakeamistake

These questions are not specific to the measurement of this indicator but can be included in the survey in general to control for social desirability in the measurement of other indicators included in this Reference Guide.

Strengths• Thisindicatorcanidentifyleadersinthecommunitywhoinfluenceotherstoadopthealthybehaviors.

• Theindicatorcanalsorevealthechannelsthroughwhichpeoplearebeinginfluenced.

• Genderaspectsoffindingsmaybeimportant(seebelow)

Weaknesses• Thisindicatorissubjecttosocialdesirabilitybiasandresultsshouldbeinterpretedwithcaution.

• Theindicatordoesnotexplorethereasonswhyarespondentwouldnothaveencouragedotherstoadopt a healthy behavior.

Gender Implications: An analysis of this indicator may reveal gender differences as women, as traditional caregivers, are more likely to share information on services and practices, especially when related to children. It is also possible that men share information on products and services, although they may be sharing with colleagues rather than with friends and relatives. This indicator will attempt to measure the role of gender in the encouragement of adoption of healthy behaviors.

References:Crowne & Marlowe, Social Desirability Scale (1960) and Reynolds, William, Short Form of the Crowne and Marlowe Scale (1982)

14. Bed Net Care and Repair

PurposeIt has been observed that bed nets, which are intended to last 3-5 years, often have significant tears after much shorter periods of time, limiting their effectiveness. If bed nets could last for longer there would be a potential cost saving replacement of bed nets would need to occur less frequently.


49

Currently it is unknown whether bed net care and repair behaviors at the household level increase the lifespan of the bed net. Research is currently underway to ascertain whether bed net care and repair lead to increased bed net lifespan. Research is also underway to ascertain whether communications messaging has a positive impact on bed net durability; the initial results of this research are expected in the second half of 2014.

At this time, there are online resources regarding net care and repair and bed net durability monitoring. The ‘Knowledge for Health ‘Care and Repair of Mosquito Nets Toolkit’ includes formative research tools, protocols and reports; materials developed for BCC campaigns focusing on bed net care and repair; and tools and questionnaires for evaluating bed net care and repair behaviors.

The Evaluation Resources section of this Reference Guide contains the ‘Net Care and Repair Household Survey Module’. Countries can adapt the survey module by including specific messages which are being transmitted through communications campaigns on bed net care and repair. Extra or different options can be included for questions 33 and 34.

In addition to the ‘Care and Repair of Mosquito Nets Toolkit’, the World Health Organization has released in September 2013 the ‘WHO Guidance Note for Estimating the Longevity of Long-Lasting Insecticidal Nets in Malaria Control’, which includes guidance on durability monitoring and recommendations for countries and partners.

Definition‘Net care and repair’ refers to actions that will maintain mosquito nets in good condition so they can be used for the prevention of malaria. Caring for nets entails preventing damage to nets. This is done by handling nets carefully, keeping them away from sources of damage, and washing nets gently and not too often. Repairing nets refers to closing holes and tears as soon as they appear by stitching, patching, tying knots, or any other method.

Indicators on net care and repair can be defined from the questions below.

Numerator: The number of respondents who have engaged in a net care of net repair activity


http://www.k4health.org/toolkits/care-repair-LLIN

http://www.k4health.org/toolkits/care-repair-LLIN/net-care-and-repair-household-survey-module


http://www.who.int/malaria/publications/atoz/who_guidance_longevity_llins.pdf

http://www.who.int/malaria/publications/atoz/who_guidance_longevity_llins.pdf


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Measurement Method:


Q1001Have you ever experienced any holes in the nets you own?

YES

NO

1

2

Q1002

How did the hole(s) happen? TORE WHEN GOT CAUGHT ON EDGE OR NAIL

WAS PULLED AND TORE ON CORNER

WAS BURNED BY A CANDLE OR SPARKS

WAS CAUSED BY RATS OR MICE

IN ANOTHER WAY (SPECIFY):

______________________________

DON’T KNOW

1

2

3

4

88

99

Q1003Over the last 6 months, have you ever tried to repair any of these holes or get them repaired by someone else?

YES

NO

1

2

Q1004

How were the holes repaired? STITCHED

KNOTTED OR TIED

USED A PATCH

IN ANOTHER WAY (SPECIFY):

______________________________

1

2

3

88

Q1005

Over the last 6 months, who made repairs to the holes in your nets?

HOUSEHOLD MEMBER

TAILOR

FRIEND OR RELATIVE

COMMUNITY VOLUNTEER

OTHER (SPECIFY): _______________

1

2

3

4

88


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Q1006

What was the main reason holes were not repaired?

NO TIME FOR THIS

IT IS NOT NECESSARY

DON’T KNOW HOW

DO NOT HAVE MATERIALS TO REPAIR

HOLES ARE NOT BIG ENOUGH TO REPAIR

IT IS NOT POSSIBLE TO REPAIR HOLES

OTHER (SPECIFY): _______________

1

2

3

4

5

6

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Q1007

What, if anything, do you do at home to prevent nets from tearing or getting holes?

KEEP AWAY FROM CHILDREN

KEEP AWAY FROM PESTS

ROLL UP OR TIE UP WHEN NOT IN USE

HANDLE NETS WITH CARE

DO NOT SOIL WITH FOOD

KEEP AWAY FROM FLAME OR FIRE

WASH GENTLY

WASH ONLY WHEN DIRTY

INSPECT NETS REGULARLY FOR HOLES

REPAIR SMALL HOLES QUICKLY

IT IS NOT POSSIBLE TO PREVENT HOLES

DO NOTHING

OTHER (SPECIFY): _______________

1

2

3

4

5

6

7

8

9

10

11

12

88


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Q1008

What is the recommended way to wash a mosquito net?

GENTLY

IN A BASIN

WITH MILD SOAP

ONLY WHEN DIRTY

NO MORE THAN ONCE EVERY 3 MONTHS

NOT IN THE STREAM

OTHER (SPECIFY): _______________

1

2

3

4

5

6

88

Interpretation:As noted above, it is currently unknown whether bed net care and repair behaviors at the household level increase the lifespan of the bed net, though current research aims to provide this information shortly. Measurement of this indicator will provide information on the behaviors currently practiced with regard to bed net care and will provide important insights for the design of BCC campaigns.

Strengths:• TheSurveyModuleincludesquestionsonbednetcareandrepair;butthe“other”optionmayreveal

sources of damage previously unknown.

• ThisindicatorcanbemeasuredwithrelativelyfewquestionsandcanbeusefulforthedesignofBCCmessages.

Weaknesses:• Giventheuncertaintyastowhetherbednetcareandrepairactuallyprolongthenetlifespan,the

measurement of this indicator may have limited application.

References:Care and Repair of Mosquito Nets Toolkit, http://www.k4health.org/toolkits/care-repair-LLIN

Net Care and Repair Household Survey Module, http://www.k4health.org/toolkits/care-repair-LLIN/net-care-and-repair-household-survey-module

WHO Guidance Note for Estimating the Longevity of Long-Lasting Insecticidal Nets in Malaria Control, http://www.who.int/malaria/publications/atoz/who_guidance_longevity_llins/en/index.html




http://www.who.int/malaria/publications/atoz/who_guidance_longevity_llins/en/index.html



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15. Non-adoption (subjective/objective) of recommended malaria interventions

• Non-useofbednets

• Non-useoftreatment/barrierstotreatment

• Non-compliancewithIPTp(notgetting/takingSPatlastANCvisit)

• RefusalofIRS(notgetting/allowingIRS)

• Refusaltogettested/diagnosedatlastfeverepisode

Additional indicator:Proportion of people who do not adopt malaria interventions, by reason for non adoption recall hearing or seeing specific malaria messages (reported by each specific message)

Purpose:The purpose of these indicators is to determine the reasons for the non adoption of malaria interventions. These indicators are useful for gauging the prevalence of various barriers across the country and for gauging barriers relative to one another. These indicators also provide information on which barriers are significant and which are site-specific. Response options should include objective and subjective reasons for non-compliance/non-adoption of malaria interventions so that program managers have access to information which can assist in the design of more effective programs.

Qualitative formative research is the best way to identify barriers to healthy malaria behaviors; in cases where this is not possible, these questions can be used to identify topics that can be further explored in qualitative studies.

DefinitionThese indicators measure the reasons for the non-adoption of recommended malaria interventions. There are separate indicators for each recommended malaria intervention, with respondents being asked whether they adopted the recommended malaria intervention and if not, why not.

Numerator: The number of respondents who did not adopt a recommended intervention



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Measurement


BED NET USE

Q2001Did anyone sleep under this

mosquito net last night?

YES

NO

NOT SURE

1

2

99

Q2002

Who slept under this mosquito net last night?

RECORD THE PERSON’S NAME

AND NUMBER FROM THE HOUSEHOLD SCHEDULE.

NAME

____________________________

LINE NUMBER

Q2003For those children who did not sleep under the bed net last night, what were the reasons for not sleeping under the bed net?

TOO HOT

TOO COLD

CHILD CRIES

CHILD AFRAID

NOT ENOUGH NETS

NET NOT HUNG UP

USED BY ADULTS

NET NOT USED WHEN TRAVELLING

NET NOT IN GOOD CONDITION

NET BAD FOR CHILDREN’S HEALTH

NET HAS TOO MANY HOLES

OTHER (SPECIFY): _______________

1

2

3

4

5

6

7

8

9

10

11

88


55


Q2004For those adults who did not sleep under the bed net last night, what were the reasons for not sleeping under the bed net?

TOO HOT

TOO COLD

NET NOT HUNG UP

NET NOT USED WHEN TRAVELLING

NET NOT IN GOOD CONDITION

NET HAS TOO MANY HOLES

OTHER (SPECIFY): _______________

1

2

3

4

5

6

88

INTERMITTENT PREVENTIVE TREATMENT IN PREGNANCY (IPTp)

Q2005 During this pregnancy, did you take any drugs to keep you from getting malaria?

YES

NO

DON’T KNOW

1

2

99

Q2006

If “no”:

Why didn’t you take drugs to keep you from getting malaria while pregnant?

DID NOT KNOW I HAD TO TAKE DRUGS

DRUGS WERE NOT PROVIDED

NO CLEAN WATER

HAD NOT EATEN YET

STOCK OUT OF DRUG AT HEALTH CENTRE

HEALTH STAFF REFUSED TO GIVE ME DRUGS

SIDE EFFECTS

OTHER (SPECIFY): _______________

1

2

3

4

5

6

7

88

INDOOR RESIDUAL SPRAYING (IRS)

Q2007At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?

YES

NO

DON’T KNOW

1

2

99


56


Q2008If “no”:

Why not?

DO NOT BELIEVE THAT SPRAYING CAN KILL MOSQUITOES

WE WERE NOT AT HOME

DON’T LIKE THE SPRAY

SPRAYING CAUSES ILLNESS

FEAR OF CHEMICAL USED

COULD NOT MOVE FURNITURE OUT

OTHER (SPECIFY): _______________

1

2

3

4

5

6

88

DIAGNOSIS AND TREATMENT

Q2009Has (NAME) been ill with a fever at

any time in the last 2 weeks?

YES

NO

DON’T KNOW

1

2

99

Q2010Did you seek advice or treatment for

the illness from any source?

YES

NO

1

2

Q2011If didn’t get tested:

Why did you not get testing for (NAME)?

HEALTH CENTRE TOO FAR

DO NOT TRUST THE MALARIA TEST

NO MALARIA TESTS AT THE HEALTH CENTRE

DO NOT LIKE THE HEALTH CENTRE STAFF

NO MONEY FOR TEST

OTHER (SPECIFY): _______________

1

2

3

4

5

88


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Q2012If didn’t get treatment:

Why didn’t you get treatment for (NAME)

HEALTH CENTRE DID NOT HAVE DRUGS

OTHER DRUGS CAN CURE THE FEVER

DO NOT LIKE HEALTH CENTRE STAFF

NO MONEY FOR TREATMENT

OTHER (SPECIFY): _______________

1

2

3

4

88

Interpretation:To facilitate analysis, the barriers related to the non-practice of recommended behaviors can be coded as ‘subjective’ or ‘objective barriers’. Subjective barriers are primarily attitudinal, such as the non use of bed nets due to heat, or not getting tested due to a dislike for the health facility staff. Objective barriers are primarily structural, such as someone being away from home, drug stockouts at the health facility or a lack of resources to pay for a service.

The numerator for the additional indicator would be the number of people who do not adopt an intervention, by reason for non-adoption. The denominator for the additional indicator could be “number of respondents who did not adopt the intervention”. This will provide the proportion of those did not did adopt an intervention for a particular reason out of all those who did not adopt the intervention.

Strengths• Thisindicatorcanmeasuresubjectiveandobjectivebarrierstotheadoptionofrecommended

behaviors. Both are measures of real barriers and both are important as they result in different interventions.

• Context-specificreasonscanbeaddedtotheoptions

• The‘other’categoryisparticularlyusefulandcanrevealbarrierspreviouslyunknown.

WeaknessesRespondents may be hesitant to reveal the reasons for non-adoption of recommended behaviors. Enumerators’ training should include methods by which to make respondents comfortable and by which to probe the respondent for more detail.

16. Proportion of members of the household who sleep outside the house, by month

PurposeOutdoor sleeping habits may affect people’s susceptibility to malaria as bed net use may be reduced. Hammock nets are available for people who sleep outdoors.


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Definition This indicator measures the proportion of household members or visitors who sleep outside of the housing structure in the open air. This indicator can be disaggregated by the household members (men and women) and by visitors (men and women). The reason for non-use of bed nets while sleeping outdoors is measured.

Numerator: Total number of people sleeping outdoors

Denominator: Total number of people in the household

Measurement Method:


Q3001Does anyone in your household sleep outdoors?

YES

NO

1

2

3002

Who sleeps outdoors? MEN WHO ARE AWAY FROM HOME FOR WORK

WOMEN

PEOPLE VISITING THE HOUSEHOLD

CHILDREN

OTHER (SPECIFY): _____________

1

2

3

4

88

3003On average, how many nights in a month do these people sleep outside?

3004

When sleeping outdoors, do these people use a net?

MEN – YES

MEN – NO

WOMEN – YES

WOMEN – NO

VISITORS – YES

VISITORS – NO

DON’T KNOW

1

2

3

4

5

6

99


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3005

If they are not using a net while sleeping outdoors, what are the reasons for not using a net?

NO NETS AVAILABLE

DIFFICULT TO CARRY A NET WHEN TRAVELLING

NOT ENOUGH NETS FOR EVERYONE

TOO HOT

THERE ARE NO MOSQUITOES

OTHER (SPECIFY): _____________

DON’T KNOW

1

2

3

4

5

88

99

3006

During which months do you use a mosquito net?

Select all that apply.

JANUARY

FEBRUARY

MARCH

APRIL

MAY

JUNE

JULY

AUGUST

SEPTEMBER

OCTOBER

NOVEMBER

DECEMBER

1

2

3

4

5

6

7

8

9

10

11

12

3007Have you ever gone to the forest and slept there in the nighttime?

YES

NO

1

2

3008Last time you went and slept in the forest, did you sleep under the net?

YES

NO

1

2


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3009Was it a hammock net or bed net? HAMMOCK NET

BED NET

1

2

3010Was this hammock net dipped/soaked into insecticide liquids?

YES

NO

1

2

Interpretation:This indicator measures who sleeps outdoors and whether they are protected by a net.

Gender implications: It is critical to disaggregate this indicator by sex to determine differences in outdoor sleeping habits. Men are more likely to be sleeping outdoors when they travel away from home. It is important for malaria programs to estimate what proportion of people are sleeping outdoors and whether they are protected by insecticide treated nets.

Strengths:• Thisindicatorcanprovideusefulinformationaboutthehouseholdmemberswhosleepoutdoorsand

whether or not they are protected

• Providesusefulformativedatatodeterminetargetaudience’spracticesandneeds

• Context-specificreasonscanbeaddedtotheoptions

• The‘other’categoryisparticularlyusefulandcanrevealbarrierspreviouslyunknown.

Limitations • Respondentsmaybehesitanttorevealthesleepingpracticesofhouseholdmembersandvisitors

• Respondentsmaynotbeabletotellhowmanynightsonaveragetheysleepoutdoors

• Thequestionregardingtheduringwhichpeopleuseabednetmayhavetobeadaptedtosuitthelocaldetermination of time – by season, for example.

Upcoming Activities Requiring MonitoringAs the malaria epidemiology shifts in countries due to gains in malaria control, changing habitats due to climate change and development, and other factors, there is a need for monitoring and evaluation of new BCC interventions.

The section outlines issues in the formulation stage, with research being conducted and results pending. As such, this section will be considered under construction until the results of the pilot studies are known and can be incorporated into refining indicators and associated data collection tools. As these practices are mainstreamed and recommended by WHO, this indicator Reference Guide will be updated.

Malaria BCC is likely to become important for the following interventions and the subsequent monitoring and evaluation of these BCC activities will be important:


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1. Seasonal Malaria Chemoprevention (SMC)

Indicators for measuring BCC activities to promote seasonal malaria chemoprevention will be developed if needed. In the interim, programs should adapt existing BCC indicators for BCC activities related to this intervention.

2. Larviciding

Indicators for measuring BCC activities to promote larviciding will be developed if needed. In the interim, programs should adapt existing BCC indicators for BCC activities related to this intervention.

3. Intermittent Screening and Treatment (IST)

Indicators for measuring BCC activities to promote intermittent screening and treatment will be developed if needed. In the interim, programs should adapt existing BCC indicators for BCC activities related to this intervention.

4. Mass Drug Administration (MDA)

Indicators for measuring BCC activities to promote mass drug administration will be developed if needed. In the interim, programs should adapt existing BCC indicators for BCC activities related to this intervention.

5. Outbreak Response

Indicators for measuring BCC activities to respond to malaria outbreaks will be developed if needed. In the interim, programs should adapt existing BCC indicators for BCC activities related to this intervention.

6. Reactive/Active Case Detection

Indicators for measuring BCC activities to promote reactive or active case detection will be developed if needed. In the interim, programs should adapt existing BCC indicators for BCC activities related to this intervention.

Reporting guidelinesSee companion guide on Reporting BCC interventions.


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Annex

Four Commonly-Used Theories of Communication and Behavior ChangeTheory-based programs and indicators help us understand how and why change happens. These indicators are based on previous research and theories about the determinants of behavior change for malaria, family planning, HIV, and other health areas. Data shows that improving knowledge is not enough to increase the uptake of desired behaviors. Other factors such as audiences’ attitudes and characteristics of the desired behavior also need to be addressed. Theories help us map where the audience is in the process of behavior change and how they will get to the desired change. They provide insights on the decisions, motives, barriers and facilitators associated with change.

Below are five commonly-used behavior change and communication theories. These theories share some similar elements but each emphasizes slightly different constructs and processes. They have been adapted from the Online Training Series on Evidence-Based Malaria Social & Behavior Change Communication and a series of research primers on SBCC. In this annex, we provide an overview of each theory and how their constructs are reflected in the indicator guide.

Extended Parallel Processing Model (also known as Risk Perception Attitude Framework)

Perception of risk, self-efficacy and response efficacy have been associated with preventive behaviors. [1-19, Boulay 2014 in review] Several core indicators (7 through 10) measure these constructs which are based on the Extended Parallel Processing Model (also known as the Risk Perception Attitude Framework). (Rimal and Real, 2008) EPPM describes how reason and emotion interact during individual decision making.

There are two components to the model – fear or threat (emotion) and efficacy (reason). Fear has two parts: severity and susceptibility. Efficacy – or confidence in one’s ability to control or manage the threat or risk perceived - is composed of three parts: response efficacy, self-efficacy and barriers.

Key TermsFear or Threat

• Susceptibility refers to the belief that the disease or threat can actually happen to them. Indicator 7, proportion of people who perceive they are at risk from malaria measures susceptibility.

• Severity refers to how serious people believe the threat (malaria) to be. This is reflected in indicator 8, proportion of people who feel that consequences of malaria are serious.

Efficacy

• Response efficacy refers to a perception that a proposed action or solution will actually control the threat. In the case of malaria – a person’s belief that bed nets serve as good protection against malaria is an example of response efficacy. Indicator 9, proportion of people who believe that the recommended practice or product will reduce their risk, mirrors response efficacy.

• Self-efficacy is a measure of self-confidence that a person can perform an action to control the threat. Self-efficacy can refer to a person’s confidence in correctly and consistently using a bed net to prevent


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malaria. Indicator 10, proportion of people who are confident in their ability to perform a specific malaria-related behavior, measures self-efficacy.

• Thelastpartofefficacy,barriers, refers to perceptions of factors which may hinder someone from practicing the behavior to reduce the threat. Research has shown that individuals can have the knowledge and skills, positive beliefs, attitudes, and intentions toward a specific behavior, yet they avoid engaging in the recommended behavior. A trigger to motivate action is needed.

Putting it all togetherEvaluators can expect desirable behavioral responses when people have strong risk/threat perceptions coupled with strong beliefs of efficacy toward the recommended response (Figure 1, top left box). When people experience significant fear but have little belief that they can take action or that their actions will effective, they will be more likely to deny the importance of the issue, act defensively or avoid it (Top right box). If the threat is perceived not to be serious but there are easy and effective measures available, individuals may be slightly motivated to act (Bottom left box). If the threat is not serious and there are no feasible or effective actions that individuals can take, they will likely do nothing about the issue.

For example, people may feel that net use is easy but feel little fear about the risk of malaria infection during the dry season (Bottom left box). Behavior change communication programs may wish to increase the perception that community members remain susceptible to malaria during the dry season and that its consequences can still be severe (Top left box). Using the indicators provided, evaluators can measure the extent to which these programs affected perceptions of risk and efficacy and whether these constructs were determinants of year-round net use.

Figure 1. Extended Parallel Processing Model

Highly motivated to take

protective action

High Efficacy(Able to respond

effectively)

EFFICACY DETERMINES REACTION

Low Efficacy(Unable to respond

effectively )

High Threat(Vulnerable to Serious Harm)

Low Threat(Invulnerable,Trivial Threat)

Low motivation, may be some

protective action

Denial, defensiveness,

avoidance

No Response


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Social Learning Theory (also known as Social Cognitive Theory)

Social Learning Theory emphasizes the importance of modeling and self-efficacy. According to this theory, people learn by:

1. Observing what other people do

2. Observing what happens to those people as a result of their behavioral choices

3. Evaluating the relevance and importance of those consequences for their own life

4. Attempting to reproduce the action themselves

Self-efficacy is an important part of this theory. According to Bandura, “perceived self-efficacy affects every stage of personal change. It determines whether people even consider changing the behavior, whether they can enlist the motivation…and how well they have maintained the changes.” (Bryant and Zillman, 2008) Role-modeling should thus be oriented to build people’s skills and belief in being able to exercise them.

The first step, observing what other people do, is reflected in indicator 12, proportion of people that believe the majority of their friends and community members currently practice the behavior. Even if real behavior change has not yet occurred, communication can increase the public’s perception that change is occurring or has occurred, creating the necessary momentum and supportive environment for actual change. This indicator measures the ability of communication strategies to persuade the intended audience that their friends, family, and other fellow community members are adopting the recommended behavior and that adherence to that behavior is increasing, decreasing, or staying the same.

The second step, observing what happens to those people as a result of their behavioral choices, is the basis for indicators 8 and 9 (8 - Proportion of people who feel that consequences of malaria are serious; 9 - Proportion of people who believe that the recommended practice or product reduce their risk). Individuals gauge the impact these behaviors have had on others (whether they are rewarded or punished socially, materially, physically) as they reflect on the relevance and importance of these consequences on their own lives (step 3). Indicator 7, the proportion of people who believe they are at risk of malaria, is an indication of step 3.

Indicator 10, proportion of people who are confident in their ability to perform a specific malaria-related behavior, can be used to track changes in self-efficacy as a result of exposure to a campaign and how much self-efficacy has contributed to the desired behavior change.

Figure 3. Social Learning Theory

Environment

Person

Behavior


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Putting it all togetherMedia campaigns based on the social learning theory use relatable figures – figures like the target audiences – to model the health issues and build life skills (indicator 10, proportion of people who are confident in their ability to perform a specific malaria-related behavior). This is most evident in long-running drama serials with family planning messages or a dramatic film addressing malaria in pregnancy. Social learning theory has also been used in individual or small group interventions where participants get the opportunity to observe their peers and support for practicing the behavior, such as condom use or partner communication, is provided.

Theory of Planned Behavior(also known as the Theory of Reasoned Action)

According to the Theory of Planned Behavior, people base their intentions on three things: whether they think the behavior is bad or good, what they think they are expected to do, and the extent to which they can carry out the behavior. This section is drawn from an SBCC research primer on the Theory of Planned Behavior.

Figure 2. Theory of Planned Behavior

Attitude

Subjective Norm

Intention Behavior

Perceived Behavioral Control

Key Terms

• Attitude –Beliefs that the behavior is good or bad based on whether its outcomes are positive or negative. This construct is reflected in indicator 11, proportion of people with a favorable attitude toward the product, practice or service and indicator 9, proportion of people who believe that the recommended practice or product will reduce their risk.

• Subjective norms – Perceived social pressure; Beliefs about what their peers expect them to do and whether they will be supported or ridiculed. Indicator 12, proportion of people that believe the majority of their friends and community members currently practice the behavior.

• Perceived behavioral control – Beliefs about whether they have the necessary knowledge, tools, and ability to carry out the behaviors is reflected indicator 10, proportion of people who are confident in their ability to perform a specific malaria-related behavior.

• Intention – According to this theory, the stronger a person’s intention to practice a healthy behavior, the more likely that person will actually perform that behavior. But, it is important to remember that many outside factors and restrictions can prevent an individual from performing a behavior, even when they have an intention to do so. Intention is strongest when attitudes, subjective norms, and perceived behavioral control favor the behavior.

http://www.healthcommcapacity.org/hc3-research-primers-aid-in-sbcc-program-design/


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Putting it all togetherA campaign in Tanzania sought to increase perceptions that bed nets are the socially accepted approach for avoiding malaria, foster people’s confidence in their ability to use bed net every night and improve the fatalistic attitude that malaria is an unavoidable and constant presence in people’s lives.

The program’s initial evaluation demonstrated that exposure to the activities improved the self-efficacy necessary to take action to prevent malaria. Nearly 77% of those exposed to the program put all their children under bed nets the previous night, as opposed to 34.6% of those unexposed. Exposure to the campaign significantly increased the perception that nets are effective in stopping malaria and the belief that nets are useful and easy to use.

Social norms and the belief in one’s ability to use nets effectively were significantly associated with net ownership. Thus, those exposed to the campaign activities shifted their attitudes and were more likely to act on their intention to own and use a bed net.

Diffusion of Innovations

This theory describes several factors that influence how quickly an idea or behavior is adopted. The diffusion depends on characteristics of the innovation, communication channels, time and the social system. This section has been adapted from an SBCC research primer on the Diffusion of Innovations Theory.

Figure 3 represents the diffusion S-curve. It illustrates how people are initially slow to adopt new behaviors, but as the behavior becomes better known and accepted, more people quickly start to practice it. Eventually the behavior becomes commonplace with fewer new adopters.

Figure 4. Diffusion S-Curve

Perc

ent

of a

dopt

ion

Time

100%

Some innovations quickly become popular, while others require more explanation and practice before they are popularized. Effective communication can help an innovation become more popular, making the curve steeper. Similarly, the characteristics of an innovation or health behavior will influence how rapidly it can be adopted. Table 1 describes the main characteristics of an innovation, as well as their meaning for program implementation. As people become more familiar with an innovation, they are more likely to adopt it.



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Table 1. Characteristics of Innovations and Related Communication Interventions

Putting it all together

Implementers can track the progress of their interventions by creating graphs like the S-curve shown above as data on the program’s reach are evaluated. Ideally, program implementers are seeking to make the graph narrower and taller – reaching more people, quickly. Diffusion of Innovations approaches work best when applied to issues that can be influenced by prominent members of society or spread through traditional methods of communication. Indicator 13, proportion of people who have encouraged friends or relatives to adopt the specific practice, can help identify opinion leaders who may have influenced the behavior of people with regard to malaria interventions.

The Health Belief Model

This model illustrates the importance of beliefs about the risks, benefits, barriers and self-efficacy in behavior change. According to this model, if individuals regard themselves as susceptible to malaria, believe that malaria would have potentially serious consequences, believe that net use/IPTp/testing and treatment would be beneficial in either reducing their susceptibility to malaria or alleviating it severity, and believe the benefits of the behavior outweigh the barriers, they are likely to act to reduce their risks. The model also argues that a cue to action is needed to trigger preventive action. The model differs from the others in that it does not explicitly state the role of emotion (like fear, as in EPPM).

Figure 5. The Health Belief Model (from Glanz et. al., 2008)

AgeGenderEthnicity

PersonalitySocioeconomics

Knowledge

Modifying Factors Individual Beliefs Action



Percieved susceptibility

to and severity of disease

Perceived benefits

Perceived barriers

Perceived self-efficacy

Percieved threat

Putting it all together

Descriptions of these constructs and their relationships to the indicators are described above. One example of a cue to action may be, “if you see a small hole in your net, repair it immediately.” Implementers using the Health Belief Model should assess the relationship between these constructs and the desired behavior as well as evaluate the role of recall of the specific cue to action given in the campaign.


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BibliographyThis document draws from a variety of surveys implemented in different countries by different partners. Documents consulted include:

Survey questionnaires

1. Measure Evaluation. Demographic and Health Survey.

2. Liberian Red Cross. Community Based Health / Disaster Management Program Malaria Prevention Baseline Survey Questionnaire.

3. PSI Madagascar. Madagascar Questionnaire: Post-Campaign Evaluation of Phase I and II of the Universal Coverage Free Mass LLIN Distribution Campaign.

4. Roll Back Malaria Partnership. Malaria Indicator Survey.

5. MENTOR Initiative. Net retention, utilization, condition, preference and IEC survey questionnaire.

6. UNICEF. Multiple Indicator Cluster Survey.

7. Population Services International. TRaC Survey.

8. JHUCCP and Malaria Consortium. Senegal post campaign evaluation 2009-2010.

9. Sierra Leone NMCP & Canadian Red Cross. Nine Month Evaluation of the Measles-Malaria Integrated Campaign in Sierra Leone.

10. UNHCR. Net Coverage and Durability Survey.

Resource Documents

11. Care and Repair of Mosquito Nets Toolkit http://www.k4health.org/toolkits/care-repair-LLIN

12. Family Health International (FHI). Monitoring HIV/AIDS Programs: A Facilitator’s Training Guide. Module 6: Monitoring and Evaluating Behavior Change Communication Programs. 2004.

13. Household Survey Indicators for Malaria Control, June 2013 http://www.rollbackmalaria.org/toolbox/docs/rbmtoolbox/tool_HouseholdSurveyIndicatorsForMalariaControl.pdf

14. Management of Severe Malaria, WHO 2012 http://apps.who.int/iris/bitstream/10665/79317/1/9789241548526_eng.pdf

15. Global Fund Monitoring and Evaluation Toolkit, Part 4 – Malaria, November 2011 http://www.theglobalfund.org/en/me/documents/toolkit/

16. Seidel R. 2005. Behavior Change Perspectives and Communication Guidelines on Six Child Survival Interventions. A joint publication of AED and JHU/CCP with support from UNICEF.

17. WHO guidance note for estimating the longevity of long-lasting insecticidal nets in malaria control, September 2013 http://www.who.int/malaria/publications/atoz/who_guidance_longevity_llins/en/ index.html











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Theory Resources • Theprologueofthismanualprovidesanoverviewofseveralhealthcommunicationtheories:

- de Fossard, E. (1996). How to Write a Radio Serial Drama for Social Development: A Script Writer’s Manual. Baltimore, MD: Johns Hopkins University School of Public Health. http://www.jhuccp.org/sites/all/files/How%20to%20Write%20Radio%20Serial%20Drama%20for%20Soc%20Develop%20.pdf

• Thesetoolkitscontainsseveralreadingsonhealthcommunicationtheory:

- K4 Health. Toolkits: Communication Theory Readings. Retrieved from: http://www.k4health.org/toolkits/tanzania-ace/communication-theory-readings

- K4 Health. Toolkits: Communication Theories and Models. Retrieved from: http://www.k4health.org/toolkits/uganda-fpcommunication/communication-theories-and-models-0

- Online Training Series on Evidence-Based Malaria Social & Behavior Change Communication. Retrieved from: http://www.networksmalaria.org/networks/online-training-series-evidence-based-malaria-social-behavior-change-communication

• Threatmanagement:

- Cho, H. & Witte, K. (2005). Managing Fear in Public Health Campaigns: A Theory-Based Formative Evaluation Process. Health Promotion Practice, 6, 482–490. Retrieved from: http://hpp.sagepub.com/content/6/4/482.full.pdf

• Sociallearningtheory:

- Bandura, A. (2004). Health Promotion by Social Cognitive Means. Health Education Behavior, 31, 143–164. Retrieved from: http://people.oregonstate.edu/~flayb/MY%20COURSES/H671%20Advanced%20Theories%20of%20Health%20Behavior%20-%20Fall%202012/Readings/Bandura%2004%20HP%20by%20social%20cognitive%20means.pdf

• Theoryofplannedbehavior:

- Ajzen, I. Theory of planned behavior. Retrieved from: http://people.umass.edu/aizen/tpb.html

- HC3 Research Primer. Retrieved from: http://www.healthcommcapacity.org/hc3resources/theory-of-planned-behavior-an-hc3-research-primer/

• Diffusiontheory:

- K4 Health. Toolkits: Reading 6A: Chapter 1, “The miracle of Oryu Li” & Chapter 2, “The convergence model of communication and network analysis” from Communication Networks: Toward a New Paradigm for Research. Retrieved from: http://www.k4health.org/toolkits/tanzania-ace/reading-6a-chapter-1-%E2%80%9C-miracle-oryu-li%E2%80%9D-chapter-2-%E2%80%9C-convergence-model

- HC3 Research Primer. Retrieved from: http://www.healthcommcapacity.org/hc3-research-primers-aid-in-sbcc-program-design/

• HealthBeliefModel

- Janz, N. & Becker, M. (1984) “The Health Belief Model: A Decade Later.” Health Behavior and Education, 1, 1-47. Retrieved from: http://heb.sagepub.com/content/11/1/1.short

- Glanz, K., Rimer, B. & Viswanath, K. (2008) Health Behavior and Health Education. San Francisco, CA: Jossey-Bass.

http://www.jhuccp.org/sites/all/files/How%2520to%2520Write%2520Radio%2520Serial%2520Drama%2520for%2520Soc%2520Develop%2520.pdf%20



http://www.k4health.org/toolkits/tanzania-ace/communication-theory-readings

http://www.k4health.org/toolkits/tanzania-ace/communication-theory-readings

http://www.k4health.org/toolkits/uganda-fpcommunication/communication-theories-and-models-0

http://www.k4health.org/toolkits/uganda-fpcommunication/communication-theories-and-models-0

http://www.networksmalaria.org/networks/online-training-series-evidence-based-malaria-social-behavior-change-communication

http://www.networksmalaria.org/networks/online-training-series-evidence-based-malaria-social-behavior-change-communication

http://hpp.sagepub.com/content/6/4/482.full.pdf

http://hpp.sagepub.com/content/6/4/482.full.pdf

http://people.oregonstate.edu/~flayb/MY%2520COURSES/H671%2520Advanced%2520Theories%2520of%2520Health%2520Behavior%2520-%2520Fall%25202012/Readings/Bandura%252004%2520HP%2520by%2520social%2520cognitive%2520means.pdf



http://www.healthcommcapacity.org/hc3resources/theory-of-planned-behavior-an-hc3-research-primer/

http://www.healthcommcapacity.org/hc3resources/theory-of-planned-behavior-an-hc3-research-primer/

http://www.k4health.org/toolkits/tanzania-ace/reading-6a-chapter-1-%25E2%2580%259C-miracle-oryu-li%25E2%2580%259D-chapter-2-%25E2%2580%259C-convergence-model

http://www.k4health.org/toolkits/tanzania-ace/reading-6a-chapter-1-%25E2%2580%259C-miracle-oryu-li%25E2%2580%259D-chapter-2-%25E2%2580%259C-convergence-model



http://heb.sagepub.com/content/11/1/1.short


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2. Panter-Brick C, Clarke SE, Lomas H, Pinder M, Lindsay SW: Culturally compelling strategies for behaviour change: a social ecology model and case study in malaria prevention. Soc Sci Med 2006, 62:2810-25.

3. Macintyre K, Keating J, Okbaldt YB, Zerom M, Sosler S, Ghebremeskel T, Eisele TP: Rolling out insecticide treated nets in Eritrea: examining the determinants of possession and use in malarious zones during the rainy season. Trop Med Int Health 2006, 11:824-33.

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9. Beer N, Ali AS, Eskilsson H, Jansson A, Abdul-Kadir FM, Rotllant-Estelrich G, Abass AK, Wabwire-Mangen F, Björkman A, Källander K: A qualitative study on caretakers’ perceived need of bed-nets after reduced malaria transmission in Zanzibar, Tanzania. BMC Public Health 2012, 12:606.

10. Keating J, Hutchinson P, Miller JM, Bennett A, Larsen DA, Hamainza B, Changufu C, Shiliya N, Eisele TP: A quasi-experimental evaluation of an interpersonal communication intervention to increase insecticide-treated net use among children in Zambia. Malar J 2012, 11:313.

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16. Hill J, Noor AM, Hoyt J, van Eijk AM, D’Mello-Guyett L, ter Kuile FO, Steketee R, Smith H, Webster J: Factors Affecting the Delivery, Access, and Use of Interventions to Prevent Malaria in Pregnancy in Sub-Saharan Africa: A Systematic Review and Meta-Analysis PLoS Med 2013, 10:e1001488.

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AcknowledgementsStaff from the following government agencies and organizations have contributed to this Indicator Reference Guide:

Centers for Disease Control (CDC)

Family Health International (FHI 360)

ICF International

Johns Hopkins University Center for Communications Programs (JHUCCP)

Johns Hopkins University Bloomberg School of Public Health (JHSPH)

Malaria No More

Population Services International (PSI)

President’s Malaria Initiative (PMI)

Tulane University School of Public Health and Tropical Medicine

United Nations Children’s Fund (UNICEF)

United States Agency for International Development (USAID)

USAID/Maternal and Child Integrated Program (MCHIP)


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