MALARIA COMMUNICATION STRATEGY

Transcription

1 MINISTRY OF PUBLIC HEALTH AND SANITATION MALARIA COMMUNICATION STRATEGY Division of Malaria Control

2 Achieving Progress and Impact onmalaria Allow your house to be sprayed with long acting insecticide for malaria control As a pregnant woman visit the health facility immediately you realize you are expectant to receive malaria preventive measures Ensure every member of your household sleeps under a insecticide treated net, every night whatever the season, to prevent malaria When your loved ones develop fever, visit the nearest health facility for a malaria test. If malaria is confirmed, seek the recommended medicine, ACT (Artemisinin Combination Therapy)

3 Any part of this document may be freely reviewed, quoted, reproduced or translated in full or in part, provided the source is acknowledged. It may not be sold or used in conjunction with commercial purposes or for profit. Malaria Communication Strategy Division of Malaria Control. Malaria Communication Strategy i

4 Table of Contents Table of contents List of figures & tables Foreword Acknowledgements Abbreviations Executive Summary ii iii iv v vi vii CHAPTER 1 General background and Programme Context 1 CHAPTER 2 Communication Needs assessment 4 Assessment of the current situation 4 Key challenges and implications on the communication strategy 8 CHAPTER 3 The Communication Strategy 11 Strategic Approach 11 Goal of strategy and anticipated outcomes 11 Key Audiences 13 Key Message Themes Communication Channels, Tools and Tactics 18 Summary of key messages, communication tools and methods 18 for priority audience groups Communication support for the launch and implementation 27 of Affordable Medicines for Malaria Summary of key messages specific to the ACT-m Medicines 31 CHAPTER 4 Implementation Framework 32 Implementation Plan CHAPTER 5 Continuing Research, Strategy Monitoring and Evaluation 36 Continuing Communication/BCC Research 36 Strategy Monitoring and Evaluation 36 ACSM Activity Process and Outcome Indicators Annex 1 Members of the ACSM Technical Working Group 39 Annex 2 Current List of Contributors 40 ii Division of Malaria Control. Malaria Communication Strategy

5 List of Figures Figure 1: 2009 Kenya Malaria Risk Map Figure 2: Uptake Of Malaria Control Interventions 1 36 List of Tables Table 1: Strategic Approach Table 2: Key Elements of the Model Theme 1: Malaria prevention and vector control Table 3 (A): Message theme: Acquisition/ownership and proper and consistent use of 14 LLINs to prevent malaria infection Table 4 (B): Message theme: Increased uptake of IPT in pregnancy in endemic zones, 15 and treatment for malaria in pregnancy Table 5 (C): Message theme: Encourage acceptance of IRS as preventive strategy 16 Theme 2: Malaria case management and treatment Table 6: Message theme: Improve treatment-seeking and appropriate medicine use Table 7: Target Audience Table 8: Summary of key messages specific to the ACT-m Medicines Table 9: Implementation Plan Table 10: ACSM Activity Process and Outcome Indicators Table 11: ANNEX 2: List of contributors 40 Division of Malaria Control. Malaria Communication Strategy iii

6 Foreword This National Malaria Communication Strategy document ( ), which is in alignment with the Kenya National Malaria Strategy gives strategic directions to guide the development, implementation and monitoring of the communication and behaviour change component of malaria prevention and control. It provides a planning framework aimed at defining communication and behaviour change objectives, the key target groups, messages, channels and communication interventions at different levels. It revolves around raising awareness about malaria, addressing the key determinants in behaviour for prevention and control interventions with the ultimate goal of a long-term normative shift in malaria related behaviours among the key target groups national wide. This strategy will be the guiding document for all partners to implement a unified and cohesive behaviour change and communication plan and allow for complementing programmes among partners The main malaria control behaviours that need to be adopted and maintained by individuals, families and communities include among others Early diagnosis and effective treatment, Intermittent Preventive Treatment(IPTp) of pregnant women with SP and malaria prevention with special emphasis on consistent use of Long Lasting Insecticidal Nets and Indoor Residual Spraying(IRS).Particular attention has been paid to enhance the understanding and awareness of the benefits of malaria prevention and treatment and address barriers to community level actions as enumerated in the National Malaria Strategy. Much appreciation goes to all stakeholders who contributed technically and financially to the development of this document. I hope this strategy will raise the profile of malaria control interventions at all levels and promote the partnership approach desired Dr. S. K. Sharif MBS, MBChB, M. Med. DLSHTM. MSc Director, Ministry of Public Health and Sanitation. iv Division of Malaria Control. Malaria Communication Strategy

7 Acknowledgement The Ministry of Public Health and Sanitation is indebted to many individuals and organizations without whose support and collaboration the development of this Malaria Communication Strategy for Kenya would not have been possible. We are grateful to Clinton Health Access Initiative for the financial assistance in the development of this document. The development of this strategy could not have been successfully completed without encouragement and technical support from Dr. Elizabeth Juma, Head of Division of Malaria Control, Dr. Willis Akhwale, Head of Disease Prevention and Control and Dr. S. K. Sharif, the Director of Public Health and Sanitation. We greatly appreciate the contributions of the various malaria Technical Working Groups and partners who participated in the discussions and for giving feedbacks that enriched the final product. A complete list of members of these Technical Working groups is found in annex 1. Finally, we would like to thank in advance all those organizations and individuals who will work with the National Malaria Control Programme to realise the vision of malaria- free Kenya. Dr. Willis S. Akhwale, MBS Head, Department of Disease Prevention and Control Ministry of Public Health and Sanitation. Division of Malaria Control. Malaria Communication Strategy v

8 Abbreviations ACSM ACTs AMFm ANC AIDS CBOs CHW DHMTs DOMC HIV IEC IPT IRS ITNs KNBS KDHS LLINs MIS NHSSP NMS SP TB USAID VCT Advocacy, Communication and Social Mobilization Artemisinin-based Combination Therapy Affordable Medicines Facility malaria Antenatal Care Acquired Immune Deficiency Syndrome Community-based Organizations Community Health Worker District Health Management Teams Division of Malaria Control Human Immune-deficiency Virus Information, Education and Communication Intermittent Preventive Treatment Indoor Residual Spraying Insecticide-treated Nets Kenya National Bureau of Statistics Kenya Demographic and Health Survey Long-lasting Insecticidal Nets Malaria Indicator Survey National Health Sector Strategic Plan National Malaria Strategy Sulphadoxine-pyrimethamine Tuberculosis United States Agency for International Development Voluntary Counselling and Testing vi Division of Malaria Control. Malaria Communication Strategy

9 Executive Summary The government of Kenya has, over the years, made malaria control and management a high priority recognizing it as the primary cause of ill-health responsible for 30% of all out-patient attendance and 19% of admissions besides still being the leading cause of death of children under five. The DOMC has since its establishment implemented malaria control interventions as outlined in its operational documents, including the National Malaria Strategy (NMS) and the National Malaria Policy. These interventions include case management; management of malaria and anaemia during pregnancy; vector control; and epidemic preparedness and control. The current national malaria strategy ( ) has carried on the emphasis on these interventions, and set targets to be achieved under each in the 8-year period. To build on its past achievements and meet the specific goals under the current National Malaria Strategy, and in line with the recommendations of the 2009 Programme Performance Review, the DOMC needs a well-planned and locally appropriate communication strategy that would respond well to current priorities. The new strategy is more integrated and encompasses Advocacy Communication and Social Mobilization (ACSM) to bring about sustainable social and individual behaviour change. It acknowledges challenges in the areas of prevention and vector control; malaria in pregnancy and case management and proposes strategies for effective communication with relevant stakeholders. The communication strategy is aligned to the objectives of the National Malaria Strategy , specifically Objective 5: By 2014, strengthen advocacy, communication and social mobilization capacities for malaria control, to ensure that at least 80 per cent of people in malaria areas have knowledge on prevention and treatment of malaria. This strategy supports the achievement of this objective through the following approaches: Communication, to build on current high levels of knowledge about malaria prevention; create awareness about appropriate case management and health care seeking behaviour, while addressing barriers to change in attitudes and practices identified in the situation analysis. The strategy defines the approaches that will be used to reach the targeted audience for maximum benefit and participation in malaria prevention, treatment and control. Advocacy, to secure leadership and commitment of stakeholders at all levels, and to strengthen the multi-sectoral response to malaria control Social mobilization, to ensure local communities participation in malaria control initiatives and continued public education; Communication to support the launch and implementation of the Affordable Medicines Facility malaria (AMFm) facility Division of Malaria Control. Malaria Communication Strategy vii

10 The strategy employs the ACSM model that links advocacy, communication and social mobilization to bring about and sustain desired outcomes in the individual and community. It is anticipated that the effective implementation of the strategy will lead to: Increased demand and use of LLINs Improved uptake of IPT in pregnancy Increased numbers of people seeking prompt, appropriate treatment with the right medicines within 24 hours of onset of malaria symptoms Improved adherence to prescribed treatment by clients Increased acceptance of Indoor Residual Spraying in communities Increased involvement of local communities in malaria control The strategy carefully delineates the various primary and secondary stakeholders, their information needs and recommends the messages and communication channels tools and tactics that should be used to reach them and ensure positive behaviour change that will eventually lead to the realization of the objectives. It provides an implementation framework at national, regional and local levels and looks at the aspects of capacity building for ACSM and the coordination roles of DOMC and partners. It finally makes recommendations for the integration of the proposed activities into other health programmes to increase their impact. The process of the development of the communication strategy involved consultations with key stakeholders in the private and public sectors as well as development partners. It took cognizance of the changes in the malaria control programme in Kenya such as the change in the treatment policy as well as the introduction of the Affordable Medicines Facility malaria (AMFm); the impact of HIV/AIDS in the fight against malaria; new knowledge and best practices in health communication; and changes in the Kenya communication context over the last decade or so. viii Division of Malaria Control. Malaria Communication Strategy

11 1 General Background And Programme Malaria is one of the most serious public health problems in Kenya, affecting millions of people every year. Despite considerable efforts to control and treat the disease, the most recent Kenya Demographic and Health Survey (KDHS) (KNBS 2010)1 estimates that about 24 million Kenyans are at risk of infection each year, with the most affected being pregnant women and children. Malaria is reported as the primary cause of ill-health accounting for 30% of all outpatient attendance and 19% of admissions (DOMC, 2007), and is still a leading cause of death in children under five. The Division of Malaria Control (DOMC)2 estimates that 29% of the Kenya population lives in malaria endemic zones, with millions more exposed to the seasonal transmission of the disease. Malaria in pregnant women contributes significantly to negative outcomes for the mother and baby, including anaemia, low birth weight and infant deaths, and it is one of the most common causes of spontaneous abortion. In addition, the ill health associated with the disease exacts a devastating toll on social and economic productivity, undermining local development in some communities. Over the years, the government, through the Ministry of Health, has made malaria control and management a high priority. This commitment has been articulated in several government documents and plans, including the National Health Sector Strategic Plan (NHSSP) I and II, and Vision The DOMC has since its establishment implemented malaria control interventions as outlined in its operational documents, including the National Malaria Strategy (NMS) and the National Malaria Policy. These interventions include Figure 1: 2009 Kenya Malaria Risk Map case management; management of malaria and anaemia during pregnancy; vector control; and epidemic preparedness and control. The current national malaria strategy ( ) has carried on the emphasis on these interventions, and set targets to be achieved under each in the 8-year period. The communication challenge Kenya has made significant gains in fighting malaria in the last few years, under the leadership of the DOMC with the support of the different stakeholders and partners. In April 2001, the DOMC developed a 5-year Information, Education and Communication (IEC) implementation plan to support the NMS. The plan focused on broad IEC approaches in support of the four NMS strategic approaches at the time. To support its implementation, a communication strategy was developed to provide a broad framework to guide communication efforts for 1. KNBS and ICF Macro Kenya Demographic and Health Survey Calverton, Maryland 2. Division of Malaria Control Kenya Malaria Indicator Survey. Nairobi 3. DOMC (2006). Malaria Communication Strategy. Ministry of Health Division of Malaria Control. Malaria Communication Strategy

12 malaria control and support the implementation of IEC activities. However, anecdotal reports indicate that this strategy was not rolled out and implemented as expected. Several reasons were given for this, including lack of finances to support its dissemination and systematic implementation. To build on these past achievements and meet the specific goals under the current National Malaria Strategy, the DOMC requires a wellplanned and locally appropriate communication strategy. The 2009 Programme Performance Review recommended that the communication strategy be reviewed and updated to ensure that it responds well to current priorities. The revised/updated strategy will aim to support the key objectives of the malaria control programme as outlined in the national strategy. There has also been changes in the malaria control programme in Kenya that need to be reflected in a new communication strategy. For instance, since the strategy was drawn up in 2006, Kenya s treatment policy has changed from use of SP/ Fansidar medicines to the more effective Artemisininbased Combination Treatment (ACTs). To enhance access to ACTs, the Affordable Medicines Facility malaria (AMFm) was launched in The revised communication strategy needs therefore to include activities to promote the AMFm. There has also been a slight change of focus in the Kenya malaria programme, from increasing use of LLINs by the population most at risk of malaria (pregnant women, children under five years of age and people living with HIV/AIDS) to more emphasis on universal coverage (one net for two persons). There is also need to increase awareness and uptake of IPT as part of focused antenatal care and to promote acceptance and demand for indoor residual spraying. The government has also recently created the Division of Child and Adolescent Health, opening new possibilities for an expanded programme for malaria-free schools initiatives through its school health activities. In addition, in keeping with recent political developments in Kenya, the Division of Malaria Control will be decentralising its activities to county and district level, and this too needs to be reflected in the new communication strategy. HIV has also presented an additional challenge that must be taken into consideration in the fight against malaria. A report by UNICEF4 highlights this challenge and cites evidence showing strong interaction between Malaria and HIV. One of the key findings as presented in the report is that adults and pregnant women living with HIV in malaria areas face a higher risk of symptomatic malaria infection as HIV suppresses immunity. HIV infection may also lower the efficacy of malaria treatment. The report further argues that malaria increases the viral load in HIV-positive people, which can be detrimental to their overall health UNICEF Malaria and Children Progress in Intervention Coverage Division of Malaria Control. Malaria Communication Strategy

13 Changes in the Kenya communication context since 2006 have opened up new avenues and challenges for malaria communication, which need to be reflected in an updated strategy. For instance, opening up of regional radio services, regional newspapers and increased use of cellular phones has made it possible for programmes to communicate with more specific audience groups. Availability of marketing and media consumption data and services has also made it possible to segment audiences in more detail. Finally, the new/revised communication strategy needs to reflect new and current knowledge and best practices in public health communication. In the last ten years, there has been a steady shift from purely IEC/product-oriented activities to more process-driven strategic behavioural communication approaches. These allow for a more flexible approach for better identification of specific target behaviours and barriers, and suggest communication activities, key messages and support services needed to achieve and sustain the desired new behaviour. In recognition of the fact that behaviour change is sometimes dependent on the broader social context, a more integrated strategy that encompasses advocacy, communication and social mobilization (ACSM) is now preferred, to bring about sustainable social and individual behavioural change. A report on the 2009 EARN (Roll Back Malaria) mission to Kenya recommended that the DOMC communication activities shift focus from IEC to the broader ACSM, and to reflect the best practices in public health communications. Advocacy primarily targets public leaders or decision-makers; communication generally targets individuals or sub-populations in the public; and social mobilization aims to secure support from the broad public and specific communities. Used together, the interventions are believed to produce more lasting change. This updated communication strategy provides the framework for this integrated approach. Division of Malaria Control. Malaria Communication Strategy

14 2 Communication Needs Assessment Assessment of the current situation In order to inform the development of this communication strategy and to ensure it fully supports the National Malaria Strategy , an assessment was carried out to establish the current situation and practices around the key areas that are the focus of the National Malaria Strategy prevention and control; and effective case management. The assessment also sought to establish the current activities and priorities in advocacy, communication and social mobilization around the key focus areas and the gaps that need to be addressed through this strategy. The assessment involved a review of available published literature, reports and documents from the Division of Malaria, and key informant interviews with individuals selected with the assistance of the Division. Following is a summary of the findings, and a discussion of the implications of the findings on the Communication Strategy. The assessment found that knowledge of malaria illness (transmission, symptoms, and complications) and use of bed-nets as a prevention measure has been consistently high in different parts of the country. For instance, Njoroge FK et al (2009) found that majority (86.9%) 5 of pregnant women attending antenatal clinics in Kilifi had adequate level of knowledge around malaria transmission and prevention. Opiyo P et al ( ) found that 96% of respondents in a study conducted in Rusinga Island knew that young children were at highest risk from severe malaria; 76% also knew pregnant women were also at high risk. In the same study, 95% of respondents correctly identified common symptoms of malaria onset. A similar proportion knew what caused malaria (mosquito bites). Findings on prevention and vector control The National Malaria Strategy ( ) targets that by 2013; at least 80% of people living in malaria risk areas should be using appropriate malaria prevention interventions including LLINs. The strategy promotes four main approaches to malaria prevention: Universal coverage with long lasting insecticidal nets (LLIN) including the malaria free schools initiative Indoor residual spraying Providing intermittent preventive treatment (IPT) in pregnancy; and Other integrated vector management strategies However, knowledge of malaria transmission and acquisition is commonly not matched with corresponding protective behaviour even in high malaria risk zones. For example, although in several studies bed-nets were often mentioned, use was generally found to be modest. The Kenya Demographic and Health Survey 2008/2009 indicates that while 61% households in the nationwide survey had at least one net, only 47% of children and 49% of pregnant women who slept under a bed-net used an ITN. Opiyo et al found that only 58% of respondents in the Rusinga Island study used bed-nets, and only 37% had slept under one the night before the survey Njoroge FK, Kimani VN et al. Use of insecticide treated bed nets among pregnant women in Kilifi District, Kenya. East Afr Med J Jul; 86(7): PubMed abstract accessed online 6. Opiyo, Pamela, Richard Mukabana et al. An exploratory study of community factors relevant for participatory malaria control on Rusinga Island, Western Kenya. Malaria Journal 2007, 6:48. Open Access Division of Malaria Control. Malaria Communication Strategy

15 Findings on low use of nets were corroborated in interviews with stakeholders, some of whom felt that distribution of nets has not been accompanied by adequate instructions on how to use them: The challenge [with nets] comes... with them sleeping under these nets. They go to the clinic and they are given nets... when they go to the house, they realize, hey, this net has four corners, my house is a thatched roof and it has a really high ceiling I can t be able to hang it... So you find that there are actually issues when it comes to the usage of nets... My children sleep on the floor, how do I hang this net in a way that is not going to be so cumbersome for me? (Key informant) Other key informants expressed concern that in some communities, symptoms of complicated malaria such as convulsions and coma often are not associated with malaria, and instead are attributed to curses and witchcraft. Such misconceptions affect the subsequent case management behaviour. The National Malaria Strategy emphasizes on vector source reduction to sustain gains made from indoor residual spraying. However, research shows that although most communities are aware that removal of stagnant water helps control mosquito breeding, this is not widely practised. The Rusinga Island study found that although 33% of respondents knew this as a form of controlling mosquito breeding, there was no corresponding action. In addition, only 16% used insecticides in the house, although there was high level of awareness among the respondents. One key informant revealed that there have been challenges with Indoor Residual Spraying as a prevention measure, because it has not been widely accepted by the local communities: One [complaint] being that the chemical we use has an irritating smell.... The chemical also does not stop the mosquitoes coming to the house and also does not kill other pests like cockroaches. Other concerns expressed include community members reticence at allowing strangers into their homes, and re-plastering of walls in some villages, eroding the protection offered by the spraying. IPT in Pregnancy: Government policy directs that all pregnant women in malaria endemic areas attending antenatal care services should access at least two or more doses of SP/Fansidar medicines as a preventive measure against malaria infection. However, the KDHS shows that only 14% of pregnant women reported receiving IPT; Gikandi PW et al 8, in a community survey in four districts of Kenya, found that only 22% of women who had attended antenatal clinic took two or more doses of IPT-SP. Some key informants felt that IPT in pregnancy is undermined by women s tendency to start ANC visits too far into their pregnancy, such that giving them the recommended doses becomes a challenge. Other reasons given for poor uptake of IPT in pregnancy include local beliefs against discussing pregnancy in its early stages; and poor attitude of providers to mothers who show up at the clinics late into their pregnancy. Sometimes [IPT] is not seen as a priority for pregnant women; birthing issues take precedence even with clinic staff (Key informant). Findings on malaria case management Effective case management of malaria depends on early, accurate diagnosis with blood tests and prompt treatment with an effective medicine. In the 7. KNBS and ICF Macro Kenya Demographic and Health Survey Calverton, Maryland 8. Gikandi PW, Noor AM, et al. Access and barriers to measures targeted to prevent malaria in pregnancy in rural Kenya. Trop Med Int Health Feb; 13(2): PubMed Abstract. Division of Malaria Control. Malaria Communication Strategy

16 National Malaria Strategy , it is anticipated that by 2013, 80% of all self-managed fever cases will be receiving prompt and effective treatment, and that all cases seeking services at health facilities will receive appropriate diagnosis and effective treatment. However, the findings of this assessment indicate that given the current situation, a lot of effort will need to be made to achieve this objective. Access to Treatment Kenya changed the treatment policy to the more efficacious ACTs in Although the medicines have been available since then, the recent KDHS showed that only 8% of children who got treatment for malaria received ACT medicines, and only 4% of these obtained it on same day or next day. Programme documents from the DOMC also show that access to ACTs has remained low, at 29%, and only in 15% of the cases is the treatment sought within 24 hours. It is evident from studies conducted in various parts of the country that many Kenyans choose to treat malaria infection first at home without going to a health facility, only visiting the health care centre when the illness becomes severe. A review of literature by Chuma Jane, Timothy Abuya et al ( ) found that in general, most people self-treated first, and then either sought help from formal health facilities or traditional healers, or used a traditional remedy at home. It appears that most people seek treatment from the health facility on average two days after the onset of symptoms; Nyamongo ( ) found that patients in Kisii delayed seeking treatment from health facility to minimise expenditures incurred as a result of the sickness. Even in cases of children, seeking treatment from the health facility is delayed a study in Bungoma found that 47% of children under 5 years with fever were treated at home and only received the treatment on the second day after the onset of the symptoms. According to the DOMC documents, there have been improvements in the proportion of children with fever seeking treatment from health facilities, but few seek treatment within 24 hours. Sumba Peter et al, ( ) did find that adults in a study in Nandi District were more likely to seek treatment within a day (24hrs) of onset of malaria symptoms for themselves than for their children. In this particular study, the most common source of first treatment for self-diagnosed malaria in both children and adults was the health facility. This differs from findings from trends in other regions, where high tendency to treat malaria at home first with either over-the-counter medicines or medicines left over from a previous malaria episode has been observed. Diagnosis Monitoring Outpatient Malaria Case Management under the 2010 Diagnostic and Treatment Policy in Kenya January 2010 report revealed that 23% of patients were tested for malaria prior to treatment across all facilities. In facilities with diagnostics, 42.5% of patients were tested. Th low testing rate is further compounded by the none adherence of health workers to test results in that 52% of test negatives receive AL and 635 of all patients who were not tested also got AL as per the same quality of care survey January Regarding laboratory testing to confirm malaria, some key informants felt that it was not popular and confirmatory diagnosis Is therefore not often requested for because people tended to think they can tell when they have malaria, especially in malaria-endemic areas. This is worsened by health workers who do not, in a majority of cases, insist on 6 9. Jane Chuma, Timothy Abuya et al. Reviewing the Literature on access to prompt and effective malaria treatment in Kenya: implications for meeting the Abuja targets. Malaria Journal 2009, 8:243. Open Access 10. Nyamongo IK. Health care switching behaviour of malaria patients in a Kenyan rural community. Institute of African Studies, University of Nairobi. PubMed abstract accessed online 11. Hamel, Mary J, Amos Odhacha et al Malaria Control in Bungoma District: A survey of home treatment of children with fever, bed-net use and attendance at antenatal clinics. Bulletin of the World Health Organization No Peter O Sumba, S Lindsey Wong et al. Malaria treatment seeking behaviour and recovery from Malaria in a highland area of Kenya. Malaria Journal 2008, 7:245. Open Access Division of Malaria Control. Malaria Communication Strategy

17 tests: Health workers are themselves not all that convinced of the need for [laboratory testing] so will tend to diagnose based on the presentation of symptoms. (Key informant) Types of medicines used in treatment Kenya introduced the more effective artemisininbased combination therapy (ACT) in 2006 as part of its malaria treatment package, replacing SP medicines as first line of treatment medicines. The current malaria strategy promotes increased access to ACTs through the AMFm facility. However, although the medicines have been available since then, the recent KDHS showed that only 8% of children who got treatment for malaria received ACT medicines, and only 4% of these obtained it on same day or next day. The Malaria Indicator Survey 2010 showed that of all antimalarials prescribed, amodiaquine was highest at 35.2%, ACT followed at 28.7, SP was at 11.2 and other antimalarials at 13.8%. Chloroquine and Quinine were also used to manage uncomplicated malaria at 7.5% and 3.6% respectively. Programme documents from the DOMC also show that access to ACTs has remained low, at 29%, and only in 15% of the cases is the treatment sought within 24 hours. Although the GoK provides ACTs in public facilities for free, Chuma et al cite a study that showed that they are not given to clients, even when in stock, for a variety of reasons, including fear of stock-outs and providers own biases regarding which patients deserved to get it due to its perceived cost. Other findings regarding ACTs include the following: Stock-outs means that the medicines are sometimes in short supply, which can undermines access to it in health centres. The government has mainly concentrated training, support supervision and advocacy efforts on the public and mission sector leaving out private practitioners who as per the malaria indicator survey 2010 constitute a third of treatment seeking options vis a vis the public sector which constitutes 59%.Chemists and other medicine vendors continue to prescribe malaria medication even though they are not trained to do so, posing a risk to correct use and adherence to medicines. In addition, ACTs have been perceived as generally expensive for the health sector: Current prices for the medicines in private facilities is prohibitive and affects their uptake; in some cases, the medicines cost over Ksh 600 per dose which is unaffordable to most people (key informant). According to Dr Desmond Chavasse of Population Service International, the high cost of the medicines could threaten the fight against malaria 13. However, it is expected that the AMFm facility will make the medicines available to more Kenyans who seek treatment in private health facilities and pharmacies, where they will now be available at a much reduced cost. Adherence to malaria treatment Improper use of treatment medicines has direct impact on their effectiveness, and could lead to future resistance. Unfortunately, it appears that malaria treatment generally has high levels of non-adherence clients do not take medicines as prescribed and inappropriate use is widespread, regardless of where the treatment was obtained. Chuma et al found in their literature review that only 12% of clients reported proper use in home treatment; only 2% of children in Kilifi given chloroquine bought from shops got the adequate dose. More often than not, adherence instructions are not followed; 40% Division of Malaria Control. Malaria Communication Strategy

18 of caretakers taking children for malaria treatment at a health facility in one of the studies reviewed by Chuma et al could not recall the correct dosage instructions moments after leaving the pharmacy. In relation to ACTs, it was found that some clients continued to prefer the older SP medicines because of their perceived simple dosage (ACTs were considered cumbersome). Key informants interviewed also gave this as a reason for poor adherence: Once they are given this medicine [AL], the adherence to the three day dosage, when you are given the regime of how you are supposed to take the medication, you find that some of these rural women get challenged in terms of if they are supposed to wake up at night and give their child medicine. Because there is the 8 hours, then 12 hours, the morning and evening and so it becomes a challenge. (Key Informant) Key challenges and implications on the communication strategy In summary, the results of the assessment show the following behaviours are still persisting, which will have to be addressed through the communication strategy: Prevention and vector control: Despite high knowledge of malaria (transmission, symptoms, complications), low use of the insecticide-treated bed-nets persists. Lots of people, including less than half of young children and pregnant women in malaria zones are still not using nets correctly and consistently. The communication activity will build on the existing high awareness levels to help communities move to practising protective behaviours consistent and appropriate use of LLINs. Environmental management the communication strategy will address the lingering challenges of draining stagnant water to reduce mosquito breeding grounds, and also dispel the misconceptions around clearing of bushes. Indoor residual spraying - there were expressed concerns that some communities have not fully understood the protective benefits of IRS, and there are concerns about some of the products used for spraying. The communication strategy will address these, and promote acceptance of IRS in the areas where it is being offered. Malaria in pregnancy*: The assessment results show poor uptake of IPT in pregnancy, attributed to general poor attendance for antenatal services, and the tendency to present for ANC late in the pregnancy. The communication strategy will address this with messages specifically targeting mothers and community in areas where IPTp is recommended, and promote early initiation of antenatal care, and making at least four visits during the pregnancy. The strategy will also address fears around taking malaria medicines while pregnant. Case Management Recognition of malaria symptoms and delay in seeking treatment is still a concern. The communication strategy will seek to increase correct symptoms recognition, and encourage early initiation of diagnosis and treatment, as well as acceptance and demand of laboratory diagnosis. 8 *Only Applicable in Western, Nyanza and Coast Provinces Division of Malaria Control. Malaria Communication Strategy

19 The communication strategy will also address medicine adherence promote correct use of medicines, discourage discontinuation before the dose is complete. ACTs the assessment showed that there is need to increase awareness of ACTs in local communities, and among service providers, and to address concerns about their effectiveness, affordability, and access. Health workers should practice diagnosis based treatment hence there is need to increase testing rate and adherence to test results so that only test positives are treated and the negatives investigated further for other illnesses. Private practitioners (30%) and shops (12%) still constitute a large proportion of treatment seeking options ( MIS 2007) Current treatment seeking behaviour in communities is heavily tilted towards home-treatment, including for children. The communication strategy will address the need to visit a health facility to receive a correct diagnosis through laboratory testing, and to receive the approved treatment. The communication strategy will also need to address service provider concerns and increase their awareness that ACTs are the recommend first-line treatment medicines for proven malaria, and not any other medicines. The perception that ACTs have complex dosage instructions will also need to be addressed so clients understand how to use them easily. The strategy will also support the public education activities around ACTm-branded medicines, and will include advocacy messages/ activities to ensure sustainable supply of the right medicines in the healthcare system. Other factors identified through the assessment that need to be considered in the design of the communication strategy include the following: Length of communication campaigns - there has been lack of continuous/sustained messaging about malaria in the past; longest campaign lasts 3-6 months, not long enough to produce lasting change in attitudes and behaviour. Using local terminologies for fever and malaria is important, and taking into consideration low literacy levels in some communities. A study in Division of Malaria Control. Malaria Communication Strategy

20 Tanzania 14 concluded that the lack of a local term for IPT had probably led to the low awareness of it among women who had received ANC services. and resources so that universal distribution of LLINs is not disrupted, and can be sustained through government s own funding. Direct communication with community members will be needed, to influence treatment-seeking behaviour, and clarify the need for lab testing. Some patients were reported to confuse tests for HIV and malaria because they both require drawing blood. Focusing on men through messages specific to them is important because they have influence on their families decisions around malaria. Disseminating the Ministry of Health s policy treatment guidelines to all health workers health workers will need to access and understand the current treatment guidelines and how to apply them. 2. Improved distribution of LLINs through integration into all health and social services including maternal and child health services; school system; community networks and all public health campaigns. The DOMC needs to secure and increase resources for public health education through leveraging resources and skills available in partner agencies and other government departments. 3. The availability of Indoor Residual Spraying DOMC needs to secure more resources to expand it beyond the current coverage and to increase community acceptance, sensitize leaders in IRS regions and use them to educate their communities. It may be necessary to use community medicine vendors as a special channel of communication and information dissemination relating to malaria case management. Other findings that have implications on the communication strategy Advocacy The assessment also highlighted the following issues that the DOMC needs to address through sustained advocacy and communication: 1. Continued support for universal distribution as part of the public health programmes: It is important that the DOMC secures commitment 4. ACTs continued advocacy is needed to sensitize policy makers and leaders on the need to further reduce costs of the medicines, and to allow rapid diagnosis kits into the hands of the communitybased health workers, to increase access to proper diagnosis. Stakeholders currently implementing malaria activities in Kenya The Division of Malaria currently coordinates a wide network of partners involved in malaria control and management activities through the various working groups. These networks are part of the existing systems and infrastructure that the Division can leverage in implementing the communication strategy for better results Mushi, Adiel, Joanna Schellenberg et al Development of a BCC strategy for a vaccination-linked malaria control tool in southern Tanzania. Malaria Journal 2008, 7:19. Open Access Division of Malaria Control. Malaria Communication Strategy

21 3 The Communication Strategy Vision A malaria free Kenya Purpose This communication strategy is aligned to the objectives of the National Malaria Strategy and supports their achievement through the following approaches: Communication, to build on current high levels of knowledge about malaria prevention; create awareness about appropriate case management and health care seeking behaviour, while addressing barriers to change in attitudes and practices identified in the situation analysis. The strategy defines the approaches that will be used to reach the targeted audience for maximum benefit and participation in malaria prevention, treatment and control. Advocacy, to secure leadership and commitment of stakeholders at all levels, and to strengthen the multi-sectoral response to malaria control. Social mobilization, to ensure local communities participation in malaria control initiatives and continued public education; Communication to support the launch and implementation of the Affordable Affordable Medicines Facility malaria (AMFm) Goal and anticipated outcomes This strategy supports the achievement of the objectives of the National Malaria Strategy by ensuring that by 2013 at least 80% of people in malaria-prone areas will have adequate knowledge, right attitude and behaviour on prevention and management of malaria. Anticipated outcomes Increased demand and use of LLINs Improved uptake of IPT in pregnancy in malaria endemic zones Increased numbers of people seeking prompt, appropriate treatment with the right medicines within 24 hours of onset of malaria symptoms Improved adherence to prescribed treatment by clients Increased acceptance of Indoor Residual Spraying in communities Increased involvement of local communities in malaria control Strategic Approach The ACSM model evolved from development programmes, where it has been used for social transformation. The three components advocacy, communication and social mobilization - link to bring about and sustain desired new outcomes in individuals and the community, and can be perceived as follows: Division of Malaria Control. Malaria Communication Strategy

22 Table 1: Strategic Approach Advocacy Communication Social mobilization Government and partners make malaria control high priority Government and partners ensuer adequate and consistent supply of resources for malaria control and treatment Government develops policies supportive of stronger malaria prevention, control and treatment activities. Communication learn about malaria prevention, symptoms, risks, and correct management, and adopt appropriate behaviour People with malaria-like symptoms seek prompt and appropriate care Communication work with the government and partners to adopt measures to eliminate malaria infections Communications take responsibilty to ensure appropriate malaria prevention and treatment in their location The needs assessment revealed that while knowledge and awareness of malaria, its causes and consequences are high among the populations living in malaria zones, practice of the key protective behaviours promoted by the Malaria Control Programme is not as widespread. The choice of communication activities and key messages in this strategy targeting malaria prevention, control and management are therefore informed by primarily by the Health Belief Model, which recognises and addresses people s perceptions of disease threat, and the recommended behaviour for preventing the problem. It is helpful in understanding people s inaction or non-compliance to new health behaviours, and in identifying the messages that can persuade individuals to make healthy decisions. The key elements of the model 15 and their application to key messages are as follows: Table 2: Key Elements of the Model Belief Concept Perceived susceptibility one s opinion of risk of getting a condition Perceived severity one s opinion of seriousness of a condition and consequences Perceived benefits one s opinion of the effectiveness of the recommended action to reduce risk or severity of condition Perceived barriers- opinion about tangible, psychological, social costs of taking the recommended actions Cues to action strategies to encourage action Self-efficacy confidence in one s ability to take the recommended action Application to malaria communication Provide key messages on prevention and control measures Provide key messages on consequences of untreated malaria, and/or using wrong medicines Provide information on diagnosis and proper treatment Address fears and misconceptions around adopting the recommended preventive behaviour including IPT in pregnancy Provide info on where to get recommended treatment, about affordability and ease of use of the recommended medicines Provide info on preventive measures, where to get treatment, how to use treatment; how to manage environment Messages that explain ease of use of medicines; demonstrate how to use LLINs correctly; Source: Glanz, Karen, Barbara Rimmer and Sharyn Sutton Theory at a Glance A guide for health promotion. National Institutes of Health, Bethesda, (adapted from the ACSM Framework for TB, 2006, WHO): Division of Malaria Control. Malaria Communication Strategy

23 Key Audiences The following are the primary and secondary audiences for this communication strategy. PRIMARY AUDIENCE 1. The general population and communities living in malaria-prone areas in the country. To encourage widespread use of LLINs and increase the general awareness of the malaria menace, it is important to have communication activities that target the general population. 2. Pregnant women living in malaria risk areas: Pregnant women in highly endemic areas can be asymptomatic of malaria infection and may not recognise that they are at risk group for malaria. SECONDARY AUDIENCE 1. Health service providers - nurses, clinicians and laboratory technicians. They are an influential source of information to communities, and their knowledge, attitudes and behaviours can affect uptake of services and their role in the community. 2. Community leaders. This includes village elders, chiefs, elders, religious leaders and politicians/ political players. They have influence on what their communities do, and can play a significant role in encouraging the adoption of protective behaviours in the malaria programme. They are also usually better skilled and educated and can be a useful channel for delivering information to the rest of the community. 3. Care givers in households with children less than five years in malaria endemic zones. Children under five years are the most vulnerable group to malaria. Caregivers are critical to significantly reducing illness and death in infected children. Caregivers need communication to improve symptoms recognition and the subsequent careseeking behaviour. 4. Heads of households in malaria areas. Particularly targeting men as they play a critical role in their family s decisions around healthcare, including providing money for travel to health care facilities for treatment. They can also have a positive influence on their families use of LLINs, acceptance of IRS, and can influence their wives ANC attendance behaviour. 3. Community health workers this includes community health workers, village health volunteers, extension workers, and public health technicians. As Level 1 service providers, they are in close touch with the community and can influence their behaviour significantly. 4. Pharmacists they provide an important first contact with the community members and can be useful channels for disseminating information about correct case management. 5. Members of District Health Management Teams in malaria-prone and risk districts it important that they understand the key issues around malaria prevention and appropriate treatment so that they can include promotion activities in their work-plans Division of Malaria Control. Malaria Communication Strategy