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UNICEF’s communication for development activities for malaria

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1 UNICEF’s communication for development activities for malaria
(C4D MAL) Valentina Buj, Global Malaria Advisor Health Section, UNICEF RBM CCOP Meeting September 2016

2 What is C4D? Communication for Development (C4D) is one of the most empowering ways of improving key social outcomes for children and their families. In UNICEF, C4D is defined as a systematic, planned and evidence-based strategic process to promote positive and measurable individual behaviour and social change that is an integral part of development programmes, policy advocacy and humanitarian work. C4D uses dialogue & consultation with, and participation of children, their families and communities. It privileges local contexts and relies on a mix of communication tools, channels and approaches to encourage a two-way dialogue and maximize everyone’s potential to be an agent of change. UNICEF’s C4D approach tailors messages to the circumstances of different groups and is intended to impart immediate and long-term benefits. It encourages inquiry and participation by women, children, community leaders, traditional healers, health workers and other key groups. Is based on human rights principles of inclusivity, equity and universality “Social transformation” is an evolving term. Current understanding in UNICEF is that social transformation is the outcome we hope to achieve when systems, policies, institutions, services, supplies, human resources are in place – the SUPPLY SIDE of our programming - and people in society at all levels - the DEMAND SIDE of our programming - initiate , access and demand services and participate in sustained actions that address positive behaviors: knowledge, attitudes and practices – that would ultimately transform into social norms, and other key factors that cumulatively promote good social practices, such as those related to malaria prevention, treatment and control and, many other behaviours that are in the best interests of the child. C4D always: -- Builds on lessons learned and on evidence to change behaviours across levels in society, to create a sustainable process of social change. -- Is a participatory process built on values-based strategies, messages and activities to promote social transformation. -- Supports changing health systems, public systems and social norms through ongoing efforts – not only short-term campaigns or one-off events. Given malaria’s disproportionate impact in developing countries and as agent of poverty: it is vital that vulnerable and marginalized populations (e.g., women with disability, nomadic populations, isolated communities, etc.) are given a voice as part of communication planning and implementation. An integrated approach that uses diverse media and channels to reach all intended participants at scale might include, for example, not only the national mass media or development and distribution of posters, but also --community media, --interpersonal communication during door-to-door visits or at the health centre, --puppet shows or street theatre and --the efforts of community leaders.

3 Objectives of the C4D approach: to create a dialogue leading to behavior change
Empower individuals/groups to implement local solutions Build relation and trust between communities and service providers Create demand through local-level advocacy and thereby ensure resource allocation and coordination by district directors, to create and sustain social transformation. From To Individual focused Community focused Message Dialogue Based on “knowledge to practice” paradigm: “people hear” Based on cognitive determinants (self-confidence, leadership, sense of collective efficacy): “people do” Beneficiaries Partners Agenda is imposed Agenda is agreed Close ended Open ended Elicit an organized participation by communities From “providing messages” to “facilitate discussion”, different communication tools and different competencies are needed From providing solutions to discussing solutions (on the adoption of EFP and on service provision). Deliberate creation of mutual accountability Community decides what to focus on. The surprise is that the focus remains pretty much the same…only that they feel responsible for it. Plan for the unforeseen. From “adoption of MILDA” to “adoption of priority practices identified by community” and increased empowerment Be clear and understandable: small, doable actions Be appealing, memorable – can hold attention of intended participants Be credible and believable Be acceptable and appropriate to local culture and language Be relevant to intended participants’ circumstances Address barriers, norms and beliefs in the community

4 Coordinating Across Levels to Effect Change
This figure illustrates how a C4D strategy works at each programme level to improve outcomes. This pyramid shows major components of the C4D process: Starting from base of pyramid at the bottom, behaviour and social change, at household level. Then we see social mobilization in the middle, orange level, with health facilities and communities and then advocacy, at the top of the pyramid in turquoise. Usually, for malaria control, primary participants for behaviour and social change are not only mothers and other caretakers but also everyone (for example, community leaders, elderly people, fathers and everyone who is well respected in the community) who can influence for example, that LLINs/ITNs are used, e.g., giving priority to children and pregnant women. Secondary participants are those who can influence the behaviours of the primary group. They are the actors in the social mobilization process; they include service providers, teachers, local leaders, community media, social networks,civil society organizations and organized networks. Includes governmental and non-governmental individuals and organizations, associations, social and religious groups, media and local influentials – all those who can influences the primary participants to change their behaviours and social practices collectively. Tertiary participants arethe audiences for advocacy, those who have the power to make decisions on policies, resource allocation, programmes and building structures. Outcomes of advocacy may include development of health facility and school policies that support pregnant women and children in using LLINs nets regularly and correctly. It includes advocacy for mobilization of resources. Tertiary participant groups for advocacy may include everyone from top to bottom and bottom to top: Head of state, prime minister, parliamentarians, key public servants; religious and traditional community leaders; social and business leaders, women leaders, civil society and NGO leaders; media executives and producers; companies/private sector; celebrities — everyone who may have positive influence on public opinion Remember - Each level of participant group requires different communication objectives and C4D approaches but messages and strategies should be harmonized across all levels.

5 UNICEF’s C4D approach incorporates 4 major steps
Assessment (Research) The key objective is to develop an in-depth understanding of: i) local cultures, values, needs, preferences; and ii) obstacles to access and use of treatment and prevention methods Examples of research methods are focus group discussions, direct observation and door-to-door surveys. UNICEF’s equity focus calls for special efforts to include marginalized or excluded groups. Analysis of qualitative and quantitative data that have been collected in the assessment phase Must be an analysis of both participants and behaviours discusses ideas to improve practices & implementation is feasible with the target communities identifies what messages & approaches resonate with different participant groups and then solicits additional ideas and feedback Design of the communication strategy Monitoring and evaluation These steps can: • Overlap and occur at the same time • Be revised regularly to address new information • Be adapted to meet needs of long-term process The assessment phase of the planning process provides time to learn about characteristics of families that do and do not use bed nets, and factors in their homes or communities that influence their behaviour • Ensure special efforts to include marginalized or excluded groups such as: Ethnic minorities; Religious minorities; women with disabilities; rural communities; Urban slum dwellers; nomadic communities and women in emergency or conflict situations. Involve them in planning and system-changing activities (e.g., changes in the social, political and community systems and power structures that are needed to support malaria protection behaviour—such as nightly use of ITNs—encourage suspicion of malaria and recognition of key symptoms and prompt care-seeking behavior). Community participation (including vulnerable and marginalized groups and older children) is one of C4D’s tenets. Identify suitable strategies for key participant groups through consultative process (diverse communication channels, messages and materials to reach all intended participants at scale). Based on identified motivators & leading to clear, feasible, measurable malaria protection and treatment objectives Make sure recommended practices are designed to fit women’s and families’ lives

6 Monitoring & evaluation is often overlooked in BCC capacity building: C4D M&E logframe
Highlights what is working with participant groups Identifies problem areas and why they are not working as planned Fixes problems during implementation Solicits continuous feedback from participants and their communities Evaluation: Baseline data (qualitative and quantitative) Ongoing monitoring mechanism and analysis Post-strategy/implementation survey Did we bring about positive changes in: Social norms & processes Power relations within different levels of society Policies, systems and funding Knowledge and skills Health and social practices It’s important not to confuse what you are doing (e.g., activities) with how you are doing (e.g., actual behavioural changes across levels). Behaviour monitoring gathers information for all levels of participant groups. Information is quantitative and measurable: For primary participant groups, it addresses some of the intermediate behavioural outcomes (e.g., attendance at group sessions, contacts with community groups, husbands’ and fathers’ practices in terms of ensuring their wives and children sleep under nets; grandparents who report that they urge their grandchildren to sleep under nets). For secondary and tertiary participants, it addresses the C4D activities that support bed net use (e.g.,communication sessions conducted using interactive skills, health care providers who counsel fathers and mothers on a regular basis, funds allocated for C4D, policies enacted, social mobilization conducted throughout the year). The information is collected as defined in the C4D M&E logframe, using a variety of methods as appropriate. These long-term changes in behaviour, and their impact on ITN use,health and development goals, are also the focus of the evaluation that is often done when a programme ends. The evaluation can repeat the KAP study that was done as part of the assessment. Monitoring and evaluation are measuring activities. That’s why it is important to have measurable objectives for desired behaviour changes and for the programme. Each of the first three activities on this slide measures something before, during and after the programme: The baseline study measures the situation that exists when your programme begins in terms of ITN use rates, other intermediate parameters and other social and cultural determinants. Ongoing monitoring and evaluation measure any positive or negative behaviour or social changes while the programme is active. The post-intervention evaluation measures the results of the programme. Social norms and social processes – examples: increased social support for involvement of fathers in child care, participatory approach to the definition of most needed community services in support of ITNs. Power within different levels of society – example: increased number of women from marginalized populations who recognize ITNs as a human right and feel entitled to ask questions and demand services that would support better practices. Policies, systems and funding – example: national or local policies that provide support and resources for distribution of nets. Knowledge and skills – examples: knowledge of how to prevent malaria or recognize the signs of malaria. Health and social practices – examples: more parents who ensure their children sleep under bed nets; increased number of district directors of health who allocate adequate resources to implement district-level communication activities. Together, M&E answer two questions: “How are we doing?” and “How did we do?”

7 Current UNICEF C4D actions for malaria
Current malaria strategies rely predominantly on individuals and communities to take action to protect and treat themselves. These include: hanging ITNs after appropriate instruction; and seeking treatment and diagnosis - especially at the community level. UNICEF is focusing on an integrated approach to the management of fever including increasing communities’ confidence in a negative malaria diagnosis such that they seek and receive the correct diagnosis and treatment for their child’s condition. Engagement and participation of different communities and social groups All malaria control interventions require community engagement and participation (especially vulnerable populations) to to facilitate the adoption of recommended measures; and to help advocate for increased access and government and donor support for these essential interventions. UNICEF therefore recommends that a participatory approach to communication be considered and included as part of the malaria control process “from the initiation of activities. ” Community health workers are a key part of the puzzle because they know the correct treatment and prevention methods and are valuable local trusted members of the community. UNICEF also focuses on communication to create “demand”—be it for nets, effective drugs or diagnosis—before, during and after the provision of all malaria commodities.

The C4D strategy was developed using: Findings from the 2007 Malaria Indicator Survey (MIS) Inputs from community stakeholders via a "Triple A" process (Assess the problem, Analyse its causes, and initiate Actions to improve the situation). Actions: Training of distributors and their supervisors Training of follow-up teams Training of community mobilizers (demonstrators) Community-based demonstrations Mass distribution of ITNs & Follow-up on the use of ITNs Participation and ownership Partnerships tapping into local structures, services and resources Project aimed to sustain changes by: Integrating all strategic processes leading to ITN use by children and pregnant women into the routine activities of local health care system Encouraging community involvement and participation This participatory process involved key stakeholders engaging in an ongoing interactive cycle that repeats the problem-solving sequence at different times in the campaign period, leading to regular modifications and improvements in the approaches taken. The communication campaign strategy included several key activities: Training of distributors and their supervisors A 10-day training for distributors and supervisors was conducted. The training focused on knowledge related to malaria and LLINs, functionality of bednets, proper usage and care of bednets, distribution process and logistics, specific roles and responsibilities of team members, data recording, interpersonal communication skills, and use of geographic positioning system (GPS) to map out households and areas where nets have been distributed. The distribution mode was pilot-tested in one village and modifications were made. Training of community mobilisation agents (demonstrators) A group of 10 community-based drama performers selected from local drama groups received a 2-day training about basic malaria knowledge, such as the definition, causes, prevention, symptoms, and detection of malaria. The training emphasised that the most vulnerable groups are children under 5 years of age and pregnant women. The information was drawn from UNICEF’s Facts For Life and other locally produced information material. The group created an interactive performance that portrayed messages about basic malaria knowledge, as well as demonstrated the proper use and benefits of using LLINs. Training about follow-up data Health Education Assistants, comprised of community health workers and members of the village health committees, received training on interpersonal communication and how to assess proper use of bednets using a house-to-house strategy. Their role was to check and assess knowledge and skills among the population and collect data on proper hanging, frequency of use, and care of bednets. Community-based demonstrations Demonstrations preceded bed net distribution in 33 communities, which were designed to prepare communities for and sensitise them about the upcoming mass distribution. In each village, demonstrators performed at local primary schools and during kgotlas, a public meeting where members of the community gather to discuss matters of interest for the community. The village traditional leader, also called the “kgosi,” presides over the "kgotla". The presentations were interactive - with performers engaging community members in a dialogue on issues related to malaria and benefits of using bednets. Mass distribution of nets followed soon after community demonstrations in each location. During distribution, each household was also provided with a poster calendar with peak malaria months shaded in. Following distribution, Health Education Assistants and Village Health Committee members conducted follow-up. As a follow up of the Okavango pilot in 2009, about 20,000 ITNs were also distributed in Ngamiland, another malaria endemic district. In 2010, the project was scaled up to the five malaria-endemic districts (Okavango, Ngamiland, Chobe, Boteti, and Tutume), where 96,000 bednets were distributed by July 2010. Development Issues:  Malaria, Maternal Health Key Points:  Malaria is one of the major public health problems in Botswana and is endemic in the northwest part of the country, mainly in five districts. According to the most recent Malaria Indicator Survey (MIS), in three of the malaria-endemic districts, 9.4% of households have at least one ITN. Only 6.5% of children under 5 years of age and 3.8% of pregnant women used an ITN to protect themselves from malaria. In response to this, Botswana has made the elimination of malaria a public health priority. According to UNICEF, the ownership of LLIN in Okavango increased from 12.6 % to 91 % after the intervention and the usage increased from 5.3% to 40% (MIS 2007; Okavango Pilot Evaluation Report 2009). They credit the evidence-based C4D strategies as a driving force and important factor for the successful LLIN distribution campaign. Key aspects of the C4D programme in Botswana are listed in this slide. Highlights included: • Training of distributors and their supervisors • Training of community mobilizers (demonstrators) • Training of follow-up teams. Health Education Assistants (community health workers and members of the Village Health Committee) were trained in interpersonal communication and how to assess proper use of bed nets using a house-to-house strategy. Their role is to assess knowledge and skills among population and collect data on proper hanging, frequency of use and care of ITNs. • Community-based demonstrations. Demonstrations preceded ITN distribution, meant to prepare communities for and sensitize them about mass distributions. In 33 villages covered, demonstrators performed at local primary schools and during community-wide gatherings where decisions are usually made by consensus. At these presentations, --performers engaged community members in dialogue on issues related to malaria and benefits of using nets, and --community members actively participated, coming forward to feel the net, hang it up and lie under it, experiencing its protective nature. • Participation and ownership. Participatory strategy engaged communities through use of community-based performers who did demonstrations in their own and surrounding villages. These events were highly interactive, and performers used local languages to disseminate messages in the different locations. • Partnerships, local structures, services and resources. The project was funded by the Ministry of Health, Okavango Sub-District and Clinton Foundation, which acquired ITNs through Malaria No More and UNICEF. Local participants included traditional leaders, clinics, community health workers and Village Health Committees in each village.

9 “Edutainment” Case Study: Madagascar
“I attended the performance with my children and my husband and we were very happy. This was the first time we saw this kind of a puppet show. We will definitely follow the advice we received through the performance so that we don’t get malaria. It was great ! When is the next performance ?!” Mrs. Naviviny, mother of three children, Anahidrano UNICEF undertook a C4D analysis and found that generally, rural audiences in Madagascar trust media as authoritative, reliable, objective and holding most potential for life-improvement; There is no perceived gender bias in radio content and radio use. Focus groups found that knowledge of malaria is fairly good among the target groups, except for some misconceptions regarding transmission. Intervention: a mix of interpersonal (home visits and village dialogue); mass communications (local radio); and “edutainment” approaches were chosen as the most effective way of communicating messages on malaria prevention and treatment. Edutainment is particularly effective at involving the community, and utilizes folk groups, puppet shows, and sports events as the main vehicles for communication These are complemented with other sectoral programme components related to HIV/AIDS prevention, child protection, parental education and young child development. C4D analysis Generally, rural audiences in Madagascar trust media as authoritative, reliable, objective and holding most potential for life-improvement; There is no perceived gender bias in radio content and radio use. Radio is the most common electronic media available. Television and internet are for the wealthy only at this stage, with only 9% penetration of TV in households, according to the last DHS. Newspapers are produced in Antananarivo and generally not widely available outside of the capital – rural illiteracy reduces potential large rural readership. Approximately 75% of media content is entertainment. There is a desire for “better and more local content” – especially educational content and development information. In terms of priority content for media consumers, health information is viewed as the second most important need after agriculture. Madagascar possesses a rich creative performance environment. It is proposed that as part of the C4D strategy a more intensive applied media and performance arts mobilization for child survival takes place. Madagascar seems to be a rich environment for the “edutainment” approach and this has proven to be the case for HIV/AIDS and WASH communication. Access to media was evaluated and 91% of the communes in the region have short wave and 63% FM radio coverage. Only 50% of the communes have public television coverage. In Sofia, NGO operated mobile video units have visited only 8% of the communes and a total of 27% of the communes have benefited from interpersonal communication initiatives of various NGOs, CBOs and associations. In Sofia, health authorities have reported very weak capacity and participation of community agents in behaviour change processes. A UNICEF assessment showed that the existing IEC materials are insufficient both in terms of quantity and quality to promote behaviour change. Focus groups found that knowledge of malaria is fairly good among the target groups, except for some misconceptions regarding transmission. Also, self-medication and seeking advice from traditional healers are practices which seem to take priority over a visit to the community health centre. The production of IEC materials and the identification/updating of messages were done based on the findings of the focus group discussions. As other malaria prevention communications had been undertaken in Sofia before, it was necessary to produce an inventory of the materials used in the region in order to update them based on the findings of the focus groups. The project relies on community participation to foster sustainability and ownership of the adopted behaviours. The community is involved at every step, from planning to actual communication activities, and monitoring and evaluation. The sensitization activities are ensured by a network of village animators. As the project’s main actors, they will be selected by the villagers themselves, which is also a way to develop the community’s responsibility. They will serve as volunteers and will sensitize the entire community on the malaria prevention package, on care-seeking for children under five with malaria, and on IPT for pregnant women. They will use a range of methods: interpersonal communication (home visits), village dialogue, sensitization days supported with the use of various IEC materials. The triple A approach proved to be very effective in developing a sense of responsibility and ownership among the communities. Indeed, it engages a wide range of community groups in the process: leaders, authorities, community members, and resource people in the fokontanys (administrative structure at sub-commune level). This small community evaluation (3A) is conducted at the beginning of the project in each fokontany, then every two months. The process helps the community understand the issues addressed by the project as well as the causes of the issues and involves the community in identifying solutions and subsequently planning and implementing the corresponding actions. The approach comprises three steps: Assessing the situation, Analyzing the problems and identifying and planning Actions to be undertaken. Results after 6 months: Increase from 39% to 72% of PW reported sleeping under an ITN the night before Increase from 14% to 37% of pregnant women received the second dose of IPT; and 88% of parents reported that a child should be brought to the basic health centre at the very onset of fever.

10 Mobile Phone Case Study: Kenya
UNICEF supported the dissemination of daily instructional text messages on malaria treatment to health care workers. A follow up study found that there was a 24% improvement in correct malaria case management among those receiving the messages compared to those not receiving the texts. The intervention was long-lasting as the improvement was found both immediately after intervention & 6 months later. A further follow-up study found that daily text messages: created an enabling environment that prompted health care workers to take action by implementing correct malaria case management practices; created demand among the participating health care workers for additional mHealth capabilities (ie. to manage severe malaria in children and malaria in pregnant women). Jones, C. O. H., B. Wasunna, et al. (2012). ""Even if you know everything you can forget": health worker perceptions of mobile phone text-messaging to improve malaria case-management in Kenya." PLoS ONE 7(6): e38636-e38636. The intervention was highly sustainable (as measured by cost-effectiveness) as the cost per additional child correctly managed was US$0.50 under study conditions; but would US$0.36 if implemented by the Ministries of Health in the same area, and estimated at only US$0.03 per child if implemented nationally.

11 Reaching Adolescents Case Study: Mozambique
Black Gold (Ouro Negro) is a serial radio drama in Mozambique designed to change behaviours that will improve children's health and development. It uses an entertainment-education approach to provide information, engender reflections and stimulate debate on child and maternal deaths, diseases, injuries, and violence. Priority areas include education, nutrition (including infant and young children feeding), hygiene and sanitation, HIV/AIDS prevention, maternal and child health, prevention of malaria, ending child violence and child marriage. Its primary audience is women aged 15-35, as well as caregivers and front-line service providers, such as community health workers, nurses, teachers, domestic helpers, and police officers.

12 Challenges Going forward
Increasing access Avoiding the use of the incorrect drug or incorrect dosage (increasing the quality drugs) Improving training of providers Increasing confidence in diagnosis Harnessing the private sector for good Stockouts – if demand is increased, supply must keep up Getting to elimination will require massive scale-up in terms of human resources & sustained financial investments plus Active case detection Containing insecticide and drug resistance Malaria hot-spots An effective malaria vaccine Improved health systems Improved infrastructure and delivery Roots of drug resistance

Experience in the field shows that ongoing attention is needed to maintain improvements in malaria control. C4D strategies should be flexible. They should be able to respond to changing practices and circumstances as well as people’s needs and preferences by changing the programme’s activities, messages, materials and communication channels as needed. By reporting data on behaviour and social outcomes and their impact on health and nutrition (evidence),malaria programmes can celebrate successes, address weak spots (feedback and problem-solving) and advocate for resources (support) to enable long-lasting results and system shifts. • Without continued attention and people’s involvement and participation, improvements in malaria control practices can be lost. Resources, opportunities, obstacles and constraints vary by country, but the four elements at the bottom of this slide apply everywhere. • Creating a cycle of evidence, feedback, problem-solving and support at local levels will help maintain high participation to ensure a continued capacity to encourage and support use of ITNs by children and pregnant women and early care-seeking behaviour in case malaria is suspected. feedback research through focus groups to find out whether people have heard and understood the messages and what the remaining obstacles to behaviour change are, as well as efforts to monitor the availability of commodities to ensure that the demand generated was met by sufficient supply. Ultimately, it is the behaviour of government officials and health care providers, NGO field staff, community volunteers, local political leaders and others that will support the malaria control behaviours of communities over the long term andmake supportive behaviours and policies commonplace—the expectation rather than the exception. EVIDENCE FEEDBACK PROBLEM SOLVING SUPPORT But simply providing correct information is not enough; the quality of health care and health care providers is also critical

14 Programme Planning: Communication Tips for Malaria Control
Integrate several communication channels: (e.g. edutainment followed by community discussions on the episodes followed by decision on how to reach people not exposed to TV) Facilitate participatory dialogue based communication rather than message based communication (need for different types of communication material and competencies) Promote community engagement (need for a deliberate effort to engage communities in a partnership) Integrate malaria prevention and care with other themes (people tend to lose interest in one theme only) Consider non-traditional channels that may be effective in the local context (e.g., shopkeepers in rural Kenya were trained to recognize malaria and dispense appropriate drugs). Portray positive social norms and gender roles for use of ITNs and seeking timely and appropriate care for malaria.

15 Resources Available: Core Communication Skills for Service Providers and Community-based Workers, Especially with Community Members: A Short Note for C4D and Other Programme Specialists in UNICEF. Webinar on integrating C4D into malaria programming

16 Thank You Merci Obrigado Melesi Asante Sana Twasanta Mani Matondo Wasakidjila wa bunyi
© Maggie Hallahan

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