Liberia Ministry Of Health National Malaria Control Program

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Liberia Ministry of HealthNational Malaria Control ProgramMalaria Communication Strategy2016–20201

Liberia National Malaria Communication Strategy 2016-202022

Liberia National Malaria Communication Strategy 2016-2020ForwardMalaria is endemic in Liberia and the entirepopulation of more than four million is at risk.Children under five and pregnant women are themost affected groups. According to data from therecent Health Facility Survey, outpatient and inpatientdeaths due to malaria have decreased since 2005.Even so, there are still challenges that affect progress.Coverage of intermittent preventive treatment formalaria in pregnancy has decreased since 2011.1The fourth Liberia National Malaria Strategic Plan(NSP) for 2016–2020 addresses the need to scaleup malaria control and prevention activities to buildon gains made under the Millennium DevelopmentGoals and to continue making progress under thenew Sustainable Development Goals (SDG). This newNSP addresses gaps observed in the implementationof the 2010–2015 Strategy and puts forth a moredetailed budgeted strategy dealing with the malariasituation in Liberia by these target dates. Given thelessons learned from negative effect of the EbolaVirus Disease (EVD) on malaria programming, the NSPincludes a plan to ensure malaria control activitiesare able to continue with minimal disruptions in theevent of an emergency.The objectives and activities set out in this documentreflect the priorities and goals of World HealthOrganization (WHO), the Roll Back Malaria Partnership(RBM), and the President’s Malaria Initiative (PMI). Bestpractices and successes from other African countrieswill also inform the scale-up of future malaria controland prevention measures, from the health facilitydown to the community level. In addition, a new focuson private sector involvement will increase broadercoverage of health-care delivery in Liberia.Three broad strategies make up Liberia’s renewedcommitment to malaria prevention and control.The first strategy refers to a more effective malariacontrol and prevention and focuses on improvedtreatment through scaled up availability and use ofArtemisinin-based Combination Therapy (ACT) asthe first-line treatment for malaria. The scale-up isthree-tiered: firstly, making fixed-dose combinationtherapies available in all health facilities, and training1 Liberia Demographic Health Survey. 2013health staff in their use; secondly, reinforcing therole of the community health committees and theirhealth workers by providing malaria control toolsand training these workers for their tasks; and thirdly,making the same ACT drugs available in the privatesector, among private health care providers, and inpharmacies and medicine stores. All the above willbe backed by parasitological testing of all suspectedmalaria cases before treatment in line with the WHO3Ts: All suspected malaria cases be tested beforetreatingOnly parasitological confirmed malaria be treatedTrack malaria testing and treatment to guageprogress made on reducing malara burdenThe second strategy is a vector-control approachthat is also three-tiered. Vector-control activitieswill provide long-lasting insecticide-treated nets(LLINs) through mass distribution to all family unitsand routine distribution to pregnant women atantenatal visits and institutional delivery-to ensurepregnant women and newborn babies continue tobe protected from malaria in between mass universalcampaigns. The strategy will also continue targetedindoor residual spraying (IRS) of households andwill consider other vector management strategies ofenvironmental control to achieve maximum results.The third strategy will focus on malaria in pregnancyinterventions. Liberia’s newly updated NationalGuidelines for Malaria in Pregnancy (2015) followsWHO recommendations on timing, frequency, anddosage protocol (the first dose as early as possiblein the second trimester and subsequent doses givenone month apart until delivery) for intermittentpreventive therapy for malaria in pregnancy (IPTp).2Social and behavior change communication (SBCC)activities to prevent and control malaria in pregnancyinclude encouraging pregnant women to sleep underLLINs, increasing the number of pregnant womenwho receive maximum coverage of IPTp, and ensuringprompt testing and treatment seeking for fever.2 World Health Organization. WHO policy brief for theimplementation of intermittent preventive treatment of malariain pregnancy using sulfadoxine-pyrimethamine. 20133

Liberia National Malaria Communication Strategy 2016-2020The National Malaria Control Program (NMCP) willalso work to identify coordinating mechanisms,surveillance systems, and social mobilizationresponsibilities during emergency response. Thisemergency preparedness emphasis does not changehow social mobilization operated during the EVDoutbreak, but it does lay out guidance and a seriesof considerations that will allow malaria activitiesto continue alongside those related to emergingthreats and emergencies. It is hoped that furtherdevelopment of a platform for addressing routineand emergent needs for social mobilization will alsoprepare the NMCP to engage in pre-eliminationefforts in the future.The purpose of the Malaria Communication Strategy2016–2020 is to contribute to targets laid out in theNSP 2016–2020 by intensifying social and behaviorchange activities at all levels of society. Recentfindings indicate a high community knowledgeabout the cause of malaria and how to prevent it,however, there are gaps between knowledge andpractice. Based on findings from the EVD response,innovative community and interpersonal behavioralchange communications will be strengthened. SBCCtrainings for service providers, community healthvolunteers (CHVs), TV shows, radio spots, leaflets,drama, road shows, community dialogues, andschools health promotion are examples of channelsto be used to close gaps between malaria knowledgeand practice. The key messages developed for thisMalaria Communication Strategy will place emphasison positive actionable messages for communitiesand individuals, underscoring the importance ofsleeping under LLINs, seeking early treatment forfever, completing ACT therapy, allowing rooms tobe sprayed during IRS, and the need for pregnantwoman to take their preventive malaria medicinethree or more times before delivery.This Malaria Communication Strategy is the second tobe developed. The first strategy was finalized in 2005.The 2016 revision is the result of two consultativeworkshops involving partners of the Ministry ofHealth, donors, non-governmental organizations andinternational partners. The strategy produced is anexample of tight collaboration between the NationalHealth Promotion Division (NHPD), the CommunityHealth Services Division (CHSD), the NMCP andpartners.4The global malaria control landscape has changed agreat deal since 2005. The Liberian malaria landscapehas changed significantly as well and requires arenewed examination of partnerships, strategicapproaches, key messages, and strategic use ofcommunication channels to further encourage theadoption of positive behaviors to prevent and controlmalaria.This revised Malaria Communication Strategy takescurrent knowledge, beliefs, and practices into accountto better contribute to the overall goal of halvingmalaria cases and deaths by 2020. The strategy seeksto facilitate the achievement of the following NationalStrategic Plan 2016–2020 objectives: To increase access to prompt diagnosis andeffective treatment targeting 85% of populationby 2020.To ensure that 80% of the population are protectedby malaria preventive measures by 2020.To increase the proportion of the population whopractice malaria preventive measures from 40%to 85% and sustain knowledge at 98% by the endof 2020.Although the Malaria Communication Strategyseeks to support all three of these objectives, theachievement of the third will be the chief priority ofthis strategy, as it is the most closely aligned withachievable SBCC activities.Increasing consistent use of LLINs will be the coreintervention of this revised strategy. This does notimply a lesser role of case management and malariain pregnancy interventions. Achievement of theother objectives will come to focus during theimplementation of this revised strategy.This second edition of Liberia’s National MalariaCommunication Plan builds on a wealth of experienceand will serve as a guide to a more coordinatedstrategic approach to malaria communication withthe Liberian people.Daniel SomahNational Malaria Control Program SBCC Focal PersonRepublic of Liberia

Liberia National Malaria Communication Strategy 2016-2020AcknowledgmentsThe Ministry of Health through the National Malaria Control Program extends profound thanks and appreciationto Center for Disease Control and the President’s Malaria Initiative, Management Sciences for Health, HealthCommunication Capacity Collaborative, Partnership for Advancing Community-based Services, PlanInternational Liberia, the World Health Organization Liberian office and the United Nations Children’s Fund forfinancial and technical support in revising the Malaria SBCC Strategy. Your support was indeed strategic to theprocess, a gesture for which we owe you a depth of gratitude.We also acknowledge the invaluable contributions of other National Malaria Control Program partnersincluding: national and international NGOs, the National Health Promotion Division of the Ministry of Health.This acknowledgment would be incomplete without recognition of the Global Fund for HIV/AIDS, Tuberculosisand Malaria. The Global Fund has greatly assisted the NMCP to begin concretization of its vision. We entertainthe hope that the Liberian people will enjoy a life free of malaria in the near future.We recognize the technical leadership of the NMCP manager, Oliver Pratt, as well as Kwabena Larbi, ofManagement Sciences for Health, who helped develop the early draft of this strategy. Government officials andpartners who contributed to the final review and edition of this strategy include:Paye Konah Nyansaiye, Deputy Program ManagerNational Malaria Control ProgramDaniel Somah, SBCC Focal PersonNational Malaria Control ProgramRev. John Sumo, DirectorNational Health Promotion DivisionRichard Zeon, SBCC FPNational Health Promotion DivisionMark Arthur, CHSD OfficerChristie Reed, Resident AdvisorCommunity Health Services DivisionPresident’s Malaria Initiative, CDCMike Toso, Program OfficerHealth Communication Capacity CollaborativeTeah Doegmah, Senior Technical AdvisorHealth Communication Capacity CollaborativeJustin DeNormandie, BCC Technical AdvisorPartnership for Advancing Community-based ServicesSiadeyo Torgbenu, BCC ManagerPartnership for Advancing Community-based ServicesIbrahim Kampara, Technical AdvisorPlan International LiberiaVictor Koko, Research OfficerNational Malaria Control ProgramAgnes Jannafo, MIP CoordinatorNational Malaria Control ProgramWynston Williams, ProcurementNational Malaria Control ProgramJoseph Olade, IT SpecialistNational Malaria Control ProgramAsatu Donlo, iCCM CoordinatorNational Malaria Control ProgramAgnes Nador, Vector Control CoordinatorNational Malaria Control ProgramWolo Jetoh, Vector TechnicianNational Malaria Control ProgramHawa Gbah, iCCM AssistantNational Malaria Control ProgramRoseline Chesson, Technical AdvisorVectorWorksAmanda Newlove, Response VolunteerPeace Corps5

Liberia National Malaria Communication Strategy 2016-2020Table of ContentsACRONYMS.7INTRODUCTION.9BACKGROUND.10ROLL OF COMMUNICATION IN MALARIA.10PATHWAYS CONCEPTUAL FRAMEWORK.13STRATEGIC COMMUNICATION FOR MALARIA CONTROL.14STRATEGY 1: VECTOR CONTROL.14Policy, roles and responsibilities.14Problem statement, SBCC emphasis.15Behavioral objectives, communication objectives, key promises, supporting points.16Audiences.17Agents, messages.18Monitoring.19Evaluation.20STRATEGY 2: MALARIA IN PREGNANCY.21Policy, roles and responsibilities, problem statement.21SBCC emphasis.22Behavioral objectives, communication objectives, key promises, supporting points.22Audiences.23Agents, messages.23Monitoring, evaluation.24STRATEGY 3: MALARIA CASE MANAGEMENT.25Policy, roles and responsibilities.25Problem statement, SBCC emphasis.26Behavioral objectives, communication objectives, key promises, supporting points.26Audiences, agents, messages, monitoring.28Evaluation.29EMERGENCY PREPAREDNESS.30REFERENCES.316

Liberia National Malaria Communication Strategy n-Based Combination TherapyAction and Investment to Defeat MalariaAntenatal CareCommunity-Based OrganizationCounty Health TeamCommunity Health WorkerCommunity Health Services DivisionCommunith Health Services SupervisorsDistrict Health Promotion Focal PersonLiberia Demography Health SurveyFaith Based OrganizationGlobal Technical Strategy for malariaHealth Promotion Focal PersonInterpersonal CommunicationIntermittent Preventive Treatment in PregnancyIndoor Residual SprayingInsecticide-Treated NetIntegrated Vector ManagementLong-Lasting Insecticide-Treated NetMaternal and Child HealthMalaria Communication StrategyMillennium Development GoalsMalaria in PregnancyMalaria Indicator SurveyMinistry of HealthRapid Diagnostic TestNational Family Health DivisionNon-Governmental OrganizationNational Health Promotion DivisionNational Malaria Control ProgramNational Malaria Strategic PlanOutpatient epartmentRoll Back MalariaPresident’s Malaria InitiativeSocial and Behavior Change CommunicationSustainable Development Goals7

Liberia National Malaria Communication Strategy yrimethamineTraditional Birth AttendantTrained Traditional MidwifeTechnical Working GroupUniversal CoverageVector ControlWorld Health Organization

Liberia National Malaria Communication Strategy 2016-2020IntroductionThe fourth Liberia National Malaria Strategic Plan(NSP) will employ a multi-faceted approach toscaling-up malaria control and prevention activitiesbetween 2016 and 2020. Innovations introduced inthis Malaria Communication Strategy reflect lessonslearned in Liberia since 2005, as well as global guidanceon new areas of focus and priority. As countries reviewprogress made under the Millennium DevelopmentGoals (MDGs), it is important to acknowledge thatchanges in approach are needed to sustain and buildupon gains made.all engaged in the fight against malaria. A “humancentered response,” to increased access and availabilityto malaria commodities and services, is described astreating those living in malaria affected communitiesas the first point of reference, not as “extras.” TheLiberian National Malaria Control Program’s Socialand Behavior Change unit expects allocated resourcesto increase interpersonal communication (IPC)and social mobilization activities that address theunique and changing contexts within which differentcommunities exist.The newly developed Sustainable DevelopmentGoals (SDGs) focus on action that promotes economicgrowth, social inclusion, and environmentalprotection. The Liberian National Malaria ControlProgram is committed to achieving both economicgrowth and reduction of malaria morbidity andmortality, with a new focus on engagement with theprivate sector to increase access to rapid diagnostictesting, and treatment for all. Social and behaviorchange communication (SBCC) will create demand forthese products as they become increasingly available.The President’s Malaria Initiative (PMI) has investedheavily in efforts to prevent and control malaria inLiberia. During the Ebola crisis, PMI support sustainedhealth services and worked to adapt LLIN and malariacase management strategies in a challenging andchanging environment. PMI’s new strategy for2015–2020 is consistent with support provided inthe past, and continues to focus on scale-up of coreinterventions like increased use of LLINs, promptcare seeking and appropriate treatment of fever,and prevention of malaria in pregnancy. Social andbehavior change communication activities plannedin Liberia’s Malaria Communication Strategy prioritizethese core interventions, particularly increased LLINuse.The World Health Organization’s (WHO) recentlylaunched Global Technical Strategy for Malaria 2016–2030 provides additional direction on means withwhich to reduce malaria morbidity and mortality.The call for universal coverage of core malariainterventions for all populations, with a focus on useof surveillance to inform decision-making resonateswith lessons learned in Liberia during the Ebola crisis.As a result of this experience, Liberia’s NMCP is focusingon emergency preparedness, and developing a set ofguidelines for maintaining malaria social mobilizationactivities during future crises. Sustained focus ona robust emergency preparedness system benefitsall health areas, and prepares Liberia for future preelimination efforts that require attention to every lastcase of malaria. Behavior change efforts will need tobe tailored to help communities contextualize whatit means to take action, even in the absence of animmediate threat.The Roll Back Malaria Partnership (RBM) has recentlyupdated its guide to collective action the Action andInvestment to defeat Malaria (AIM 2016–2030) forAs global priorities and targets shift and evolve,the Liberian National Malaria Control Program willcontinue to adopt innovative means with which tocontextualize malaria prevention and control in itscommunities. This second edition of Liberia’s MalariaCommunication Strategy provides a framework fromwhich county, district, and community planning,implementation, and evaluation will take placethrough 2020.Oliver PrattNational Malaria Control Program ManagerMinistry of HealthRepublic of Liberia9

Liberia National Malaria Communication Strategy 2016-2020BackgroundMalaria transmission is holoendemic and stablethroughout the year in Liberia, leaving overfour million inhabitants are at risk of malaria infection.According to the most recent Health Facility Survey,malaria accounted for over 42% of outpatient and39% of inpatient deaths. Between 2013 and 2014,gains that might have been made to reduce malariamorbidity and mortality in Liberia were madeincreasingly improbably as the Ebola outbreakdismantled much of the country’s health system.The Liberia Demographic Health Survey 2013, takenbefore the outbreak, showed: 24% of children under five who had a fever inthe previous two weeks received artemisinincombination therapy (ACT)56% of those in households that own at least oneinsecticide-treated net (ITN) slept under one thenight before63% of children under five in households that ownat least one ITN slept under one the night before63% of pregnant women in households that ownat least one ITN slept under one the night beforethe survey48% of women received two or more doses ofIPTp during their most recent pregnancyThe Ebola crisis had an incalculable impact on theavailability of and access to malaria services andcommodities. Due to lack of trust in health facilitiesduring the crisis, the National Malaria ControlProgram (NMCP) and Medicines Sans Frontiers Francecarried out two rounds of mass drug administrationin the New Kru, Logan, Clara, and Tweh Townships onBushrod Island to stem potential increases in infectionduring a time when use of health facilities was greatlyreduced. Use of rapid diagnostic tests to confirmmalaria among those with fever was suspended inmany areas due to fear of contact with bodily fluids.As malaria prevention and control activities resume,short- and mid-term progress should be viewed inlight of these challenges.Coordination, supervision, and implementationof malaria communication activities in LiberiaCentral level: Malaria social and behavior change10communication (SBCC) is the shared responsibilityof the NMCP, Community Health Services Division(CHSD), and the National Health Promotion Division(NHPD). All three divisions are independent entitieswithin the Ministry of Health that work together toachieve common goals. In a malaria context, theNHPD coordinates and validates SBCC messages andmaterials. The NMCP SBCC unit provides strategicguidance, a work plan, and program evaluation. Bothdivisions rely on the CHSD at the County, District andCommunity levels for supervision of activities.County and District levels: The CHSD overseescommunity health structures but operationalizationof the SBCC plans at all levels is done throughNHPD. County-level heath promotion activitiesare overseen by County Health Promotion FocalPersons (CHPFP) of the CHSD. Each county has oneHealth Promotion Focal Person (HPFP). Most HPFP’swill have received SBCC training at some point. Thisis less common among District Health PromotionFocal Persons (DHPFPs). Trainings to improve skillslike interpersonal communication (IPC) are fundedthrough implementing partners rather than the NHPD.The ability to schedule regular trainings or SBCC skillsbuilding that increase a deliberately designed set ofskills over time rests on coordination between theNMCP, CHSD, NHPD, and their partners.Community level: CHVs provide health promotionactivities at the community level. These include trainedtraditional midwives (TTM) and general communityhealth workers (gCHV). CHVs, gCHVs, and TTMs aresupervised by the Officer-in-charge of catchmentfacility community health committees (CHC). Thesecommittees are responsible for the supervision ofhealth promotion activities at the community andengage chiefs, elders, and community members asneeded. As noted in the Revised National CommunityHealth Services Strategy 2016–2021, effectivecommunication in communities relies on the activepresence of both CHCs and CHVs.Role of communication in malariaInformation, education, and communication (IEC)is the process of working with individuals and

Liberia National Malaria Communication Strategy 2016-2020communities to promote positive, healthy behaviors.SBCC takes this process a step further by promotinghealthy behaviors and deliberately working toestablish a socially supportive environment that willenable individuals and communities to initiate andsustain new behaviors. While information is essential,it is important to recognize that making informationavailable is not the objective of communication.Effective communication is an exchange, oneinfluenced by psychological, cognitive, andemotional factors. Strategic communication seeksto address multiple behavioral determinants, andthe environment within which they exist, in order toachieve positive health outcomes.Elements of several theories of behavior changeinform this strategy’s approach. These include: Protection Motivation Theory:3 A model basedon this theory, called the Extended ParallelProcess Model, has been used to predict behavioras a response to simultaneously increasingconfidence act, and perceived fear (susceptibility,severity).Social Cognitive Theory:4 Knowledge acquisitionoften comes from observing others. Increasingan individual’s confidence in their ability to takecertain actions must be accompanied by positiveresponses received after performing it, and thepresence of an enabling environment.Theory of Reasoned Action:5 Decisions to takecertain actions are based on an individual’smotivations and expectations. Attitudesregarding whether the result of an action willbe positive or negative, and subjective normsregarding perceived social pressure or supportare important factors that influence intention toact.Liberia’s Malaria Communication Strategy willinfluence positive behavior change by addressingindividual attitudes, beliefs, and practices, whileworking to improve the social and environmentalcontexts within which they exist. The PathwaysFramework6 (Figure 1), based on the socio-ecologicalmodel of behavior change,1addresses the followingelements:3 Rogers RW, Protection motivation theory. 1983.4 Bandura A, Social cognitive theory. 1977.Underlying conditions: Liberia’s human resources,financial resources, social, political, and economicconditions make up underlying conditions thatinfluence structural, social, and individual behaviors.Communication domains: Communication activitieswill focus on working to improve the socio-politicalenvironment (favorable environment and policies),working with those who provide health services andinformation (to improve access to services and lifesaving commodities), and working with individualsand their communities.Exposure and reach: It is necessary to record thenumber of those reached with SBCC activities, and toconduct pre and post tests or surveys (when possible)to indicate whether or not activities had the intendedeffect. A proportion of those exposed to SBCC malariamessages who demonstrate accurate knowledgeof malaria’s cause and ways to prevent it, and reportpracticing priority behaviors, will indicate the relativesuccess of activities and campaigns. Refer to theactivities section of each intervention strategy.Initial outcomes: The short-term effect ofcommunication activities can be measured byobserving changes in not only knowledge, butattitudes, beliefs, values, perceived risk or benefit,emotional responses, self-efficacy (confidence),perceived social support and personal advocacy.Changes in these factors may lead directly to behaviorchange, but often signal progress towards it overtime. For this reason, it is essential to measure not onlycommunication objectives, but behaviors that leadto positive health outcomes. These attitudes can bemeasured using the Roll Back Malaria CommunicationCommunity of Practice Guidelines.2 No key promises orsupporting points are included for objectives relatedto knowledge. Refer to communication objectives inthe evaluation section of each intervention.Behavioral outcomes: Observed or reportedchanges in behavior are a more robust indicatorthat individuals and communities are becominghealthier. Often measured using household surveys,measures of changed behaviors should be reported5 Fishbein M, Ajzen I, Theory of reasoned action. 1967.6 Kincaid DL, Figueroa ME, Underwood C. Pathways.11

Liberia National Malaria Communication Strategy 2016-2020as a proportion (%) of the total number of those whoresponded to questions. Refer to behavioral objectivesin the evaluation section of each intervention.Impact: Results in terms of sustainable health willbe measured in terms of decreased morbidity andmortality. The goal of Liberia’s National MalariaStrategic Plan 2016–2020 is to decrease malariamortality by 50% by 2020. These indicators aremeasured by the Malaria Indicator Survey, andDemographic Health Survey. Impact indicators s

fever, completing ACT therapy, allowing rooms to be sprayed during IRS, and the need for pregnant woman to take their preventive malaria medicine three or more times before delivery. This Malaria Communication Strategy is the second to be developed. The first strategy was finalized in 2005. The 2016 revision is the result of two consultative

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