Background
Considered one of the leading causes of death in the developing world, malaria, a mosquito-borne parasitic infection, affects about 3.2 billion people in 95 countries [
1]. Sub-Saharan Africa has the highest burden of the disease, accounting for over 90% of the deaths [
1,
2]. Malaria control programs have made substantial progress in recent years to decrease the burden of disease. This has been made possible through the initiation of the Roll Back Malaria (RBM) program, at the start of the new millennium [
3,
4]. The RBM program signified global efforts to combat malaria in predominantly low-income malaria endemic countries [
3,
5,
6]. The strategy aimed for a coordinated improvement in the management, prevention and treatment of malaria, by increasing access to prevention and treatment tools [
3,
4,
7].
While great strides have been achieved in fighting malaria since the inception of the RBM Plan in the year 2000, the recent (2017 and 2018) World malaria reports show a slight increase in malaria-related deaths compared to previous years, which has been attributed to insufficient levels of access and uptake of malaria prevention tools [
1,
8].
Malawi has not been spared the devastation, current statistics present it as an area of high prevalence [
9].
Plasmodium falciparum is the most prevalent parasite responsible for close to 5 million cases annually in a population of roughly 17.5 million people [
2,
10]. Much like in other parts of sub-Saharan Africa, there has been a decrease in the number of cases since the adoption and implementation of the RBM strategy for malaria control, the trend however still remains worryingly high [
2,
9]. The population most at risk are women and children, and specifically those residing in desolate conditions in remote and rural areas with poor access to preventative and treatment interventions [
9‐
11].
It is well documented that malaria control tools are both efficacious in preventing the disease, however, the human behaviour aspect of the intervention strategies is weak in that the efficiency of such mechanisms rely heavily on positive human health seeking behaviour [
12,
13]. The major challenge lies in appropriate adoption of control tools by the target population, which to a large extent includes challenges with accessing prevention and treatment tools [
11,
13,
14]. Health information and education campaigns have been dispersed in various forms to encourage and attempt to reinforce positive health behaviours [
12,
13]. The RBM plan for disease control now strongly recommends incorporating Behaviour Change Communication (BCC) as an important strategy for malaria control, especially in developing countries with poor health systems [
13].
BBC is rooted in socio-cognitive theories on health behaviour. The theoretical model examines the influence of a person’s environment on attitudes, norms and perceptions towards a specific health problem. When used as an intervention, BCC uses advocacy through specific channels of communication to target or influence a person’s intentions towards specific behaviours [
15]. BCC works to improve on knowledge of a disease. It stimulates a conversation within the community to promote change in attitude and perceptions of a particular disease. It also works to improve skills on self-efficacy for disease prevention and efficient use of disease prevention tools and health services [
10,
12,
13,
16]. The idea behind BCC is to engage a targeted audience into giving them the skills to overcome environmental restrictions and negative perceptions in order to perform the desired act [
12,
17]. Although BCC is considerably a novel addition to the RBM strategy, it has been shown to influence health seeking behaviours with the improved communication and importance of using prevention and treatment tools more efficiently [
12]. The RBM partnership admits that the BCC tool they prescribe is yet to go through rigorous evaluation, as BCC strategies for malaria control have not been extensively studied [
13].
The Health Animation model is a community engagement approach used to promote positive health behaviour for disease control. This is supposed to be achieved by focusing on influencing a mindset of understanding the threat of disease and promoting positive health seeking behaviours [
10,
18]. This involves the provision of information through peer-led health education and communication of diseases [
10]. The HA approach was pioneered and is promoted by the non-governmental organization, The Hunger Project (THP), for awareness and prevention of disease in developing countries [
10,
18]. This concept works within THP’s larger framework of community development through collective accountability and action [
18]. The model makes use of a volunteer recruited from within the community, by the community, to train in leadership skills that help unite the community in working towards a common goal, good health and subsequently development [
10,
18]. The HA is given leadership training for leading all communal development activities and is provided with training in a condensed version of the science behind illness and disease control. The idea is to then impart knowledge through peer led education, to unite the community in working together for promotion of good health through collective action, most importantly for communicable diseases [
10].
The current analysis is based on the Majete Malaria Project (MMP), in Chikwawa District in Southern Malawi [
19]. MMP is a multi-stakeholder community-based project for malaria control. Embedded within its community-based activities is an RCT testing malaria intervention in various combinations [
19]. The context of this research in presented in the protocol publication by McCann et al. [
19]. The implementation of the HA workshops is presented in the publication by Malenga et al. [
10] and van den Berg et al. [
18]. The MMP project adapted the HA model which THP had previously used for HIV/AIDS awareness and tailored it for malaria awareness and control. The role of the HA in the context of this research was to run community workshops on malaria control in order to influence positive health seeking behaviour of peers in their community [
18]. This was to encourage the appropriate adoption and use of malaria control interventions such as Long-Lasting Insecticide-treated Nets (LLIN) and MMP specific interventions of Larval Source Management (LSM) and House Improvement (HI) which were distributed within the community through MMP and the local health system. The workshops were also used as a platform for the community to voice their challenges with malaria control more broadly, and a space to discuss collective solutions to mitigate infection and access treatment. The workshops in this study were run bi-monthly for a period of 2 years prior to data collection. They typically involved the volunteer arranging for a community meeting within their village, where they used a predesigned curriculum to introduce concepts and information on malaria control and the role of all households in committing to compliance with use of interventions for mitigating the burden of disease through collective action [
18]. The workshops were interactive, with visual aids and were conducted in the local language,
Chichewa, for appropriate communication. This process is later followed up with community members reporting a change in health behaviour, which is monitored through the health system in terms of the trend of new infections reported [
10,
18].
This paper presents findings of a qualitative assessment of the experience of the HA model as a tool for IEC for malaria control. Specifically, the analysis highlights the perceptions of the trained community volunteers while implementing the HA approach for community engagement and peer influence, to understand the challenges and successes associated with peer led health education for malaria control in rural communities with poor health systems.
Methods
This study is an exploratory qualitative assessment of the experiences of HA model for malaria control in a rural setting with limited access to health services. Using a total of 3 FGDs and 23 IDIs with HAs, the assessment explored the experiences of community members trained to implement malaria workshops as a mechanism to facilitate learning about malaria and communicating the importance of adopting positive health behaviours to reduce the burden of malaria in their communities. Specifically, the questions asked participants to describe their experience hosting community meetings, working with MMP staff and the support from government health workers. They asked to reflect on their perceptions of malaria behaviour in the community as well as their homes before and after the introduction of the MMP project. They were asked to relay the most obvious changes, and how the MMP project interventions, including the malaria workshops, were received by the community. They were also asked to give feedback on challenges they experienced carrying out the workshops, and what recommendations they would have for future projects of a similar nature.
The context of this research is described in the publication by McCann et al., 2017 [
19], and van den Berg et al., 2018 [
18]. The implementation of the HA programme is presented in a publication by Malenga et al., 2017 [
10], in the Chikhwawa District of southern Malawi. For an in-depth exploration of HA perceptions and experiences, qualitative methods were considered the most appropriate using the BCC model as a guide for data collection and analysis.
Setting
The research was conducted in communities surrounding the Majete Wildlife Reserve, specifically among those community members who were participating in the randomised control trial of MMP. The Majete Wildlife Reserve is located in the Southern Region of Malawi, straddling 3 districts of Mwanza, Blantyre and predominantly Chikhwawa district. Chikhwawa is a low-lying area in the Shire Valley on the southern end of Malawi, with a population of a little over half a million people. The area is prone to droughts and annual flooding which have substantial impact on food security and livelihoods. Chikhwawa district specifically, accounts for the country’s highest prevalence of malaria. In Chikhwawa, malaria is responsible for 25% of all deaths in the district, where 40–45% of clinical visits and 30 to 40% of all hospital admissions are due to malaria [
20].
Data collection
Participants in both the FGDs and the IDIs were conveniently sampled. They were selected based on their involvement with the project and their capacity as a community-based HA. Participants were identified from a list of HAs registered with the project. The investigator used MMP research assistants to approach the HAs in their homes. The investigator conducted interviews with animators who were available in their home at the time of the visit. A total of 3 FGDs and 23 IDIs were conducted with HAs from the 3 different study sites. Semi-structured interview guides were developed, tested and revised before the data was collected. Each FGD had 8 participants, who were then sampled to conduct the IDIs. All interviews were digitally recorded and conducted in the local dialect, Chichewa. The FGDs were conducted in October of 2015 before the commencement of the MMP randomised control trial, and the IDIs were conducted between October of 2016 to February of 2017, 5 months after commencement of the trial.
The study participants included 14 men and 9 women. The median age for men was 30 years, and 37 years for women. The age range for all participants was from 23 to 63 years. All but one of the participants had some primary education, the participant with no education had gone through civic education and therefore possessed basic literacy. Almost two thirds of the HAs had secondary education; none had tertiary education experience. All were married with the exception of two widows. All participants were engaged in subsistence farming, with some complimenting income generation with small local businesses.
Data analysis
Digitally recorded interviews were transcribed verbatim. They were then translated into English and coded using QSR International NVivo 10 software. Themes emerging from the data were deductively derived from the question guide used in the interviews. Themes were also derived inductively from the data in the transcripts. The analysis explored some features of BCC, by assessing advocacy as a communication strategy to alter individual health belief and the role of peer influence in influencing health behaviour change.
Ethical considerations
Ethical approval for interviews was given by the University of Malawi’s College of Medicine Research Ethics Committee (certificate number P05/15/1724). All participants agreed to a written consent in the presence of a witness prior to the interview. Participants consented to have interviews digitally recorded.
Discussion
This study explored the experiences of being a HA in a rural context. The HA model for community engagement can be used effectively as a form of IEC to complement malaria control interventions. This strategy may very well improve efficiency of implementation and use of malaria control interventions in rural communities. The simplified science behind malaria control delivered through HA workshops increases the knowledge on exposure and risk of infection. This could therefore influence people to use malaria interventions more appropriately and consistently as their understanding of the threat of disease and the role of the intervention is made clearer. It is a useful intervention as a form of advocacy, by providing key messages that are accessible to the community and providing information on how to overcome contextual barriers in preventing and seeking treatment for malaria.
The results illustrate community HAs’ personal experiences in carrying out malaria workshops. They present the various strengths and weaknesses of health animation when working in the context of rural and remote communities with poor access to health services. The study also presents the contextual challenges encountered with implementing animator workshops in a community with a history of high dependency on aid and how that can strongly jeopardise the objectives of introducing this form of information dissemination for health behaviour change.
The valuable benefit of the health animation training was the opportunity provided for the volunteers to personally internalise information and understand the real threat of malaria by understanding the main causes, as well as the importance of prevention and minimising the spread of infection within one community. If leading by example, there is some potential for a community to benefit from peer influence for health behaviour change. The HAs were able to make use of malaria prevention interventions and noted the personal gains within the household. Less illness translated to less time and finances spent seeking care and more time spent on improving their livelihood through the gains in time dedicated to labour for socioeconomic benefits. There was a notable cost of volunteering through missed work opportunities, however, this was acceptable to those choosing to continue the work.
The study demonstrates that it is feasible to utilize the HA model for community engagement with malaria control if the volunteer feels well supported by the implementing partners [
10,
18]. The context of this research shows it is feasible to introduce Health Animation in a rural set up [
10]. However, characteristics of the population strongly influence how successfully the programme may be implemented [
21]. This suggests the need for adaptation to deal with challenges presented by context [
22]. Interactive sessions for introducing medical and health concepts, and facilitating the interpretation and application of these concepts to generate knowledge, as used in this study, have been shown to be more fruitful for influencing behaviour change [
23]. The challenge lies in sustainability of any change in behaviour in the long term [
10,
16,
23]. Knowledge and attitude change are generally possible through provision of concepts, information and tools [
21,
24‐
26], however the maintenance of the change in desired behaviour may require a lot more input than simply communicating health information [
21,
23].
Contextual variables can pose major challenge in implementing projects for HAs. The widespread poverty in the catchment area, coupled with the fact that it is a disaster-prone area created problems of implementation in terms of understanding the intentions of the project and the workshops for malaria control. The community expected handouts in exchange for participating in malaria workshops and conversing with HAs. Once it was clear there was no material benefit attendance of the workshops declined significantly. The problem of poverty also created a challenge in successfully internalising the intentions of the HA program as well as the importance the malaria workshops played in mitigating disease within the community. For the purposes of health information dissemination, it would therefore have to be delivered differently in this context. Additionally, if the HA programme were to be introduced as part of the health system, a form of remuneration would ensure some level of sustainability, as commitment to carrying out the workshop would increase, both in terms of the HA taking pride in having a title and formal employment, as well as a source of income for their family.
The initial pull to attend malaria workshops stemmed from the community’s curiosity to discover what the HA had learned from their trainings. They were also curious to find out what the project was about after discovering the link to the research under MMP. The HA was useful in debunking myths and standing in as a source of information for the community, when information would have been otherwise unavailable. This makes them key individuals, especially in the context of implementing health research projects with some degree of complexity. Repetition of modules when delivering the workshops meant that with time attendance declined. There is therefore the need to diversify the curriculum keeping it current or revising it with new information as and when changes are made with the health system policy. Alternatively, the delivery could be revised to make it more engaging considering the context it is delivered in.
Community leadership, through both the village chiefs and health system workers, has a strong influence in the success of such interventions. HAs felt the influence of the chief was important for enticing the community to attend workshops. The involvement of village chiefs and health systems representatives legitimises the intervention and promotes engagement with the community [
23]. The chiefs in this programme endorsed and promoted the malaria workshops as part of the larger efforts of municipal development in their communities.
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