Assessing community knowledge, attitude and practices to strengthen communication strategy for Malaria Elimination Demonstration Project in Mandla

The IEC-based communication strategy was developed and rolled out in collaboration with community members and MEDP field staff in 2017  (Fig. 1). Culture-based tools of communication were used for the IEC campaigns in MEDP. Lessons from prior studies done by ICMR-NIRTH in tribal areas were key drivers for selection of inter-personal communication as an appropriate IEC strategy for Mandla [4]. The strategy was based on the communication model used in malaria-endemic Baigachak area of Dindori district of Madhya Pradesh in 2013 by Saha et al. [5].

The key manpower strategy consisted of: (1) 235 Village Malaria Workers (VMWs) with higher secondary (10 + 2) educational level, who were locally recruited and trained to perform IEC activities in addition to active surveillance and case management; (2) 25 Malaria Field Coordinators (MFCs) with a minimum qualification of graduate (degree) level, who supervised the VMWs.

The IEC campaign consisted of: (1) Door-to-door communication at community level by using flip-books on malaria, which depicted pictographic information on malaria vectors, transmission mechanism, preventive, diagnosis and treatment aspects; (2) Specially designed malaria calendar was distributed in the places of public interest and assembly, such as “Anganwadi Centres” (Courtyard shelters) and “Gram Panchyat Bhawans” (Village council buildings). These calendars provided awareness messages in local language on transmission, prevention, diagnosis and treatment for malaria.; (3) Campaigns were conducted at middle school level, which included, exhibitions, quiz contests and popular lectures on malaria organized on regular basis; (4) Theatre-based activities including storytelling techniques were adopted; (5) School activities focussed on sensitizing the students and teachers on the misconceptions and informing them on the preventive and treatment aspects of malaria and empowering them as ‘agents of change’; and (6) IEC/T4 (Track fever, Test fever, Treat patient, Track patient) booths installed at rural weekly markets locally known as “haat bazar” (community markets). These weekly market were used for spot diagnosis and treatment for shoppers, who were febrile and approached the IEC booths.

A cross-sectional survey was conducted in February 2019 to assess the communication strategy which was designed based on information available from other areas similar to Mandla and information available from Government websites.

A structured, pre-tested interview schedule was used. Self-assessment questions on knowledge and perception on malaria as well as on the effectiveness of MEDP staff and activities before and after initiation of the project was included in the survey.

The district has nine blocks and 25 clusters. Each cluster comprises of around 12 sub-centres. Each cluster had one MFC and 8–10 VMWs. This calculation ensured full coverage of entire district with active surveillance by the project staff on a weekly to fortnightly basis. Assuming a hypothesized outcome frequency of 50% with design effect of ‘2’ and 95% confidence interval in a population size of 1,150,000, the sample size was estimated to be 768. Using clustered random sampling, 30 random samples from each cluster were selected for interview. Non-response was also considered while interviewing the respondents. Either head or any eligible member from 773 households located in nine blocks of Mandla district was interviewed. The households were stratified in the villages and randomly selected.

Out of the 773 household respondents interviewed, 67% were male and 33% were female. Most of the respondents were Scheduled Tribes (64%), followed by the Other Backward Castes (29%)—a collective term used by Government of India for disadvantaged castes, Scheduled Castes (6%), and General category (2%). Almost a quarter of the respondents (24%) had studied up-to primary school, followed by those with up-to middle school education (22%), and up-to high school or higher (34%). Around 19% of the respondents had not received any formal education.

Amongst the major occupational groups, half of the respondents worked as farmers, followed by unskilled labourers (28%), and around six percent were home makers. A very small proportion reported business (3%) and government service (2%) as means of livelihood. Only two percent were students. Around 44% of the respondents reported annual household income of INR 10,000 to 25,000 (USD 140 to 350). Fifteen percent and 20% mentioned INR 25,000 to 50,000 (USD 350 to 700) and INR 5,000 to 10,000 (USD 70 to 140), respectively. Some of the respondents (9%) could not ascertain their annual household income. The mean annual household income of the households in study area was INR 22,976 ± 1572 (USD 350 ± 22).

In terms of amenities and facilities, most of the houses were found to be “kaccha” (temporary mud houses) (68%), followed by “pucca” (brick and mortar houses) (20%) and “semi pucca” (temporary roof) (13%). Barring few, most of the households were electrified. Only 24% of the households had flush toilet facilities and another 23% had pit toilets. More than a quarter of household members used public toilets (31%) and open defecation (23%). Around 31% of the households had no vehicle to commute. Bicycle (44%) was an important means of transportation.

The main sources of drinking water were public hand pumps (50%), followed by public taps (10%). Unfiltered surface water from river, stream, pond, and lake was used by very few (2%) for drinking purposes. Overwhelming majority of them used wood (93%) as cooking fuel, followed mostly by liquid petroleum gas (39%) and dung cakes (16%). Around 78% of the households owned agricultural land.

Nearly four-fifths of the respondents (78%) mentioned that malaria is transmitted by mosquitoes. However, misconception prevailed as 7% reported that malaria spreads by drinking dirty water, 1.3% reported transmission by eating stale food, 1.3% reported transmission by touching malaria infected persons, and also by other insect bites (1.1%). Around 11% did not recognize any means of transmission of malaria. Malaria was reported as a fatal disease by 85% of the respondents (Table 1).

It was a common understanding in the community that mosquitoes breed in water. It was found that around 60% of those surveyed reported that mosquitoes breed in dirty water, in garbage (18%), and in muddy sludges and puddles (30%). Around 10% did not have any understanding of the breeding places. Only 17% of the respondents mentioned stagnant clean water as the breeding place for malaria mosquitoes (Table 1).

Fever with headaches was the common symptom reported to identify malaria (65%). Around 17% had no knowledge on how to identify malaria. Almost all (95%) had no knowledge about the types of malaria. There were only a few (5.3%) who mentioned the parasite. Around three-fourth of the respondents mentioned MEDP field workers as the main source of information on the symptoms and type of malaria (Table 1).

Efforts were made to assess the perception of the respondents on programmatic and non-programmatic preventive practices. Quite a number of respondents reported smoke by burning dry leaves of neem tree (Azadirachta indica) as the preferred way of prevention of mosquitoes, besides the use of commercially available mosquito repellent coils. Regarding programme-supported preventive measures, only 39% of the respondents reported awareness about Indoor Residual Spray (IRS) as a mosquito control measure. Only 52% respondents in this group could mention one or more government or non-government organisations responsible for IRS. Around 16% mentioned Government malaria workers and 10% reported MEDP field staff as the main source of information on IRS (Table 2). Around 41% of respondents had heard about LLINs. Most of them identified them as medicated nets, while some reported it as Government nets, insecticidal nets etc. Amongst them, 83% knew its importance in malaria control. The correct distinction between LLIN and ordinary net was made by 64% of the respondents. Furthermore, correct mechanism of usage and washing was known to 80% and 36% of the respondents, respectively. Though 95% of them mentioned its use mainly to avoid mosquitoes, three percent reported using it to protect from other insects and snakes. A small number (4%) also used it as fishing nets (Table 2). Around 41% knew about the high-risk groups for malaria. Seventy percent mentioned new-borns as most susceptible followed by the elderly (25%) and pregnant women (24%). Only few knew the names of the anti-malarial drugs (Table 2). The perception on high risk group is also considered as an indicator of preventive approach necessary for protecting the vulnerable section of the community.

Regarding knowledge about malaria diagnosis, almost everyone knew the requirement of blood specimen for testing, but only 71% (550) were aware of the Rapid Diagnostic Tests(RDTs) or the blood slides as the diagnostic tests. Amongst them, 48% of the respondents were aware of the RDTs and 52% mentioned blood slide examination as the diagnostic method (Table 3).

Around 42% (326) of the respondents reported a case of fever in their household during six months preceding the survey and amongst them, 71% (232) mentioned that the patient had gone for blood testing mostly from MEDP field staff (69%), followed by visit to government health posts (23%), and chemist shop/ private practitioners (8%). Some of the patients availed services from multiple sources for testing of blood. Overwhelming majority of the households (90%) availed these services free of cost. Those who spent on diagnosis, the mean cost amounts to INR 140 ± 161 (USD 2 ± 2.5) per blood test. Around 81% (188) of the households were informed about the test results and 5% (10) amongst them were reported positive for malaria, and another 6% (11) could not recall the result at the time of the interview.

In the event of fever, it was found that the community was consulting multiple health care providers. The first-line for treatment were Government health facilities (80%), followed by MEDP field staff (40%), programme-driven Accredited Social Health Activists (ASHA)/ Auxiliary Nurse Midwife (ANM) (18%), and chemist shops (14%). However, around 15% of the respondents reported that community members also visited priests, herbal healers and faith healers for seeking treatment for fever (Table 3). The malaria-specific treatment was provided free-of-cost by the Government and MEDP.

Though 78% of the respondents correctly reported that mosquito is responsible for the spread of malaria, the logistic regression model revealed an inverse relationship between age of the respondents and their knowledge that mosquito is responsible for the spread of malaria. Females and unmarried respondents were better aware of the transmission. Education was significantly associated with the correct knowledge of mosquito as transmission agent (AOR: 3.78, p = 0.001) and its breeding site (AOR: 8.97, p = 0.001). Further, it was observed that compared to the scheduled tribes and scheduled castes, other social groups were better aware of the transmission agent. No similar association could be established with occupation and economic condition (Table 4).

Fever with chills was reported as the main symptom of malaria by the majority of the respondents. It was found that age is positively and significantly associated with the knowledge of these symptoms (AOR: 2.80, p = 0.001). Married population (AOR: 2.18, p = 0.05), better educated (AOR: 1.68, p = 0.001) and those belonging to wealthy households (AOR: 1.87, p = 0.05) were better aware of use of programme-supported preventive measures such as use of LLIN and IRS (Table 4).

Further, positive correlation was seen between levels of education and correct knowledge on malaria diagnostic tests such as RDT/blood slide examinations (AOR: 2.96, p = 0.001). The scheduled tribes and scheduled castes groups had poor knowledge of diagnostic tests for malaria (Table 4).

Around 87% (671) respondents were aware about the MEDP field staff working in their villages. Most of them mentioned that they could recognize the workers by name in their village. Around 89% of them replied that MEDP workers visited their houses regularly every month. Forty two percent reported that during blood testing, the workers also explained in-detail about various aspects of treatment for malaria (Table 5). Most of them (88%) mentioned about the easy understanding of the messages provided by these workers, around 98% of the respondents were satisfied with the MEDP workers and expected them to keep visiting their villages as per schedule. Most of them (87%) also expressed their willingness to extend cooperation to the workers for improvement of health communication strategies. Regarding exposure to ongoing IEC activities, 81% (546) reported to have received malaria related information during home visits by MEDP workers, 19% (125) mentioned IEC camps, and 13% (88) had witnessed both activities (Table 5).

Scaling technique was adopted to construct a 0–13-point score of the MEDP activities. It was observed that higher education, non-scheduled tribes, non-scheduled castes population, and those belonging to wealthy households had better knowledge and positive attitude towards MEDP activities and the association was found to be significant (Table 6). Scores were generated at 1–5-point scale for self-assessment of the respondents towards improvement in their own knowledge on malaria before and after initiation of MEDP IEC activities (Table 7). The estimated average scores revealed that after MEDP, knowledge on malaria had improved and the association was found to be significant. The self-assessed improvement was higher in cases of respondents who were aged, female, illiterate, belonged to Scheduled Tribes/Scheduled Castes, and those in lower income group households (Table 7).