PMI Communication and Social Mobilization Guidelines

The purpose of these guidelines from the President’s Malaria Initiative (PMI) is to assist in the development, implementation, and monitoring and evaluation (M&E) of programmes to influence behaviours around malaria interventions including the following: correct and consistent use of insecticide-treated nets (ITNs), acceptance of indoor residual spraying (IRS), and adherence to treatment and prevention therapies, including intermittent preventive treatment in pregnancy (IPTp) during pregnancy and treatment with artemisinin-combined therapy (ACT) for children under five within 24 hours of onset of symptoms. The guidelines intend to increase demand for malaria services and products, as well as community involvement in malaria control.


According to the document: "The guidelines contain information about how to plan, implement, monitor, and evaluate a behavior change-social mobilization process to reach individuals and communities affected by malaria. The guidelines are structured as a planning framework. They explain how to establish goals and objectives, review existing data and conduct a rapid assessment, develop a strategy with a budgeted plan of activities, and monitor and evaluate the process." The cycle diagrammed in the document begins with planning and strategy development, continues with selecting interventions, the programme implementation; and, finally, a rapid M&E process.


Based on a review of documentation of communication interventions related to malaria IRS, ITHS, case management, and IPTp programmes, the following were found to be the patterns and consistencies:

1. "Community education campaigns - with teachers, village leaders, children, parents, and volunteers providing education:
   
   • Outreach schemes using community members as distributors of information for message dissemination have been relatively successful when proper materials and training are given to the individuals best placed in the community to take on roles as educators.
   • Small groups of committed individuals can plan and execute a project as well as if not better than a large committee.
   • When using volunteers in the community, sustaining the interest of volunteers and ensuring that relevant and achievable goals are set is essential.
2. Health worker and vendor training - These interventions commonly involved creation of job aids and materials such as posters, pamphlets, and brochures to alert community members about how to recognize signs of malaria and determine the appropriate dosage for treatment of malaria:
   
   • Medical outlets/vendors are good places to make timely information accessible.
   • Improving health worker capacity and providing clear messages about IPTp and SP has been effective in increasing coverage of SP.
   • Alternate medical vendors/providers can be successful in administering anti-malarials, not just health workers, especially in rural areas.
3. Interpersonal communication (IPC):
   
   • Interpersonal communication targeting key stakeholders can be effective in improving treatment-seeking behavior.
   • House-to-house strategy is effective in increasing appropriate use of ITNs, as most people have difficulty hanging them or are not familiar with retreatment practices.
   • In the instance of IRS, door-to-door explanation of the process assisted workers in gaining access to houses for spraying.
4. Local and Mass media campaigns:
   
   • 'Shock ' messages around malaria were not well received.
   • In all countries where campaigns ran, an increase occurred in malaria and ITN awareness and in ITN sales. Continuous, repetitive information is important for message transmission.
   • Messages tailored to a country or regions were preferable to a holistic, pan-African approach.
   • Generic mass media campaigns needed clear branding and messages to ensure awareness-raising of the appropriate products."

Planning and Strategy Development

The three PMI stages are: preparation, implementation at scale, and national ownership and sustainability. As stated in the document: "Four key elements ensure ownership and country buy-in of communication approaches at every stage in the lifecycle. Country ownership is essential to behaviour change communication (BCC) success.

1. Make communication approaches integral parts of the national malaria control efforts and malaria operational plans (MOPs)
2. Use data and evidence for design and evaluation
3. Ensure consistent, appropriate behaviours and messages across organizations
4. Involve clients, communities, service providers, the media, policy makers and political leaders in their design, implementation, and evaluation."

A diagram demonstrates programme objectives for ITNs, IRS, IPTp, and case management at each of the three stages listed above. The diagrammatic scheme is organised by audience (e.g., removal of taxes/tariffs on imported ITNs might be addressed by policy makers, and consistent use of ITNs addresses might be addressed to families) and by time periods for implementing programmes and making them sustainable.


The document gives a summary of messages based on beliefs and actions, audiences, and delivery channels. For example, messages on ITNs might be "delivered free through mass campaigns, social marketing, voucher programs". One of a number of audiences might be policy makers, who could: "ensure adequate supplies are available at front line facilities and in the community; endorse the removal of taxes and major financial barriers; and support a coordinated and harmonized ITN strategy." Or, by way of another example, messages on treatment of fever might be delivered "through community/home-based channels, the private sector, at the health facility, and in some cases, through traditional healers." One of a number audiences might be medicine dispensers, who could: "ask about previous treatments (to identify treatment failures) and symptom history; dispense the right ACT in the right doses; explain clearly how to take medication and discuss side effects; in areas of stable malaria transmission, treat all febrile children under 5 with the appropriate ACT; and ask about signs of severity and refer to health center when necessary."

Prior to completing the Malaria Operational Plan (MOP), PMI country teams do a rapid assessment. The assessment includes reviewing existing plans, identifying gaps in policy, commodities provision, and programme implementation and compiling and assessing current knowledge, beliefs, practices, opinions, and other behavioural determinants. The purpose of the assessment is to identify any community mobilisation and demand creation gaps and/or opportunities addressing cultural change, ownership, and participation, as the starting point for developing a communication strategy and activities. Rapid assessment can include the following: “household survey results, including Demographic and Health Surveys (DHS); health facility data; MOH/NMCP, health education unit policies, guidelines, training materials; programme review reports (focused program review, comprehensive review or desk review); country program profile; KAP (knowledge-attitude-practice) survey results (constitutes literature search-both published and gray); qualitative research or ethnographic study reports about what people know, believe, and do concerning malaria/fever, including what they call different types of fever, what they believe causes them, and how they treat them; other donors/partners implementing malaria activities, including bilaterals; and interviewing researchers who have conducted studies on these topics.” From these results, a formative assessment can be done. The findings from any new formative assessments, combined with those from the rapid assessment, are used to develop the communication strategy that will describe interventions and define the objectives, timing, sequencing, and frequency of activities. (The document provides a reference to A Field Guide to Designing a Health Communication Strategy, which was produced by the Center for Communications Programs at the Johns Hopkins University.)


Selecting Interventions: Objectives, Timing, Sequencing, and Frequency of Activities


For selecting interventions and designing time, sequencing, and frequency, the document offers tables sorted by audience, desired behaviours, social or other outcome, assets, challenges, suggested approaches/specific techniques, rapid assessment, and monitoring and evaluation options. For example, under the desired behavioural, social, and other outcomes column in the IRS section, the focus on sprayers includes the quality of the work and the practice of precautions for female sprayers to first be tested for pregnancy and cautioned not to spray if breastfeeding; assets column lists adequate training facilities and high staff retention for sprayers; the challenges column lists low literacy rates of sprayers; the suggested approach column lists certification of sprayers and a Q/A pocket guide as a job aide, as well as pictorial information, education, and communication (IEC) materials for safety among female sprayers; the rapid assessment column lists observations and sample surveys of sprayers; and the M&E column lists the same techniques as rapid assessment.


Programme Implementation

The programme implementation section offers a checklist of "Communication Interventions/Activities to Consider", including consensus building meetings; key message development; development of job aids and tools, as well as points for media; interpersonal communication (e.g., community-level public meetings with heads of households, house-to-house activities, or small-scale training sessions with expectant mothers given by health workers, community health workers, and other community influentials); and "Mass Media – Radio spots, Television spots, Print materials", including fact sheets of questions for people to ask health providers, slides and scripts for presenters, 'how-to-booklets and talking points for home and community visits; videos to trigger discussions; and job aids with talking points for professional health workers, drug vendors, and/or sprayers.


M&E

The document has a timeline for combining media interventions based on the MOP and a "Checklist for Effective Dissemination of Communication Materials", as well as a sample budget. It also contains capacity building and exit strategy suggestions including: "Joint monitoring and training activities with NMCP/MOH counterparts"; "Training of trainers"; and “Specific workshops on M&E, technical and creative work." Communication integration is covered in the section: "Integration of PMI Communication Activities with Other Child Survival, Maternal Health, and Infectious Disease Interventions".


The M&E section provides a list of required minimum monitoring and evaluation standards for communication activities for in-country monitoring. It includes what to describe about the process of strategy, materials, and activity development and implementation, including methodology and when the steps happened. It contains an appendix (B) of process indicators for which data is to be gathered - such as the number and frequency of radio spots; rapid monitoring question samples and a checklist; advise on recording costs - and when and how to gather data; and examples of how process indicators may relate to PMI outcomes indicators.


The document concludes with appendices and linked reference materials.