In 2015 there were approximately 212 million malaria cases and 429,000 related deaths globally, the majority of both occurring in sub-Saharan Africa (SSA).1 While surveys show that people in SSA have knowledge of the cause, signs and symptoms of malaria, as well as awareness of how to prevent it, uptake of key malaria case management behaviors remains suboptimal. Proper home care, prompt care seeking for fever, compliance with referrals and adhering to provider prescription instructions are community-level case management behaviors that must be paired with quality diagnosis and treatment among service providers.
Only half of febrile children under five were taken to a trained provider between 2013 and 2015. Of the febrile children whose caretakers did visit public facilities three-fourths received a parasitological test. Only 14% of children under five with evidence of recent or current Plasmodium falciparum infection and a history of fever were treated with artemisinin-based combination therapy (ACT). There is clearly room for improvement of malaria case management behaviors at both the community and service provider levels.
This guidance is aligned with World Health Organization (WHO) Test, Treat, Track (T3) guidance on malaria case management:
- Every suspected malaria case should be tested.
- Every confirmed case should be treated with a quality-assured antimalarial medicine.
- Every malaria case should be tracked in a surveillance system.
S ocial and behavioral change communication (SBCC) seeks to increase knowledge, change attitudes, and promote the adoption of a set of health behaviors among individuals and communities through shifting social norms. In recent years malaria SBCC campaigns have focused on influencing the knowledge, attitudes, and behaviors of not only individuals, but their social networks as well.
1 Standard indicators
2 that measure attitudinal factors like perceived fear, self-efficacy, and perception of social acceptability are improving the rigor with which SBCC activities are measured.
Case management of malaria has changed a great deal since the introduction and widespread use of rapid diagnostic tests (RDTs) and artemisinin-based combination therapy (ACT). These changes demand shifts in the way individuals, households, communities, and service providers think about malaria case management. Prompt care seeking for fever continues to be emphasized by SBCC campaigns, but families are now being asked to demand for a test before seeking medication. Service providers are being asked to replace clinical diagnosis of febrile patients with blood testing. While supply-side factors such as RDT and ACT availability play a definite role in uptake and use of these essential commodities, efforts to eliminate stock-outs should be paired with activities that establish trust in RDT reliability (response efficacy) among providers and in communities.
Rigorous monitoring and evaluation of SBCC that addresses these new case management approaches must be applied to ensure that resources are allocated to evidence-based programming. While case management SBCC interventions have changed and the standard indicators to measure their effect have only been recently adopted, the tools used to successfully measure and evaluate SBCC programs remain the same. Household questionnaires at the national and sub-national level, focus groups discussions, client exit-interviews, etc. continue to be an effective means of measuring knowledge, attitudes, practices, and social norms. However, practitioners must know where, when, and how to correctly use these measurement tools.
With this in mind, this guidance document was developed to support professionals from National Malaria Control Programs (NMCPs), health promotion units, technical working groups and implementing partners to monitor and evaluate their malaria case management SBCC activities. This reference tool highlights key considerations when developing and implementing monitoring and evaluation (M&E) strategies and activities. It also includes practical examples from three core malaria case management interventions to help troubleshoot frequently faced problems. These core interventions include:
Recognition of malaria signs and symptoms and prompt care seeking at the community level for febrile children under 5
Prompt care seeking at the community level remains the cornerstone of malaria case management. Guidance on measuring this intervention's impact is most likely to serve the greatest number of SBCC practitioners.
Demand generation for testing before treatment among parents and guardians of children under 5
The increased emphasis on testing before treatment requires SBCC programs to improve the communities’ desire for and acceptance of RDTs, so that demand matches supply and available RDTs. The second focus of this guide will describe how to measure increased demand for proper diagnosis before treatment.
Provider adherence to national diagnosis guidelines (regarding treatment according to test results)
High levels of adherence to diagnosis and treatment guidelines will ensure ACTs are more readily accessible, and used on only those who require them. To assist those working to improve compliance with national guidelines, the third focus of this guide will explore a means of measuring service provider attitudes and behaviors.
In the Examples section of this I-Kit, three interventions are paired an appropriate monitoring or evaluation approach corresponding to the three interventions listed above. Each example will use a common scenario to frame instructions on how to monitor or evaluate SBCC activities in that context. Examples will end with a program example that employed the approach described. While the examples are designed to illustrate practical, evidence-based approaches for specifically monitoring and evaluating malaria case management, the general lessons can be applied to a number of other SBCC interventions. These interventions are not included to suggest prioritization, but because they illustrate both community and service provider issues.
