In this example you will learn about how focus group discussions and in-depth interviews were used to monitor malaria case management SBCC activities being implemented to increase knowledge, change social norms, and promote gender equity in roles among caregivers of children under 5. An inexpensive quantitative method (Omnibus surveys) is introduced in this example as well. The STOP Malaria Uganda project illustrates how these qualitative methods were used to show project progress and produce concrete recommendations for improvement.
Use this example and the links included to think about how to monitor and improve malaria case management SBCC activities.
Case Study
One of the finalists schools in the National Music Dance and Drama competition perform their original song about the impact of malaria in their community. (Photo Credit: Kim Burns Case)
The Uganda Stop Malaria Project, a USAID President's Malaria Initiative-funded consortium project managed by Johns Hopkins Center for Communication Programs (partnering with the Malaria Consortium and the Communication for Development Foundation Uganda, and Infectious Diseases Institute) was implemented between 2008-2015 in collaboration with the Government of Uganda. The primary aim of the project was to reduce malaria in the country.
The Stop Malaria Project worked with the Ministry of Education to incorporate malaria as a theme in a national music, dance, and drama competition, engage communities with drama, village and group meetings, provide training in interpersonal communication and job aids for health workers.
In 2012, Communication for Development Foundation Uganda (CDFU) conducted a qualitative assessment of community mobilization interventions that aimed to increase knowledge and attitudes related to malaria prevention and control. 79 key informant interviews were conducted with district officials, school teachers and administrators, health assistants, health facility personnel and community listnership groups. 67 focus group discussions were held with parents, pupils, pregnant women and listenerships.
Results:
- District officials reported improved knowledge of malaria prevention and treatment among school children
- Pupils reported improved attitudes and practices in malaria prevention and treatment
- Focus group discussion participants were more knowledgable about malaria prevention than those not exposed
- District officials in intervention districts reported improvement towards malaria control in schools, health facilities, and in their communities
Recommendations:
- The Stop Malaria Project could be improved by increased collaboration with District Management Teams, by using participatory development and integrated work plans and budgets, participation in review meetings, and conducting joint support supervision.
- The Stop Malaria Project should actively involve males in core planning and implementation of activities supporting all intervention areas.
Replicate the scenario and learn
A five-year USAID-funded SBCC project has begun work in a Sub-Saharan African country with endemic, stable malaria transmission. Due to budget restrictions the project has been directed not to conduct baseline and end line surveys. Instead, project leaders have been instructed to conduct a midline qualitative assessment to determine whether or not project activities need to be adjusted half way through the project cycle. Qualitative research will be conducted at the community level to understand gaps in knowledge, prevailing attitudes, social norms, and gender roles among caregivers of children under 5. Project leaders have been instructed to present a report to the National Malaria Control Program, Health Promotion Unit, and USAID that describes exposure to SBCC activities and knowledge, attitudes, and practices among those exposed.
Qualitative measurement tools
Focus Group Discussions: Use quota sampling to select focus group participants. After obtaining informed consent, facilitate focus group discussions among caregivers of children under 5 who have been exposed to SBCC activities in order to:
- Determine knowledge levels of malaria signs and symptoms
- Explore the extent to which social norms and gender roles influence prompt-care seeking behavior among caregivers of children under 5
- When do mothers seek healthcare from a trained healthcare provider for their child’s malaria? What are the reasons a mother would NOT seek help for her child?
- What is the decision-process for seeking care for their child’s malaria? Is this different for male and female children? Who makes the final decision?
- Where do mothers usually go for treatment for their child’s malaria?
- Do mothers feel confident that they can get the help they need for their child?
- What are the perceptions of local facilities where child healthcare is provided?
- What are the local names for malaria?
- Are there names for different types of fever?
- What are the local names/descriptions for symptoms associated with malaria?
- What are the local perceptions of causality? Of seasonality?
- What are the local perceptions of susceptibility of a child to malaria?
- What is the local perception of severity of malaria?
- What are the local terms for fever?
- What are the local remedies for malaria?
- Where or from whom do mothers/family members/community members get information or advice about malaria? About treatments for malaria?
- Who are the individuals in the community that are perceived as opinion leaders when it comes to childhood illnesses?
- Who in the household has the final say on how a child with malaria is cared for?
- What information about malaria have mothers heard in the last 6 months? Where? What?
- Who do mothers first go to for advice or treatment for their child’s fever?
- What are the local foods, drinks, traditional remedies used to treat fever? Are these different for male and female children?
- What changes in diet are followed during the onset of fever? Are these different for male and female children?
- What are the medicines (e.g., antimalarials) to treat malaria? What forms of these medicines are taken? How much? For how long? Are these different for male and female children? What affects adherence to taking these medicines?
- What are the local perceptions of these medicines?
- What concerns do mothers have about medicines to treat malaria? Cost? Adverse reactions?
- Where or from whom are these medicines obtainable? What are the barriers to obtaining these medicines?
- During her child’s last fever, what did the mother do to manage/treat her child?
- How much support do you receive from you husband/wife when your child has malaria? What type of support?
- How much support do you receive from you friends/neighbors when your child has malaria? What type of support?
- What other types of support do you receive when your child has malaria?
- Do you think your husband (wife, family, neighbors) would approve of you using antimalarials to treat your child’s malaria?
Key Informant Interviews: Use purposive sampling to select 15-35 key informants (male and female traditional and religious leaders). After obtaining informed consent, conduct in-depth interviews to:
- Determine which prevailing attitudes contribute to social norms and gender roles (identified in focus group discussions) that influence prompt-care seeking for fever and discuss the origins of these attitudes
- Generate recommendations, based on interview themes, to inform adaptations in SBCC activities related to encouraging prompt care-seeking for fever among caregivers of children under 5
Omnibus surveys: In the common scenario above budget limitations forced project personnel to make use of an inexpensive method of assessing knowledge, attitudes, and practices of a limited number of respondents. Depending on whether your country has omnibus surveys (market surveys usually used to inform private enterprises about exposure to consumer products) it may be possible to use this relatively inexpensive quantitative tool to measure SBCC exposure and whether it is correlated with desired attitudes and behaviors.
Omnibus survey data: Purchase questions on an omnibus survey to determine:
- Exposure to malaria case management SBCC: proportion of caregivers who recall hearing or seeing a message about prompt-care seeking within the last six months)
- Attitudes (found to be important during focus group interviews and key informant interviews)
- Response Efficacy: Proportion of caregivers who believe that prompt-care seeking for children under 5 with fever will reduce their chance of suffering severe consequences
- Self Efficacy: Proportion of caregivers who are confident in their ability to overcome obstacles to prompt-care seeking
- Behavior: proportion of children under five years old with fever in the last two weeks for whom advice or treatment was sought
USAID Senegal Mid Term Evaluation Report, 2015: Use of in depth interviews with service providers and community level stakeholders to gain perspective on barriers to behavior change and uptake of services: MCH, RH, malaria, HIV/AIDS, TB; interviews focused heavily on family planning and the impact of communication campaign's influence on behavior change; measured persons reached by theme; ADEMAS used a reporting tool among CBOs to track SBCC activities during the project.
National Malaria Control Centre Information, Education and Communication/Behavior Change Communication Technical Working Group Final Assessment Report, Zambia, 2014: FDGs among key staff and in-depth interviews can be used to assess the strengths and identify areas for capacity strengthening. In 2010, Communication Support for Health (CSH) conducted institutional assessments that included a baseline evaluation of the functioning of the IEC/BCC technical working groups (TWG) TWGs placed at the MOH, NAC, and NMCC. Based on the findings of the baseline evaluation, CSH, with the Government of the Republic of Zambia (GRZ), reviewed and updated the Terms of Reference (TORs) and selection criteria for members of each TWG. In addition, CSH and GRZ developed guidelines for pre-testing and evaluating communication materials. To assist in measuring progress towards the project efforts in strengthening the TWGs, CSH carried out a final assessment with the members of the three TWGs, documenting the key successes and changes made from CSH support to the TWGs, assessing what capacity areas still needed assistance and the future plans for each TWG. The assessment was implemented using a FGD with the TWG members. A semi-structured discussion guide was developed to lead the FGDs.