The document reviews malaria prevention and treatment approaches used in USAID's Child Survival and Health Grants Program projects. It finds that the projects improved key malaria indicators like child ITN use and treatment of fevers, though national data showed smaller gains. Behavior change communication strategies included involvement in developing national tools, replication of effective approaches, and adjustments based on evaluation. Gaps identified included addressing malaria in pregnancy, demand creation with limited supplies, addressing low risk perception, improving materials for illiterate groups, and sustainability planning. Recommendations include more detailed reporting on community mobilization, promoted messages, and interpersonal contact quality and frequency.

1. A Review of the Approaches to Improve Malaria
Outcomes through Changing Knowledge,
Attitudes, and Behavior in USAID’s Child
Survival and Health Grants Program
Phase I: Preliminary Review Results
Debra Prosnitz, Kirsten Unfried, Jennifer Yourkavitch
April 25, 2013

2. Introduction
 PMI requested MCHIP conduct a review of USAID’s
CSHGP projects to examine malaria BCC to improve net
use, case management, IPTp, adherence to diagnostic
results, and care seeking.
 Until FY 13, PVO/NGOs implementing CSHGP projects
developed DIPs and submitted evaluation reports that
describe behavior change strategies.
 All projects report data on key outcome indicators, inputs,
and outputs
CSHGP Project Reports can be accessed at:
http://www.mchipngo.net/controllers/link.cfc?method=project_doc_search

3. Behave Framework
Designing for Behavior Change curriculum is available at:
http://www.coregroup.org/storage/documents/Workingpapers/dbc_curriculum_final_2008.pdf
Priority and Supporting
Groups Behavior Key Factors Activities
Pregnant women Take IPT Barriers: low knowledge of the
benefits of IPT; low perception of
the severity of malaria for self
and unborn child; ANC visits not
perceived as needed; distance
to health facility
Facilitators: desire for
uncomplicated pregnancy and
healthy baby
Radio messages, drama
groups, support materials;
Indicators: % pregnant women receiving IPT
Family members Encourage pregnant women to
receive IPT.
Barriers: low knowledge about
IPT and its benefits; and
acceptance of ANC and IPT
Facilitators: desire for healthy
outcome of pregnancy
Radio messages; drama
groups, support materials
Indicators: % women reporting family support
Health workers Counsel pregnant women about
IPT in a friendly and
knowledgeable manner
Barriers: lack of time; lack of
knowledge; lack of supply
Facilitators: desire to perform job
well; desire to improve outcomes
Counseling training for health
workers and TBAs with job
aids, improved reporting tools
(including reporting that
highlights supply issues);
improved supportive
supervision
Indicators: % records indicating counseling regarding IPT or IPT distribution
% health workers that can correctly state information about IPT

4. Methodology
1) Review of quantitative data collected by
projects (KPC) to assess improvements in
malaria indicators over time and comparison
with DHS trends; and
2) Document review (FE reports) to assess
behavior change communication strategies
and tools, interpersonal contact, and
numbers of people trained and reached with
malaria messages.

5. Included Projects
Liberia (2006-2010)
Medical Teams International (MTI)
(New Partner – 20% Malaria LOE)
Grand Cape Mount County
Pop. 138,138
Senegal (2002-2006)
ChildFund International (CFI)
(Cost Extention – 15% Malaria
LOE)
3 districts in Thies Region
Pop. 184, 259
Kenya (2004-2009)
Plan International USA
(Standard – 25% Malaria LOE)
Kilifi District
Pop. 257,522
Mozambique (2004-2009)
World Relief
(Expanded Impact – 20% Malaria
LOE)
5 districts in Gaza Province
Pop. 247,002
Cambodia (2001-2006)
Catholic Relief Services (CRS)
(Standard – 30% Malaria LOE)
4 districts in Battambang Province
Pop. 177,834

6. Results
Child ITN Use: Percentage of children 0-23 months who slept under an insecticide-
treated bed net the previous night
PVO Data National DHS Data Regional DHS Data
PVO Country
Baseline
Value
(%)
Endline
Value
(%)
Change
(%)
Averag
e
Annual
Change
(%)
Baseline
Value
(%)
Endline
Value
(%)
Change
(%)
Averag
e
Annual
Change
(%)
Baseline
Value
(%)
Endline
Value
(%)
Change
(%)
Averag
e
Annual
Change
(%)
CRS Cambodia
84.3
(80.3 -
88.3)
87.9
(82.8 -
93.0)
3.6 0.7 n/a 4.2* n/a n/a n/a 3.9 n/a n/a
Plan Kenya
21
(17 - 25)
76.7
(71.0 -
82.4)
55.7 11.1 6.0 46.7 40.7 7.4 8.5 56.9 48.4 8.8
MTI Liberia
17.7
(13.5 -
22.5)
69.3
(63.8 -
74.5)
51.6 12.9 n/a 26.4 n/a n/a n/a 32.2 n/a n/a
WR Mozambique
8.1
(3.7 -
12.5)
20.0
(14.0 -
26.0)
11.9 2.4 9.7** 17.5 7.8 1.0 22.2** n/a n/a n/a
CFI Senegal
50
(44.3 -
55.7)
97.4
(95.0 -
99.8)
47.4 11.9 7.2 29.2 22 6.3 5.4 29.9 24.5 7.0

7. Child Fever Treatment: Percentage of children 0-23 months with a febrile episode that
ended during the last two weeks who were treated with an effective anti-malarial drug
within 24 hours after the fever began
PVO Data National DHS Data Regional DHS Data
PVO Country
Baseline
Value
(%)
Endline
Value
(%)
Change
(%)
Average
Annual
Change
(%)
Baseline
Value (%)
Endline
Value
(%)
Change
(%)
Average
Annual
Change
(%)
Baseline
Value (%)
Endline
Value
(%)
Change
(%)
Average
Annual
Change
(%)
CRS Cambodia n/a n/a n/a n/a n/a 0.2 n/a n/a n/a n/a n/a n/a
Plan Kenya
18
(n/a)
67.5
(58.9 - 76.1)
49.5 9.9 10.8 11.7 0.9 0.2 18.7 8.7 -10 -1.8
MTI Liberia
3.6
(1.0 - 8.9)
32.5
(24.3 - 40.7)
28.9 7.2 n/a 37.6 n/a n/a n/a 40.8 n/a n/a
WR Mozambique
17.4
(7.3 - 27.5)
62.1
(47.1 - 77.0)
44.7 8.9 8.3 22.2 13.9 1.7 11.4 n/a n/a n/a
CFI Senegal
64
(n/a)
82.4
(n/a)
18.4 4.6 12.2 4.2 -8 -2.3 7.2 1.7 -5.5 -1.6

8. Results: Summary of BCC Strategies
 Projects had significant involvement and input into development of
national strategies and tools.
 CRS Cambodia was involved in C-IMCI working group to develop BCC
curriculum for Village Health Volunteers
 Behavior Change strategies implemented by some projects have been
replicated in other contexts by other partners and NGOs
 WR Mozambique developed and implemented the Care Group approach, a model that
has been adopted and adapted by multiple NGOs in many different contexts*
 None of the projects conducted studies that explicitly compared
communication channels or methods that address malaria, though
PDME processes examined BCC approaches, and projects adjusted
implementation accordingly
 PLAN Kenya conducted a special study on the Care Group approach; CRS Cambodia
identified gaps in overall BCC approach and hired a BCC expert to revise the strategy

9. Conclusions: Gaps and Common Challenges
 Malaria in pregnancy not specifically addressed, though may be
included in promotion of ANC uptake
 Creation of demand in a context of limited supplies
 How to adequately address low perceived risk during low malaria
transmission seasons, leading to low ITN use among those who own
ITNs
 IEC materials could be better designed for use in illiterate populations*
 Need to involve community structures more holistically, beyond filling
gaps in government health services**
 Strategies to mobilize and educate the migrant population should be
strengthened
 Inadequate sustainability planning, particularly as related to motivation
and supervision of community-based agents

10. Recommendations
 More detailed definitions of community
mobilization strategies
 More detailed reporting on what messages are
promoted in different intervention packages (e.g.
ANC promotion and IPTp)
 Systematic collection and reporting on type and
frequency of interpersonal contacts (quantitative
measures) and quality of contacts

11. Thank You!
World Relief, Mozambique