Lessons learned in Home Management of Malaria: Implementation Research in Four African countries

This 80-page report shares experiences and lessons learned over the past several years in home management of malaria (HMM), based on studies undertaken by the Special Programme for Research & Training in Tropical Diseases (TDR) and the World Bank. The report focuses on Burkina Faso, Ghana, Nigeria, and Uganda, where country teams have completed community-based studies on HMM, assessing its operational feasibility, acceptability, and (in Burkina Faso) impact on the severe disease. The document is a comparative analysis and documentation of the processes that have enabled teams to implement HMM in various settings, and authors state that the implementation steps described and lessons learned provide a valuable base on which to build.

The report explains that HMM has become a cornerstone of malaria case-management and, more generally, of malaria control in sub-Saharan Africa. The three key phases are pre-intervention, intervention, and monitoring and evaluation. Each of the countries undertook 10 steps designed to achieve the objective of increasing the extent of early and appropriate treatment of childhood fevers at household and community levels. Each country established a core working group, set objectives, and held consultations with key stakeholders from community level through to national level. The teams conducted a situation analysis and went on to select drug distributors. The intervention processes included procurement of drugs, preparation of training manuals, training of key implementers, and then the actual dispensing and use of the drugs at the community level.

Several key communication strategies are identified as part of this process:

Consultations
According to the report, two principal factors contributed to the acceptability of the projects in communities. One was the community entry process: involving key figures from all social, political, and religious groups was critical, as was using community leaders and other influential individuals to introduce the core teams to the people of the various communities. The second was the sustained and interactive nature of consultation and negotiation with stakeholders. Getting stakeholders interested in the activity involved exhaustive face-to-face consultations and discussions from the national level through to the community level – not just briefing the stakeholders and seeking their approval for the study, but actively involving them in the various discussions and negotiations. Communities in the four countries were approached either through community durbars or through meetings with community elders. The rationale for the studies and the role of each community in the intervention were explained. After the initial contact, research team members returned to consult community members whenever the need arose. This constant interaction contributed to the success of the programmes and enabled community members to share their concerns with the core working teams.

Training
A variety of training approaches were used, including group training skills, skill-enhancement strategies (during follow-on training and monthly supervisory meetings), and person-to-person communication (during individual on-site supervision of distributors and parish supervisors). In the training sessions for distributors, ample time was devoted to practical demonstrations. The trainers used role-plays and demonstrations to teach distributors how to assess, classify, and treat children with malaria and pneumonia. The distributors were then given a chance to practice and received immediate feedback. In developing training manuals it is important to consider the various categories of people to be trained and to tailor the manuals to suit their needs – the simpler the manual, the easier it is to understand. Distributors who are not fully literate represent the greatest challenge: a significant amount of time was invested in training such people and monitoring them when drugs were dispensed.

Information, Educations, and Communication (IEC)
Each of the four countries used different IEC techniques. What was common to all, however, was the pivotal role of IEC in determining the success of the interventions. In Burkina Faso, information/sensitisation tours were organised to all the communities in which the strategy was implemented. Treatment charts, drug labels, posters, and radio jingles were used to explain to community members how the drugs should be used. The project in Ghana made use of an IEC flipchart and similar strategies to improve the health care-seeking behaviour of the communities. The flipchart carried pictures that illustrated these points; it was pretested and then reviewed at a meeting of the core team. The results of the pretesting were discussed and the necessary changes were made. In Nigeria, strategies used for IEC included community sensitisation, individual counselling of caregivers by trained distributors, the use of posters and drug labels, short stories on flipcharts, plays developed by drama experts and performed by high-school children, and drug labels. The drama messages focused on the benefits of prompt and appropriate treatment and the dangers of delay between onset of febrile illness and action by caregivers. They stressed the importance of early recognition and prompt effective treatment of malaria, of giving treatment as instructed and completing the full dose, and of recognising severely ill children and referring them to the nearest health facility. Visual media and activities were used in Uganda to increase awareness and encourage the use of prepackaged drugs – posters, messages on calendars and t-shirts, drama, and games. Whenever there was contact with mothers/caregivers, messages stressed the appropriate treatment of fever (malaria) in children under 5 years of age using the pre-packaged drugs.