The Malaria Communication Guideline: Inspiring Behaviour Change is the result of three years of work, starting with our multi-phase formative study on malaria high endemic areas in Indonesia and culminating with guidelines co-developed with communities in Southwest Sumba, Manokwari, Mimika, and Jayapura. This is not a technical or expert-defined guideline – the goal was to develop a communication guideline that is relevant, contextualized to different community situations, and can be easily used by both health workers and the general public, using familiar, everyday language rather than technical terms.
The guideline was initially inspired by Empatika's formative study on the Social Determinants Influencing Access to Malaria Services, commissioned by UNICEF in early 2021. For this study we conducted adapted immersions in the four locations mentioned above, where our researchers immersed themselves in the daily lives of communities from early morning to late evening. Over five days, we listened to the stories of around 800 people from diverse backgrounds, ages, genders, and professions. They shared their understanding and attitudes about malaria, including topics such as symptoms, medication and prevention. This immersion-based process also allowed us to observe behaviors and better understand local challenges, adding rich insights from each of the eight communities.
Study findings
People's perceptions and behaviors related to malaria varied in each community, influenced by factors such as social context, information dissemination, access to health/malaria services, and each community’s experiences. One of the key findings was that people in the study locations were not overly concerned about being infected with malaria, with some even saying that malaria is an inseparable part of their lives.
“We are friends with malaria, we are one,” - local people in Jayapura, Papua
People in Jayapura, for example, told us that almost everyone there had been infected with malaria. On the other hand, some people in remote areas of Sumba, Jayapura and Manokwari considered malaria a serious illness. However, they also were not worried because antimalarial drugs are accessible and able to quickly cure malaria symptoms.
In Manokwari, people believed that malaria is an inherited disease and therefore impossible to eliminate.
Overall, we found little public information on malaria in the study locations. Malaria education was only present in one school in Timika, organized in collaboration with the puskesmas. However, we observed that the social dynamics between health workers and communities were not very good, including frustration among health workers who felt that their instructions were not understood by community members.
Co-developing solutions
These findings highlighted significant challenges for behavior change for malaria prevention. To explore ways of overcoming these challenges, in the second phase our team of researchers and facilitators returned to the study locations, co-developing potential solutions with community members through our people-driven design approach.
This phase involved people with key roles in supporting community behavior change for malaria, including women, men, young people, and health workers. During the people-driven workshops, our facilitators used prompts to facilitate participants in digging deeper into the challenges identified in the first phase and selecting one challenge to brainstorm practical solutions. This process led to deeper insights. For example, we found that the frustration felt by health workers was caused in part by the knowledge gap between health workers and the community. Through this process, health workers realized that their instructions were not effective and recognized the need to find a new, more engaging way to communicate with the community.
To counter the challenge of overly sophisticated or boring sources of information about malaria, a group of young people in Sumba proposed using drama as an interactive, fun, and informative communication tool.
Developing the communication guideline
Building on the findings of our formative study and people-driven design, UNICEF invited Empatika to collaborate with the Indonesian Ministry of Health to develop a social and behavior change communication (SBCC) guideline for malaria prevention. For this guideline, the findings from the formative and people-driven design phase, including the solutions designed by communities, were developed into a draft communication guideline for social and behavioral change. In mid-2023, we piloted the draft guideline in the same locations as the formative study. We involved puskesmas and health staff, malaria cadres, village officials, youth, and community leaders to get feedback on the content of the guideline, including explanations, activities, illustrations and sequencing of guideline topics, and what are their challenges in conducting SBCC.
During the piloting process, many communities provided feedback on the explanations and visuals used in the draft guideline. For example, communities in Manokwari thought that explanations related to behavior change could be written using easier-to-understand language, and that supporting images should be captioned. They also suggested changing the word “box story” to “malaria story” and using local stories rather than examples from other countries. In Jayapura, the community suggested adding examples of behaviors and beliefs that hinder the achievement of malaria-elimination, such as illustrations of behaviors that postpone malaria testing or the belief that malaria is normal. Communities in Sumba suggested adding pictures of how to set up bed nets properly so people can easily follow them.
Through the piloting with communities, we wanted to ensure that the guideline is relevant, can be implemented using local resources, and can help both local people and other stakeholders in planning communication activities.
The result of the guideline development process
This communication guideline presents five main steps for the communication strategy for social and behavior change (SBCC), which includes tools and activities for each step to help users understand and practically implement the SBCC strategy.
The guideline also includes a “communication and activity toolkit” section that offers up to 12 fun and interactive behavior change communication activities for children, adults, and health workers. Among them are a malaria snakes and ladders game, a mosquito breeding sites map, a drama, and malaria medicine packaging.
The key value of this guideline lies in the community involvement that took place from the very beginning, starting with the formative study in early 2021 through the draft pilot process in mid-2023. This approach helped ensure that the content of the guideline is relevant to communities and fosters a sense of ownership over the strategies and solutions offered. We strongly hope and believe that this guideline will have a positive and sustainable impact for malaria prevention.
The Malaria Communication Guidelines: Inspiring Behaviour Change is a product of a collaboration between Empatika, UNICEF, and the Ministry of Health of the Republic of Indonesia. This book is published and freely accessible at bit.ly/empatika-panduan-komunikasi-malaria.
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