Malaria Education: Tapping All Means of Outreach
by David Montez, Research Analyst
Malaria remains the leading cause of both morbidity and mortality in Tanzania, especially among young children, despite a 50 percent reduction in infection rates over the past decade. Clearly, there is an ongoing need to educate the public about malaria's causes and methods of preventing infection.
The 2010 AudienceScapes survey of Tanzania (n=2,000, nationally representative) included a module to measure people's access to information in general, and access to health information in particular, as well as access to health services. The data yield some guidelines for public health professionals seeking to educate the public about malaria:
- National and local radio continues to play a significant role in delivering malaria information to at-risk populations. However, word-of-mouth networks also require attention from public health workers, particularly among socioeconomically constrained populations with low levels of access to media outlets.
- A large proportion of Tanzanians across the country said they have access to clinics and medical doctors. However, there is great variability among respondents of different regions as to the usefulness of medical doctors as a source of information about malaria. This points to the need for increased outreach to clinics and hospitals in high risk provinces of the country like Kagera, Mwanza, and Mtwara where infection rates are twice the national average.
- A majority of survey respondents said they receive enough information about malaria prevention. However, malaria also is one of the heath issues that many Tanzanians say they want more information about. This suggests a case of improper messaging, whether it is ineffective framing of the issue or the use of inappropriate communications mediums, and the need for improved message testing.
International development NGOs, in cooperation with the Tanzanian government, have been highly active in the East African country over the past decade, distributing more than 8 million insecticide-treated nets (ITNs) to vulnerable populations. These actions, coupled with a national malaria behavoir-change communications campaign in late 2007, helped to cut in half the disease’s national infection rate.  However, many areas still have high rates of infection, notably the provinces of Kagera, Mara and Mwanza, which border Lake Victoria, and Lindi and Mtwara on the south-eastern coast, according to a 2007/2008 Tanzania HIV and Malaria Indicator Survey.
How can public health officials best reach Tanzanians in need of information about malaria? The AudienceScapes survey data provide some clues.
Radio continues to be the main go-to source for news and entertainment for most of the population, with television remaining a luxury for those outside major urban centers. The large majority of TV viewers residing outside of Dar es Salaam tend to watch TV outside the home. In most provinces, less than half of TV viewers said they watch at home. Overall, the importance of television as a source for either news or health communication increases in areas like the capital where weekly TV viewership is twice the national average.
While our survey is only a snapshot in time, on the surface it seems that information campaigns looking to expose Tanzanians to information about malaria have been successful. Nationally and in each province, about three quarters of all respondents said they had received malaria information in at least the past week. Even among women of birthing age, a key target group for malaria prevention, over 80 percent said they had received information in the past week, regardless of whether they lived in an urban or rural area.
Despite this, malaria also emerged as a leading health topic that respondents want more information about. This points to a strategic problem with malaria messaging, whether it is ineffective framing of the issue or the use of inappropriate communications mediums.
Overall, the level of an individual's consumption of news media appears to influence their level of exposure to information about malaria. Indeed, the 17 percent of our sample who had not received malaria information during the past month or longer (low access), were also significantly less likely to be daily or weekly consumers of news media (radio or television). Note that about 64 percent of the low access group resides in households earning $2 a day or less. In addition, 76 percent of this group have only a primary education or less. (Figure 3).
Interestingly, this low access group has similar levels of access to health clinics and medical doctors than those with high access to malaria information. This seems to have resulted in an equal use of medical doctors as a source for information on malaria.
Use of mass media is also a key factor for some at-risk provinces. For example, 29 percent of respondents in Kagera province said they had received information about malaria in the past month or longer. The province also has the lowest rate of weekly radio listeners in our survey (Figure 1 and 2). This gap in general media exposure in Kagera is critical as radio remains the most useful mass media tool across the country. In 2008 and 2009, radio was a crucial part of the U.S. President’s Malaria Initiative’s behavior change and communication education efforts through the broadcasting of messages stressing the importance of sleeping under ITNs, medical treatment adherence, and prevention measures.
While radio does remain a crucial tool for vulnerable and low access groups, word-of-mouth mechanisms, whether through doctors or existing social networks, act as important information dissemination mechanisms that have the potential to provide more in-depth health advice. Given the mass media use gap between low and high access groups, it is crucial for health practitioners to fully exploit local word-of-mouth networks.
Indeed, some prominent anti-malaria programs acknowledge this and have trained "Change Agents" in Tanzania to help educate the public. For example, the PMI ran a program that trained 1200 Community Change Agents in 11 regions by the end of 2009 on the proper use of insecticide-treated nets and malaria medications. The PMI's goal was to have 2900 Change Agents in the field by the end of 2010. In addition, Population Services International and the Global Fund to Fight AIDS, Tuberculosis and Malaria are training and deploying Change Agents.
Initial assessments of the initiative in 2009 showed greater awareness and knowledge of ITNs and malarial treatments but indicators measuring access and attitudes towards treatment and prevention remained low. These results highlight the challenge of behavior change communication and its ultimate goal of turning knowledge and awareness into action.
In order for these Change Agents to successfully reach vulnerable and low access populations, they need to be cognizant of the socio-economic constraints of their target audiences and be able to identify and exploit locally trusted word-of-mouth networks. These Change Agents have been tasked to work closely with local Ministry of Health clinics. These clinics offer Change Agents a venue to identify at-risk populations and community influentials, along with an opportunity to share a more in-depth educational message than a mass media message might offer.