By: Michael Gibbs
When you hear about “last mile” problems in public health, it generally references the distribution of medicine down to the local service providers. The problem is often framed in terms of government policy and infrastructure, something to be addressed from the top down. Yet in the context of malaria, that last mile is really the physical mile from clinics to people’s houses and the mental mile between what they believe about malaria and what they actually do.
The biggest problem with malaria at this point is not knowledge. A surprising number of people in this country know quite a bit about the disease. The rub lies in translating those words into deeds. For every person who says malaria is spread by mangoes or beer, there are another six or seven who know that mosquitoes cause it. The public health work isn’t just getting that last holdout to understand parasite vectors; the real struggle is getting those six or seven to protect themselves, because even the well-informed don’t always take adequate precautions.
The workshop I attended last week focused entirely on that issue. What makes malaria control difficult compared to my other jobs here (especially literacy) is the focus on practice instead of knowledge. Teaching someone how to read is not an hour-long deal. They have to practice on their own, yes, but developing even basic reading skills requires months and months of effort with a dedicated teacher. No one does a half-day session on reading and expects the entire audience to understand War and Peace, or even The Magic School Bus. In contrast, a lesson on basic malaria prevention can cover how to use LLINs (long-lasting insecticide treated nets), clean the environment around the house, and obtain basic testing and treatment in a few hours. Getting someone to apply all of that, though, requires a monumental change not only in how they manage their house but in how they see the fundamentals of health, destiny, and culture.
That exploratory process was our first objective at behavior change communication (BCC) malaria training. What to an outsider might seem like a clear-cut issue—LLINs reduce the prevalence of malaria—is often hedged with a variety of small but sharp concerns. What if nets don’t work? What if I can’t get one? What if God doesn’t want me to use one? (Common variation: “What if who gets malaria is in God’s control?”) What if they make it too hot to sleep? What if I forget to put it down most nights? What if no one else is using them? What if I don’t know how to use one?
Each one of these concerns is perfectly understandable. For many, the extent of their malaria knowledge boils down to someone saying, “Use a tent [local term for LLIN] and you won’t get malaria.” They’ve never had anyone explain the whole process of disease transmission, or show them how to hang a net, or kept reminding them until it becomes second nature (think about how long it took you to learn to wash your hands), or heard all their neighbors talk about using them.
The upshot is that any public health campaign here has to start with surveys (generally called doer/non-doer studies and barrier analysis). If the problem is access to nets then LLIN distribution by the Government of Sierra Leone is an effective way to cut malaria. But if the problem is more personal, adding more nets to the mix is necessary but not sufficient—it has to be combined with a message that addresses the barriers. If it’s religious you probably want imams and pastors talking about LLINs; if it’s skills-based, you probably want a workshop on how to set them up (actually several, with refreshers, to give people practice); and if it’s a style thing, teach them how to bluff (show off, in Krio) with the nets.
After such a campaign comes my favorite part in the health care system—collecting data, analyzing it, and making refinements. I enjoy it primarily because it provides such scope for inventive design.
The BCC training was structured so that we spent four days in a group of three steadily refining proposals for a single activity. One group focused on environmental cleaning, three on LLIN usage, and mine on testing. Our goal was to design a program that would lead Sierra Leoneans, when they had a fever, to get tested for malaria (and then taking ACTs) instead of just assuming they had malaria (and taking whatever treatment they could find). Based on pre-conference discussions with neighbors we figured that the main barriers were knowledge (most people in K Town don’t know about the tests), access (limited supply of RDTs), cues for action (nobody had a habit of getting tested), and belief in testing’s efficacy (a dearth of upbeat stories).
The first and last were ones we could directly address, the second was beyond Peace Corps’ ability to control, and the third was where we had fun. We designed an information session PCVs could quickly and easily deliver to groups in common gathering spots (wells, football matches, court barre, market, etc.). It would explain the components, costs, time required, and utility of RDTs and microscopy, hopefully addressing the first and fourth barriers. For the cue to action, we decided to distribute at our information session big yellow vouchers offering free testing. Since testing is supposed to be free to pregnant women and children under five, the groups we would target, the vouchers wouldn’t actually cost the clinic or hospital anything. Instead, they would serve as a very visible reminder of the session, and hopefully also encourage people who felt ill to get tested.
They also would serve a second purpose: data collection. Bringing in those vouchers would entitle each person to a cheap but visible prize (lollipop, sticker, temporary tattoos) so that everyone in town could see they were tested. They would get their photos taken and placed in a hall of fame inside the clinic or hospital, giving them a chance to bluff in a public place. Finally, they would be entered into a lottery for some large prize, similar to the way phone companies here attract customers. All these gimmicks would serve one main purpose—get people tested. In bringing in their vouchers, though, they would also provide us with an important dataset—the number of people we educated who altered their behavior. Basically, it could help tell us if our project was effective.
Those of you still awake will note that, to be helpful, we’d also have to find a way to measure how many people we educated didn’t use their voucher to get tested. Unfortunately, the best answer we could come up with was a survey, going door to door among those who didn’t turn their voucher in to ask if they’d had any malaria. The problem is that surveys around here are known for skewing, so our data would be skewed (perhaps enough to make the results meaningless).*
Leaving aside that problem, our experimental program is ready to go. We’d identified a need, estimated what the major barriers were, tried our best to focus on the salient issues, and checked it with the PC Salone malaria team and Sierra Leonean staff. All that’s left is the field trial, something we’ll probably do during third term. Definitely a good way to spend a week, and I look forward to applying the lessons both to malaria work and future literacy endeavors.
*If any of you can think of a way to avoid surveys and get accurate data on the treatment group that didn’t respond, please let me know. For all you statisticians/public health campaign workers out there, it would be a huge help.