Attachment J.12.pdf

Zanzibar Malaria Social and Behavioural Change Strategy 2024 - 2029

REVOLUTIONARY GOVERNMENT OF ZANZIBAR

MINISTRY OF HEALTH

ZANZIBAR MALARIA ELIMINATION PROGRAM

2024 - 2029 September 2023

ZANZIBAR MALARIA

SOCIAL AND BEHAVIOUR

CHANGE STRATEGY

Zanzibar Malaria Elimination Program (ZAMEP) Mwanakwerekwe Street, P. O. Box 407, Zanzibar

Any part of this document may be freely reviewed, quoted, reproduced, or translated in full or in part, provided ZAMEP is acknowledged as source. It should not be sold or used for commercial purposes or for profit.

Contents Foreword

Acknowledgements

Acronyms

CHAPTER ONE

BACKGROUND

1.1 Introduction

1.2 Zanzibar Malaria Profile (2022): A Snapshot of Progress

1.3. Empowering Change: Integrating Social Behavioral Strategies into the National Malaria Elimination Strategic Plan 2024-2029

1.4 Updates on SBC Implementation: Following National Malaria Elimination Strategic Plan 2018-2023

1.5 Findings: Malaria Behaviour Survey (MBS 2021)

1.6 SBC Recommendations

1.7 Lessons Learned, Challenges, and Mitigations: Navigating the Path to Malaria Elimination

1.8 Communication Landscape: Navigating the Dynamic Channels

1.9 Empowering Effective Communication for Behavioral Change

CHAPTER TWO

STRATEGIC APPROACH

Goal

Specific Objectives

Guiding Theory: Understanding Social Ecological Model

Social-Ecological Model of Communication

Social-Ecological Framework

Guiding Principles

CHAPTER THREE

IMPLEMENTATION APPROACH

Strategic SBC Matrices for Malaria Interventions: Specific Plans

Integrated Vector Control Indoor Residual Spraying (IRS) Larval Source Management (LSM)

Reactive Focal Mass Drug Administration (rfMDA)

Malaria Case Management

Malaria Surveillance and Response

Entomological Surveillance and Response

CHAPTER FOUR

SOCIO BEHAVIOURAL CHANGE COORDINATION

Roles and Responsibilities of different organs

ZAMEP Management

SBC Unit

SBC Technical Working Group

Partners

Implementing Partners

CHAPTER FIVE

IMPLEMENTATION PLAN

CHAPTER SIX

MONITORING EVALUATION & RESEARCH PLAN

Introduction

Monitoring and Evaluation Indicator Matrix

References

List of Tables Table 1 : Lessons Learned, Challenges, and Mitigations

Table 2 : Guiding Principles

Table 3 : ZAMEP Organizational Chart

Table 4 : Insecticide Treated nets (ITNs)

Table 5 : Case Management

Table 6 : Indoor Residual Spray (IRS)

Table 7 : Malaria Case Detection (MCD)

Table 8 : Larviciding Source Management (LSM)

List of Figure Figure 1: Social Ecological Model

Figure 2: Social-Ecological Framework

Foreword The Zanzibar Malaria Communication Strategy 2024–2029 is a result of the review of the Malaria

Communication Strategy 2018–2023. This strategy aligns with the Zanzibar National Malaria Strategic Plan

(2024–2028), the Global Technical Strategy for Malaria (2016–2030), the RBM Partnership to End Malaria

Toolkit and Investment plan to defeat Malaria (2016–2030), and the Roll Back Malaria Partnership’s guide to ending Malaria BCC Indicators. The operational concepts highlighted in these documents were carefully selected and arranged accordingly.

This document outlines the operational framework for advocacy, communication, and social mobilization

(ACSM) interventions in Zanzibar, taking into account the achievements and challenges in the implementation of the Zanzibar Malaria Elimination Communication Strategy (ZMECS 2018–2023) and changes in governance in the health sector and district leadership.

To ensure the operational effectiveness of the Malaria Communication Strategy 2024-2029, the key messages under each intervention were designed to suit the local context and cultural background of the community.

Furthermore, it is anticipated that malaria stakeholders will efficiently assume their roles and responsibilities, along with coordinating mechanisms in the field.

We are confident that the strategy will play a pivotal role in increasing acceptance of malaria elimination interventions through the commitment and collaboration of multi-sectoral partners at national, district, and shehia levels. I encourage all our partners to increase investment and mobilize their efforts to ensure the effective and efficient execution of this strategy as a means of achieving a malaria-free Zanzibar.

We recognize that reaching the last local malaria case is challenging; however, at this stage, concentrated efforts are critical to ending malaria in our society.

Dr. Amour Mohamed Acting Principal Secretary Ministry of Health Zanzibar

Acknowledgments The Ministry of Health (MOH), through the Zanzibar Malaria Elimination Program (ZAMEP), sincerely acknowledges the support and contributions of all frontline field workers and stakeholders who played a vital role in revising the Zanzibar Malaria Social and Behavior Change Strategy for the period 2024 to 2029, aligning it with the Zanzibar National Malaria Strategic Plan 2023-2028. This strategy stands as a crucial component of our national endeavors to combat malaria, ensuring that Social and behavioral change activities are strategic, focused, and well-coordinated.

The development of this strategy involved a series of consultative meetings with implementing partners, DHMT representatives, and program staff members. We express our gratitude for the active participation of the Ministry of Health programs, units, and representatives from the Zanzibar State University.

ZAMEP extends appreciation for the valuable financial and technical support from USAID through the

Breakthrough ACTION Project led by JHU-CCP during the review of this strategy. We acknowledge the diligent efforts and contributions of the consultant Dr. Abdullah S. Ali and the Breakthrough ACTION team, whose hard work ensured the successful revision of this strategy.

I sincerely hope all stakeholders will actively implement the malaria social, and behavior change strategy, contributing collectively to the vision of making Zanzibar malaria-free.

Shija J. Shija Manager Zanzibar Malaria Elimination Programme.

Acronyms ACD Active Case Detection

ACT Artemisinin-Based Combination Therapy

API Annual Parasite Incidence

BCC Behavior Change Communication

CBO Community-Based Organization

CORPS Community-Owned Resource Persons

DHMT District Health Management Team

DMSO District Malaria Surveillance Officer

FBO Faith-Based Organization

GDP Gross Domestic Product

HCW Health Care Worker

HPU Health Promotion Unit

IEC Information, Education, and Communication

IRS Indoor Residual Spraying

KAPB Knowledge, Attitudes, Practices, And Behavior

LLINs Long Lasting Insecticide-Treated Nets

MCN Malaria Case Notification

M&E Monitoring and Evaluation

MEEDS Malaria Early Epidemic Detection System

MOEVT Ministry of Education and Vocational Training

MOH Ministry of Health of Zanzibar

MRDT Malaria Rapid Diagnostic Test

NGO Non-Governmental Organization

PHCC Primary Health Care Center

PHCU Primary Health Care Unit

PHU Port Health Unit

PMI President’s Malaria Initiative

RGoZ Revolutionary Government of Zanzibar

SBC Social and Behavior Change

SBCC Social and Behavior Change Communication

SEM Socio-Ecological Model

SHCC Shehia Health Custodian Committee

USAID United States Agency for International Development

ZAMEP Zanzibar Malaria Elimination Program

ZBC Zanzibar Broadcasting Corporation

ZMESP Zanzibar Malaria Elimination Strategic Plan

Chapter One

BACKGROUND

1.1 Introduction

The Islands of Zanzibar have achieved remarkable success in reducing malaria transmission, reaching a point where malaria is no longer a significant public health and socio-economic concern. Both the 2017 and the most recent Malaria Indicator Surveys (MIS) in 2022 reported zero prevalence in sampled children. This shift in malaria transmission dynamics has led to a notable decrease in morbidity and mortality. For instance, the under-5 mortality rate has declined from 143 per 1000 live births in 2017 to 43 per 1000 live births in 2022.

In response to these positive trends, the Zanzibar Malaria Elimination Program (ZAMEP) consistently develops a national malaria strategic plan. This strategic plan serves as a guiding framework for stakeholders, ensuring concerted and coordinated efforts toward the goal of malaria elimination in the region.

1.2 Zanzibar Malaria Profile (2022): A Snapshot of Progress

Overview This profile offers a comprehensive view of Zanzibar’s persistent efforts in malaria control and elimination, shedding light on achievements, obstacles, and regional nuances. The island remains steadfast in its commitment to maintaining a low malaria prevalence and ultimately reaching the ambitious goal of malaria elimination.

Malaria Transmission Trends Remarkable progress has been achieved in significantly reducing malaria transmission in both islands, sustaining prevalence at less than one percent since 2007. Despite being a very low malaria transmission setting, Zanzibar has witnessed a shift in vulnerability, with children under five and pregnant women no longer considered the most at risk. Instead, youth and adult men, often engaged in nighttime occupational and social activities outdoors, now face a higher risk of infection.

Malaria Elimination Progress Zanzibar’s journey towards malaria elimination continues to show promise. In 2022, the reported malaria cases amounted to 4,557, indicating a substantial 31.1% decrease from 2021. The malaria database highlights an upward trend in annual cases, both local and imported, on Unguja over the last five years, while Pemba has experienced relative stability.

District-specific Insights Analysing data for the first 30 weeks of 2023, 2,645 imported cases were reported, surpassing the 1,912 local cases on both Pemba and Unguja. The districts most affected on Unguja are Mjini and Magharibi, influenced by population diversity and socioeconomic determinants. Over the past five years, Unguja, especially in districts like Kati, Magharibi B, and Mjini, recorded an Annual Parasite Index (API) consistently above 4 per thousand, peaking threefold during the 2020 epidemic.

In contrast, Pemba, with districts such as Micheweni and Wete, witnessed a generally low API below 2 per 1,000 population over the last five years, except during the 2020 epidemic. The epidemic wave more significantly impacted Wete and Micheweni.

Severe Malaria Management:

Admissions due to severe malaria are effectively managed in all admission hospitals. In 2022, five malaria-related deaths were reported.

This profile encapsulates Zanzibar’s dynamic progress in malaria control, portraying a holistic picture of achievements, challenges, and the ongoing commitment to malaria elimination.

1.3. Empowering Change: Integrating Social Behavioral Strategies into the National Malaria Elimination Strategic Plan 2024-2029

The formulation of the Zanzibar Malaria Elimination Strategic Plan (MSP) was meticulously crafted, drawing insights from the comprehensive performance reviews conducted in 2020 and the subsequent midterm review in 2022, specifically evaluating the outcomes of the 2018-2023 strategic plan. This iterative process ensured a foundation built on lessons learned, successes celebrated, and challenges addressed. A pivotal component within the MSP is the strategic approach under Social and Behavior Change (SBC) and advocacy. Envisioning 2026, the plan sets forth an ambitious goal: to foster positive malaria behaviors through evidence-based SBC strategies. This endeavor will unfold by the implementation of the meticulously revised Malaria Elimination SBC Strategy 2024-2029, designed to specifically target determinants that wield a significant impact on behavior adherence.

In alignment with the findings from the Malaria Behavior Survey (MBS) conducted in 2021, the reviewed strategy takes a nuanced approach. It aims to tackle determinants that play a crucial role in shaping malaria prevention and case management behaviors, with a laser focus on addressing low susceptibility and severity perceptions regarding malaria in Zanzibar.

This holistic integration of research-backed strategies into the MSP not only reflects the commitment to evidence-based planning but also underscores the dynamic evolution of Zanzibar’s approach toward malaria elimination, emphasizing adaptability and responsiveness to the region’s unique challenges and opportunities.

Greater emphasis will be placed on a targeted audience comprising individuals aged 15-24 years, as this demographic represents the most at-risk group with comparatively lower knowledge regarding malaria-associated risks compared to the older age group. The approaches employed to disseminate messages and materials will center around digital platforms and innovations, including SMS, while concurrently reinforcing community and facility-based interventions.

Furthermore, the review will emphasize the importance of strengthening community behavioural change activities for malaria, engaging community institutions, cultural groups, religious institutions, and Community Health Volunteers. Additionally, monitoring and evaluation of SBC interventions through KAPB, and post surveys on health-seeking behaviour, to identify levels and determinants of the use of malaria preventive measures.

To mitigate the effects of malaria in the prevalent Shehia, a package of program interventions has been established which encompasses both preventive and curative interventions. The main preventive interventions are insecticide-treated nets (ITN), Larva Source Management and Indoor Residual Spraying. Prompt case management is the main curative intervention using Artemisinin Combination Therapy with emphasis on microscopy and rapid diagnostic tests. These interventions have been scaled up across the Island with limited microscopy services, especially at the Port Health Unit (PHU).

The ZAMEP Strategic plan 2018-2023 aimed at eliminating malaria in Zanzibar by 2023. To realize the long-term goal, the ZAMEP developed the following strategies 1. Malaria diagnosis and treatment 2. Integrated malaria vector control and 3. Malaria surveillance, monitoring and evaluation, leadership, and program management.

1.4 Updates on SBC Implementation: Following National Malaria Elimination Strategic Plan 2018-2023.

Social Behavioral Change played a vital role in implementing different malaria actions. It was a supporting strategy that touched every aspect of the plan. Here are the goals of the malaria elimination Social and Behavioral Change strategy:

1. Increased proportion of population who seek prompt and appropriate care for symptoms of malaria.

2. Increased proportion of the population who are tested for malaria before taking malaria medication.

3. Increased proportion of health care providers who test all patients with a fever for malaria and treat based on the test results.

4. Increase proportion of individuals with confirmed malaria who take the full required dose of ACT and single dose of primaquine as prescribed.

5. Increased proportion of the population who sleep under an LLIN every night.

6. Maintained proportion of households in targeted communities who receive IRS.

7. Increase proportion of households in targeted communities who comply LSM activities in their communities.

8. Increase proportion of the households who comply with surveillance activities in their communities.

9. Increased proportion of the population who comply with entomological surveillance activities in the community.

10. Increased proportion of leaders who participate in malaria elimination activities.

For the successful realization of the stated objectives, the Zanzibar Malaria Elimination Communication Strategy 2018-2023 provides clear guidance for implementing Social and Behavior Change (SBC) activities. These include ensuring the completion of antimalarial doses for confirmed malaria patients, consistently sleeping under a treated mosquito net throughout the year, adhering to Indoor Residual Spraying (IRS) operation procedures in sprayed areas, and emphasizing the importance of early care-seeking for fever symptoms.

The capacity to effectively implement the Malaria Strategic Plan and Communication Strategy 2018-2023 involves collaboration with key change agents and stakeholders, including shehia leadership, policymakers, and other relevant authorities.

Zanzibar conducted the Malaria Behavior Survey (2021) to enhance comprehension of the socio-demographic and ideational characteristics linked to malaria-related behavioral outcomes in the Zanzibar region of Tanzania.

The aim was to ascertain the suitable focus for programmatic activities designed to enhance malaria-related ideational and behavioral outcomes. The findings and recommendations from the MBS guided the orientation of future programs dedicated to promoting appropriate malaria prevention and treatment behaviors in Zanzibar.

The subsequent description outlines the findings of the MBS 2021, showcasing the accomplishments of the malaria Social and Behavior Change (SBC) strategy

1.5 Findings: Malaria Behaviour Survey (MBS 2021)

A: Malaria Vector Control

• About 66% of households reported having at least one insecticide-treated net (ITN), but only 32% had at least one net per two household members. Intensified SBC activities aimed at addressing the determinants that significantly contribute to ITN Use and Care. The determinants include perceived self-efficacy for net use, positive attitude towards net use, and perceived supportive community norms.

• While most (85%) of existing nets in households were used consistently every night of the preceding week, most households needed more nets for all members.

• Only 37% of respondents reported consistently sleeping under a net every night of the week before the survey.

• Over half of respondents (58%) reported awareness of an indoor residual spraying program in their community.

• Among respondents who knew about indoor residual spraying, 75% held positive attitudes.

• About 86% stated they would accept indoor residual spraying services if offered.

• Only 29% of respondents had heard of larval source management or larviciding.

• Once described to them, nearly 92% had favorable attitudes regarding larviciding.

• 54% believe they can only catch malaria in the rainy season, while 52% report worrying every day during the rainy season that a family member might get malaria. This perceived susceptibility is lower among those in the low transmission risk areas.

B: Malaria Case Management (Care seeking for under five)

• Less than half of respondents (47%) believed malaria testing is efficacious at detecting malaria.

• Only 37% perceived malaria treatment as efficacious, with the lowest levels reported in Unguja.

• As expected in a low malaria transmission setting, only 9% reported having a fever two weeks before the survey, among whom 70% sought care. Among those who sought care, 71% sought prompt (within 24 hours of fever onset) and appropriate care (at a health facility or from a community health worker first).

• Perceived susceptibility is associated with 2.5 times increased odds of prompt and appropriate care-seeking for fever in children under five.

• 28% believe acquiring malaria would be severe; 26% believe every malaria case is severe; 72% believe that someone with malaria can recover completely within a few days; 51% are not worried about malaria because it can be easily treated. This perceived severity is lower among those in high-transmission-risk areas.

• 93% perceive self-efficacy to seek malaria testing and treatment (92% are confident can afford care seeking; 91% can afford testing and treatment).

C: Malaria Surveillance

• Only 24% of respondents reported being aware of RCD programs. Those in high-transmission areas

(34%) were more likely to be aware of RCD than those in low-transmission areas (19%).

• Of the 37% of respondents who reported a health worker visiting their house to test them or someone in their household for malaria, 45% reported getting tested for malaria during that visit.

Based on the MBS findings and field experience and consultations below are the recommendations that will help improve the SBC programming in future years.

1.6 SBC Recommendations

1. The MBS (2021) provided some recommendations for the SBC programs should be designed and implemented to address the following gaps:

• Low susceptibility, low severity perceptions regarding malaria.

• Low IPC about malaria – spouse/partner or friends/family past six months.

• Audiences – younger generations 15-24 are less likely to know/be aware/feel the risk of malaria than older generations – possibly older generations know about malaria from previous.

• Injection is more effective/not finishing drugs when they feel better – not knowing ACT and its effectiveness or trusting it.

• SMS focused on ideational factors may be beneficial. It is an unexplored channel that should be tested while keeping in mind the clear need to reach out to those who will be left out.

• Community and facility-based interventions – getting to the people rather than just media -> get to people who don’t have a radio, a TV, or any mobile phone.

• Attitudes about nets: Half or more of respondents reported that nets caused discomfort, and more than 70% thought free nets were inferior to more expensive versions.

• Attitudes about malaria: Only half of respondents perceived they were susceptible to malaria, and just over a quarter thought the consequences of contracting malaria would be severe.

• Prompt care-seeking: Only about half reported seeking care for fever within the recommended period. A similar proportion of all respondents thought prompt care-seeking was a social norm.

• It will be important to convey information at the community level when implementing newer or less frequent programs, such as IRS, larviciding, MDA, and RCD

2. Using evidence-based data for routine epidemiological and entomological surveillance data to prioritize SBC messages and interventions.

3. Liaise with the existing community health volunteers and others to implement community-based activities to reach the communities with malaria elimination messages.

4. Tailor approaches to audiences to disseminate the required messages. A good case study of using School Health Clubs, fishing camps and student camps. Programs to engage children and youth; use of digital platforms to support large campaigns; mobile cinema vehicles in rural areas; to engage audiences through TV, radio, and road shows since the listenership and viewership from MBS results is promising 49% and 42% respectively.

5. Continue using individuals considered trustworthy sources of information (e.g. health providers, religious leaders, teachers) to disseminate messages.

6. Continue to engage district and community structures such as DHMTs, Registered NGOs, SHCCs, and influential leaders, including religious, political leaders to mobilize communities and promote awareness of recommended interventions.

7. Strengthen community exchange visits, whereby members of SHCCs meet and share experiences, knowledge, and lessons learned with functional committees.

8. Appointing SBC Malaria Champion to assist in malaria advocacy and resource mobilization for the program.

1.7 Lessons Learned, Challenges, and Mitigations: Navigating the Path to Malaria Elimination

In the aftermath of implementing the National Malaria Strategic Plan (NMSP) and the Malaria Elimination Communication Strategy (MECS) 2024-2029, a thorough assessment revealed operational challenges that pose hurdles in achieving malaria elimination. Notable challenges included issues such as malaria importation, perceptions of susceptibility to malaria, and a low perceived risk of malaria transmission.

In response to these challenges, Zanzibar Malaria Elimination Program (ZAMEP) has undertaken proactive measures by implementing various Social and Behavior Change (SBC) interventions. While these interventions have proven effective in addressing some challenges, their ongoing consideration is imperative when crafting SBC activities in alignment with the NMSP 2024-2029.

This forward-thinking perspective emphasizes the continuous learning and adaptation needed in the fight against malaria. Partners, alongside grassroots frontline implementers, play a pivotal role in this ongoing journey. It is essential for them to not only acknowledge the field lessons learned but also keep the encountered challenges at the forefront of their minds. This collective mindfulness ensures that rectification strategies are incorporated into future initiatives.

The ensuing table provides a comprehensive summary of the invaluable lessons learned, the challenges faced, and the strategic mitigation measures adopted, underscoring the commitment to a dynamic and evolving approach in the pursuit of malaria elimination.

Table 1: Lessons Learned, Challenges, and Mitigations:

Thematic Area Lesson learnt Challenges Mitigation Measures

Social and Behavioral Change

Active Community engagement:

The presence of functional Community Health Volunteers in all districts working under the health facility health care providers technical support, and complete community engagement would be key to the success of SBC activities.

Some Shehia do not have adequate number of Community Health Volunteers.

As ZAMEP is accelerating towards zero malaria cases with few local cases identified recently in Zanzibar, partnership relations with the existing NGOs and CBOs should be strengthened to the maximum.

In all malaria community-based interventions such as targeted IRS, larval source management, surveillance and response through the reactive case detection, the role of community should be considered.

SBCC: This has been an effective approach which helped to promote changes in knowledge, attitudes, norms, beliefs and behaviors.

Malaria knowledge: Although individual and community knowledge on malaria in Zanzibar is very promising, various intervention package, fears and myths do exist.

Individual behaviour change has been observed to be a slow adaptation process resulted in low self-efficacy of the behaviours that we are promoting.

The key players are strongly requested to ensure the interactive and engaging process with communities is deployed to create custom-fitted messages and methodologies utilizing an assortment of correspondence channels to create positive practices; advance and support individual, network and cultural conduct change; and keep up suitable practices.

It is important for the key players and partners to consider the SBC programmatic suggestions outlined in the Malaria Behavioral Survey Report 2022.

Thematic Area Lesson learnt Challenges Mitigation Measures

Malaria Surveillance

Decreased incidence of malaria:

Low risk perception to Malaria in a setting of reduced malaria transmission, communities, health care providers and travelers appeared to be aware of the low malaria burden across the Island.

The implication of malaria outbreak is also known.

Percentage of children age 6–59 months classified as having malaria, according to background characteristics tested using malaria diagnostic test was zero for Unguja and Pemba1.

Malaria importation: The mobility of malaria-parasite poses challenges to elimination campaigns by way of spreading parasites, straining country-to-country collaboration, and making routine data collection difficult, especially in resource-poor settings. At global level, mobility of infected individuals has resulted in disease reintroduction after elimination, has contributed to the spread of drug-resistant parasites within and between countries2.

None

Ongoing transmission (local and imported) resulting in increased malaria cases.

Key partners and frontline workers need to insist on the importance of continuing the use of malaria preventive practices in this low and seasonal transmission setting .

According to the study findings, reasons for continued use of preventive practices include:

fear of malaria returning to high levels, presence of mosquitoes during rainy seasons, and concern about local cases from other villages or imported cases from mainland Tanzania.

In this context, focusing on SBC activities around perceived severity would need to be considered due to its importance.

Partners should continue implementing SBC activities targeting visitors and individuals returning to Zanzibar using the appropriate channels of communication. Partners should consider how their activities might improve cross-border coordination of SBC for malaria elimination, particularly with Tanzania Mainland.

Integrated Vector control

Outdoor malaria transmission:

Behaviour changes in mosquitoes from indoor to outdoor biting resulted in continuing risk of malaria from outdoor activities, including routine household activities and occasional social and cultural practices and gatherings. Gatherings and celebrations expose people to mosquito bites. Outdoor transmission is over 60% across the Islands (ZAMEP Annual Report 2023).

Change of mosquito behaviours

Approaches to prevent risks of mosquito bites and disease management need to take into account social, cultural and environmental factors. With this background the program in collaboration with partners should consider innovative SBC activities might be used to support control strategies targeting outdoor transmission.

1 Tanzania DHS-MIS 2022 2 Dharmawardena, P. et al. Characterization of imported malaria, the largest threat to sustained malaria elimination from Sri Lanka. Malar. J. 14, 177.

1.8 Communication Landscape: Navigating the Dynamic Channels

The communication landscape is the intricate environment where diverse media forms operate and interact This encompasses traditional avenues like print and broadcast media, alongside the ever-evolving digital and social media platforms3.

Over the past year, the customer communications terrain has undergone significant shifts. Those who embraced emerging channels continued to engage at heightened rates, reshaping the preferences and dynamics of communication.

Recognizing the evolving nature of communication, it becomes crucial to pinpoint the most impactful communication outlets for Social and Behavior Change (SBC) across diverse settings. The array of media forms, as mentioned earlier, offers a spectrum of possibilities for disseminating tailored information to the public, each chosen based on its contextual relevance.

For instance, insights gleaned from the Zanzibar Malaria Behavioral Survey 2021 have proven invaluable.

The survey highlighted that a substantial majority of respondents (80%) owned a mobile phone or tablet.

Simultaneously, radio (49%) and television (42% overall; Unguja 52%, Pemba 23%) maintained their relevance, with significant weekly engagement.

Delving deeper into the findings, it was revealed that while 66% of respondents in Unguja and 44% in Pemba successfully completed the malaria campaign slogan, only 44% in Unguja and 31% in Pemba reported encountering a malaria-related message in the six months leading up to the survey. These observations underscore the need for strategic and contextually relevant utilization of various communication channels, ensuring the effective transmission of crucial information and messages related to malaria prevention and control.

1.9 Empowering Effective Communication for Behavioral Change

To ensure the achievement of behavioral objectives through effective communication, partners are urged to comprehend the landscape of existing communication outlets. Identifying the most fitting channels and activities aligning with behavioral and communication objectives is paramount.

It is essential for partners to navigate the dynamic media landscape, recognizing the evolving preferences of diverse audiences. While digital channels continue to gain prominence, especially among the youth, feasibility must be considered when targeting specific audiences. The call to action is clear: leverage the insights from communication landscapes, tailor strategies to audience preferences, and harness the power of digital platforms for impactful and resonant communication. Together, let us forge pathways to transformative behavioral change through strategic and informed communication initiatives.

3 www.linkedin.com/pulse/mastering-media-landscape-key-steps-effective-naif-

Chapter Two

STRATEGIC APPROACH

2.1 Goal

To increase the correct use of malaria-recommended interventions to over 85 percent by 2029through a well-coordinated SBC activity.

2.2 Specific Objectives

1. Increase uptake and correct use of recommended malaria interventions from the 2023 baseline to over 85 percent by 2029.

2. To stimulate action around malaria through advocacy aimed at increasing funding for malaria and to strengthen links between the national and district authorities

3. To strengthen coordination and linkages of advocacy communication socio-malaria interventions and improve the dissemination of information to key target audiences at national, district, shehia, and household levels through a planned and systematic series of activities and channels.

4. To harmonize malaria ACSM activities implemented by the different partners.

The Malaria Elimination Communication Strategy supplements and is rooted in the NMSP 2024-2029. The communication strategy covers six years and aims to contribute to achieving the NMSP Strategic Objectives.

2.3 Guiding Theory: Understanding Social Ecological Model

A theory is like a roadmap, a way of explaining how things work based on careful observation. It’s a narrative that tells the story of a series of steps, decisions, reasons, and all the factors involved in an event, including places, people, barriers, and facilitators.

In shaping our strategy, we embrace the Social Ecological Model as the guiding theory to comprehend and address health behaviors effectively. This model recognizes individuals within a multi-layered framework, encompassing personal relationships, community dynamics, broader social and cultural values, and historical contexts. By acknowledging these interconnected levels, our strategy aims to develop interventions and policies that not only address individual actions but also encompass the broader social and environmental factors influencing behavior.

This approach goes beyond merely focusing on individuals, ensuring a holistic perspective that considers the diverse influences on health within the community. Consider this theory as a valuable tool guiding us to create enduring changes in behavior. To make our prevention efforts impactful, we will concentrate on individuals within specific groups, considering all the different influences surrounding them – from personal choices to their relationships and community. This methodology aligns with our objective of establishing sustainable and effective behavior changes to prevent malaria.

2.4 Social-Ecological Model of Communication

Figure 1: Social Ecological Model

2.5 Social-Ecological Framework

Figure 2: Social-Ecological Framework

2.5 Guiding Principles

The following principles will underpin the planning, implementation, and monitoring of the communication strategy and therefore, alignment with ZAMEP values, partners’ activities should be guided by the following key principles irrespective of the chronological order:

Table 2: Guiding Principles

No. Guiding principles Descriptions

Epidemiology-based intervention

The SBC interventions will be implemented based on the different epidemiological and entomological findings from the field perspective as outlined in the NMSP 2024-2029. This will ensure a targeted and evidence driven approach to tackling malaria.

Local context approach The strategy will recognize, appreciate, and make use of local structures, leadership, local knowledge and technical professional knowledge to facilitate the desired change. By understanding and embracing the local context, we aim to make the interventions culturally relevant and effective.

Equity in accessing quality health services.

Equity of access to PHC is a major social determinant of health and is considered as a strategy for addressing health inequity. In this context, the basic principle of equity is fairness in provision of health services to all community members.

Evidence-based interventions

Communication planning relies on a foundation of local and external data and theory, ensuring that our activities are informed, guided, and effective in achieving their objectives.

Gender considerations Gender-related information is crucial in program planning, data collection, monitoring, and evaluation to raise awareness of gender imbalances, advocate for change, address gender dimensions of health, and demonstrate program progress for impact

Community involvement

Taking the community is critical since malaria affects all Zanzibari.

Therefore, the involvement of communities, service providers, media institutions, policy makers, and political leaders is critical in all stages of design, implementation, and evaluation of SBC activities.

Ownership Ownership is the state or fact of legal possession and control over property, which may be any asset, tangible or intangible. National ownership and leadership are of paramount importance in SBC activities. All partners commit to follow the direction set out by the RGoZ through the MOH and ZAMEP for coordinated response.

Public Private Partnership

Engaging in public private partnerships for malaria SBC will strengthen and accelerate efforts towards increasing utilization of malaria interventions, fostering collaboration between public and private entities.

Appropriate messaging and communication materials

The strategy will encourage the development of targeted, appropriate and context specific messages and communication products for dissemination to the different audiences, ensuring maximum impact.

Using data/evidence for decision-making and program design

There should be a focus on formative research in SBC strategy and activity design, as well as use of service delivery data to further shape and target SBC activities. Furthermore, it is important to monitor and evaluate SBC activities to guide on-going program development.

Working towards integration

Integrating malaria SBC and other malaria interventions into all health initiatives is key. For example, working with Community Health Volunteers at community level during the field outreach is an opportunity to disseminate malaria SBC activities. Similarly, special events and mass campaigns create opportunities for integration of malaria messages with other initiatives.

Inclusive and coordinated partnership.

ZAMEP will continue to work in collaboration with other stakeholders in a coordinated manner. The concept of public private partnership in malaria elimination movement will be given priority.

Message harmonization Coordination across all activities to ensure that all partners are sharing the same voice. Message harmonization will ensure that the intended audiences are not confused by conflicting messages and will allow for increased message reinforcement to all targeted audiences.

Chapter Three

IMPLEMENTATION APPROACH

In the national strategic plan, the following were identified as the key strategic considerations in the design and delivery of SBC intervention to move the country toward malaria elimination.

• Design and develop innovative approaches using behavioral science.

• Deploy community-based participatory approaches to address malaria behavioral determinants and social norms.

• Leverage multimedia channels to promote positive malaria behaviors.

• Advocate for multisectoral and private sector engagement for malaria elimination.

These strategic considerations will be executed in 3 pillars based on SEM.

Pillar 1: Community-based intervention This pillar will cover interpersonal communication to allow open discussions and interactions on ITN access, use, care, and repurposing. Furthermore, this pillar deploys community-based participatory approaches to address malaria behavioral determinants and social norms.

Pillar 2: Reinforcement interventions This will involve innovative mass media, social media, and digital approaches to nudge and remind community members to sleep under ITN every night. This will ensure that many people are reached and exposed in multi-ple frequencies with the malaria messages.

Pillar 3: Enabling Environment This will involve the strategic engagement of religious leaders, influential leaders, and community leaders in disseminating malaria elimination messages to the communities. Through this pillar, multisectoral engage-ment will be key to advocating for resource mobilization across all levels to mitigate the fund constraints and challenges currently available to implement malaria interventions in achieving malaria elimination strategies.

The following are key communication approaches that are often used in this strategy.

Interpersonal Communication: based on one-to-one communication. This could be parent-child communica-tion, peer-to-peer communication, health care provider, teacher, or communication with religious or commu-nity leaders.

Mass Media: can cost-effectively reach large audiences through radio, television, and newspapers.

Mid-Media: The reach is less than that of mass media and includes public announcements (PA) and cultural theater, which has a role in engaging and interacting with the targeted audience.

Social Mobilization: aims to determine needs and raise awareness of the campaign by mobilizing partners, in-cluding organizations, groups, networks, and communities, to work together in a participatory way and enable the environment to effect positive behavior and/or social change.

Social Media/Digital platforms: is the fastest growing and evolving approach, with increasing global reach.

This approach includes digital media such as websites, emails, list serves, internet news feeds, chat rooms, vir-tual learning, and message boards. Social media, a subset of digital media, can share information and generate ideas using platforms like Facebook, Twitter, Linked In, and WhatsApp

3.1 Strategic SBC Matrices for Malaria Interventions: Specific Plans

3.1.1 Integrated Vector Malaria Control

While there has been a commendable decline in malaria prevalence, recent increases in malaria cases under-score the ongoing susceptibility of Zanzibar to malaria transmission. In response, Integrated Malaria Vector Control (IMVC) stands out as a crucial strategy to mitigate the impact of malaria in Zanzibar. Through IMVC interventions, Zanzibar is steadfast in its commitment to reducing malaria transmission by implementing evi-dence-based vector control measures specifically tailored to address the varying levels of malaria transmission risk in different strata.

The Zanzibar Malaria Strategic Plan (ZMSP) 2024-2029 outlines three priority interventions integral to prevent-ing human-vector contact and fortifying malaria vector control. These interventions include:

• Insecticide Treated Nets (ITNs): Providing a physical barrier against mosquitoes, ITNs are a frontline defense to reduce the risk of malaria transmission, especially with consistent sleep.

• Indoor Residual Spraying (IRS): Targeting malaria vectors in their resting places, IRS involves the appli-cation of insecticides to indoor surfaces, further curbing the transmission cycle.

• Larval Source Management (LSM): Encompassing Bio larviciding and environmental management, LSM addresses mosquito breeding sites, disrupting the vector’s life cycle.

To optimize the impact of these interventions, Social and Behavioral Change activities play a crucial role. These activities are instrumental in fostering increased access to and adoption of ITNs, IRS, and LSM strategies, there-by enhancing the overall efficacy of the IMVC approach.

3.1.1.1 Insecticide-Treated Nets (ITNs)

Objective:

To protect all population with recommended vector control interventions according to epidemiological and ecological setting by 2028, to limit malaria transmission.

ITN Situation and Behaviour Analysis

Situation Analysis To advance the accomplishment of the primary goal outlined in the Zanzibar Malaria Strategy 2024-2029, SBC Unit of ZAMEP strategically allocates ITNs through appropriate channels ensuring sustained universal coverage. This initiative is executed in accordance with WHO recommendations, distributing one ITNs for every two household members.

In order to achieve comprehensive ITN coverage across all age groups at the Shehia level, ITNs are distributed through periodic mass distribution campaigns which occur triennially, as well as during ANC sessions and , and in response malaria epidemics.

The President’s Malaria Initiative (PMI) has been a steadfast supporter of routine ITN distribution since 2006. The most recent mass distribution campaign transpired in 2023 resulting in distribution of 221,683 mosquito nets across 53 Shehia in the Urban West Region.

Findings from the 2021 Zanzibar Malaria Behavioral Survey (MBS) indicate that approximately 85% of the household’s utilized their existing nets the night prior to the survey and consistently every night in the week leading up to the survey. Moreover, 32% of households possessed at least one net per two people. Notably, consistent ITN use is significantly higher in rural areas.

Behavioural Analysis Net Use Behaviors: The field findings revealed several barriers hindering optimal, consistent, and correct utilization of ITNs. Barriers at community and individual levels include: i) low utilization of ITNs in some districts, ii) myths and misconceptions, inadequate investment in SBC (advocacy, communication, social mobilization, and community engagement). At Shehia level, inadequate SBC-related capacity among health care providers and CHVs and lack of consistent motivation for providers to provide services were some of the barriers identified.

The MBS 2021 reported the following key findings: A robust 91% of the population possesses knowledge regarding the prevention of malaria through the use of mosquito nets. Additionally, there is a positive disposition towards mosquito nets, with an 81% favorable attitude. This favorable attitude is particularly pronounced among specific demographics, including Pemba residents, women, older respondents, rural residents, and those in the lower wealth quintiles.

Perceived self-efficacy to use nets stands at a commendable 86%.

The perception of community approval for net use is reported at 43%, with higher rates observed in Unguja, among men and older respondents, in urban areas, and among those with primary-level education. Notably, the utilization of ITNs is reported at 85%, indicating a generally high level of adoption. However, there is a concerning discrepancy, as only 37% consistently use ITNs, highlighting a critical need for intensified efforts to promote sustained and correct usage.

Findings from the conducted logical regression analysis underscore several determinants significantly influencing consistent net use. These include a positive attitude towards net use and net care, perceived self-efficacy, and perceived community norms. Moreover, residents in rural areas are more likely to utilize nets compared to their urban counterparts. Addressing these determinants and focusing on targeted interventions will be pivotal in optimizing ITN utilization, particularly in fostering consistent and correct usage practices.

Net Care & Repurposing Behaviors: Respondents also noted specific net care and repurposing actions. Most (81%) reported washing their nets, primarily with powder or liquid soap (90%).

Three-quarters reported engaging in net care such as rolling or tying up nets when not in use (31%), handling nets with care (26%), and keeping away from children when not in use (21%).

Compared to 42% of Pemba respondents who stated they had repurposed an old net, only 14% in Unguja reported repurposing. Among those who repurposed nets, most used them as protection for seedlings and crops (74%) or for fishing (14%) or drying fish (11%). This discrepancy in repurposing activities can be attributed to differing economic opportunities in the two zones, with respondents in Pemba significantly more likely to mention these actions. Understanding these regional variations is crucial for tailoring interventions and messages related to net care and repurposing practices in each zone.

SBC Recommendations:

• Intensification of consistent use and care of nets among the community members focusing on determinants with significant impact to consistent net use and care such as perceived self-efficacy, favorable attitudes toward net use, supportive descriptive community norms, favorable attitudes, and perceived susceptibility to malaria.

• Promoting proper methods of net care mainly focus on roIling and tying up of nets not in use.

• Promoting required timing of net repurposing should be three years after the nets have been used.

ITNs Audience Analysis and Strategic Approach

Audience analysis

Audience analysis is the process of collecting and assessing information about the people in your audience. It helps to understand their needs, wants, values, attitudes, and opinions. The audience is often referred to as the end-user and all communications need to be targeted towards the defined audience. Audience can be defined by using criteria such as demographics, locations, languages, interests, and beliefs.

Primary Audience:

· Decisions around net use are often made by the head of the household. This includes decisions impacting net ownership (e.g., registering for a mass campaign, supporting attendance at ANC or immunization visits where LLIN are provided, purchasing a net through the private sector), as well as net access (e.g., who in the household sleeps under the net) and use (e.g., whether nets are used, when they are used, and whether nets are repurposed for other purposes than malaria protection).

· Net care and repair actions are more typically the responsibility of female members of the household.

Examples of Primary Audiences are:

Pregnant women and their spouses.

Secondary Audiences:

· Healthcare providers have an important impact on net access based on their role in distributing nets through ANC and immunization programs.

· Teachers have an important influence through their role…