Support for Service Delivery Integration Communication - Findings From the 2016 Endline Survey of 15 Districts in Malawi

“Moya Ndi Mpamba (MNM) was widely accessible to Malawian men and women of reproductive ages as reflected in the findings. Moreover, exposure to the campaign was positively and significantly associated with positive knowledge, attitudes, social norms and health practices.” 

This report shares the findings of an end line survey to assess the impact of the Support for Service Delivery Integration Communication (SSDI)-Communication project, which was implemented between September 2011 and December 2016 in Malawi. The main aim of the project was to: 1) Create and implement social and behaviour change communication (SBCC) that addresses health issues across six health areas: malaria; family planning; maternal, neonatal, and child health; water, sanitation, and hygiene; HIV & AIDS; and nutrition; and 2) Strengthen the capacity of key partners to design, plan, implement and coordinate SBCC. SSDI-Communication engaged key partners, including the Malawi Department of Health, to collaboratively develop the Moyo ndi Mpamba, Usamalireni! health brand and campaign. The brand, which translates to “Life is precious, take care of it!” acted as an umbrella for health promotion and social and behaviour change across the project’s six health areas. As part of this campaign, SSDI-Communication developed and implemented a variety of platforms, packages, and vehicles for SBCC. These included two radio programmes, various print materials targeting individuals and families (including a Family Health Booklet, a Newlyweds Booklet, Malaria Comic Book, posters, and pamphlets); a Community Health Worker Flipchart for use during community sessions and interpersonal communication; a couples marriage counselling initiative; mass media including radio spots; strategic and technical guidance and oversight to community mobilisation groups; and district health campaigns. The survey therefore looked at community exposure to these campaign activities, and the impact of all these activities on people’s knowledge, attitudes, self-efficacy, social norms, and communication around the six health areas.

The report offers a detailed description of the campaign frameworks and approaches, as well as the key messages for each of the 6 health areas. In brief, SSDI-Communication used four overarching frameworks and approaches to guide the design and implementation of SBCC: a theoretical framework built on the foundation of the socio-ecological model; an umbrella theme and brand - Moyo ndi Mpamba, Usamalireni! - to unify all programme activities; the utilisation of a life stages approach; and the creation and use of integrated communication platforms and materials. For instance, rather than creating separate communication tools to address each of the six targeted health areas, SSDI-Communication took an integrated approach based on life stages. This meant that health messages were grouped based on the particular health needs of each life stage (adolescents, young couples, parents of children under the age of five, and parents of children older than five). In this way, the project assured that the right messages and SBCC got to the right audiences in a streamlined and cohesive way.

As explained in the report, the objectives of the survey were:

• To assess the endline levels of predictors of positive health practices (including knowledge, self-efficacy, risk perceptions, normative perceptions) as well as the health practices themselves (including with respect to nutrition, family planning (FP), antenatal care (ANC), perinatal care, long lasting insecticide treated net (LLIN) use, vaccinations, voluntary counseling and testing (VCT), abstinence, condom use, etc.)
• To determine how the predictors of health practices and health-related actions as well as positive health practices changed since the baseline assessment.
• To examine the effects of the SSDI-Communication programme by exploring associations between programme participation, predictors of positive health practices, and specific health practices.

The study relied on a stratified random sampling design, weighted by population, with 15 intervention and four control districts. The sample was stratified by district, numeration areas, and sex. The total sample comprised of 2,205 respondents; 981 men and 1,224 women.

The key findings, as outlined in the executive summery of this report, are as follows:

"Exposure to Moyo Ndi Mpamba

• Seventy-eight percent of men and 71% of women were exposed to at least one Moyo ndi Mpamba campaign activity.
• Men were exposed to significantly more campaign activities than women.
• More people in general were exposed to the radio program than the community or face-to-face activities.

WASH

• Nearly 70% of all exposed respondents reported that they wash their hands using soap and water at endline compared to 57% during the baseline. (The percent of non-exposed respondents who reported behavior was slightly lower than the overall rate at baseline.) Additionally, there was a considerable decrease in those who reported only using water (41% at baseline and 28% at endline).
• Compared to non-exposed participants, exposed participants were significantly more likely to report washing their hands with soap and water and less likely to report using water only.

Malaria

• At endline, under-five children living in households exposed to the program were more likely (92%) than those who were not exposed (84%) to sleep under a bed net the night prior to the survey.
• Of mothers who reported sleeping under a bed net, 91% at endline compared to 83% at baseline reported using an insecticide-treated net.

Fertility Preferences and Contraception

• Exposure to the campaign was associated with greater likelihood of currently using any form or a modern form of contraception for both men and women
• 45% of the population who were not currently pregnant or trying to get pregnant reported currently using modern contraception.
• Exposure to a family planning message from at least one activity from the campaign was associated with increased family planning intention among both men and women.
• Among current non-users of contraception, 81% of men and 69% of women intend to use contraception in the future.
• Women who were exposed to at least one campaign activity were significantly more likely to desire fewer children.

Maternal and Child Health

• Among women with a child 5 years old, 98% reported receiving antenatal care during their pregnancy.
• The mean number of ANC visits varied by Moyo ndi Mpamba participation or exposure:  while non-participants reported an average of 3.1 visits, Moyo ndi Mpamba participants reported an average of 3.4 ANC visits, a statistically significant difference.
• Program participants were significantly more likely to use any bed net as well as more likely to use LLINs every night during their most recent pregnancy.
• Compared to baseline, a larger percentage of women at endline reported giving birth with the aide of a trained medical attendant, and that a physician or clinical officer attended their birth. There were no differences by program participation.

HIV & AIDS

• 35% of all respondents indicated that they had talked to at least one other person about HIV/AIDs topics compared with 44% at baseline. While endline rates were lower, exposure to the program was positively and significantly associated with such conversations.
• Just below 90% of women and 82% of men sampled reported being tested for HIV compared to two-thirds at baseline.
• Exposure to the program was significantly and positively associated with HIV testing (women: 79% unexposed vs. 93% exposed; men: 72% unexposed vs. 85% exposed).

Sexual Behavior

• 21% of the total sample reported having more than one sexual partner in the past 12 months.
• Exposure to at least one campaign activity was associated with significantly reduced likelihood of having more than one sexual partner in the past 12 months.
• Overall, 14% of respondents reported using a condom at last sex.
• Exposure was not significantly associated with condom use at last sex.
• Women who were exposed to Moyo ndi Mpamba were significantly more likely to perceive that some/most of their peers would approve of their consistent condom use. There was no significant effect of exposure among men.

Gender Norms

• Exposure was associated with significantly higher gender equitable beliefs among both men and women.
• Program participants (both men and women) were more likely than non-participants to report greater levels of joint decision-making."

In conclusion, the report states that “[G]iven the clear associations between program exposure and positive outcomes, it is important to continue to use the MNM platform to convey health-related knowledge and positive attitudes, encourage social normative change and create an enabling environment for positive health practices. To improve program exposure, the findings suggest that it will be important to (1) increase radio ownership and access to radio programming and (2) expand community mobilization.  Under SSDI, Malawi has made important strides in creating an enabling environment to sustain positive health practices and support positive behavior change. By continuing the successful MNM approach, these achievements can be sustained and furthered, ushering in a healthier future for the children, women and men of Malawi.”