Breakthrough ACTION Guyana: Evaluation Report

"Overall, this evaluation found positive results supporting the implementation of multilevel interventions for malaria elimination by including innovative SBC [social and behaviour change] interventions promoting malaria prevention, testing, and treatment."

This report, published by Breakthrough ACTION, shares the results of an evaluation of the work of Breakthrough ACTION Guyana that involved the implementation of an evidence- and theory-based social and behaviour change (SBC) intervention to address malaria in remote gold-mining communities in Guyana. Implemented in collaboration with the Ministry of Health (MOH) and the Pan American Health Organization (PAHO)/World Health Organization (WHO), the initiative sought in particular to promote early diagnosis and prompt effective treatment, which WHO considers to be vital components of malaria elimination.

The SBC activities were designed to complement a volunteer malaria tester (VMT) programme to increase malaria prevention, testing, and treatment, as well as long-lasting insecticidal net (LLIN) distribution campaigns implemented by the MOH Vector Control Services (VCS)/National Malaria Programme (NMP) among mining communities in four regions where malaria is endemic. SBC activities complementing the VMT efforts included training on the SBC and interpersonal communication components, job aids (i.e., rapid counselling cards, treatment adherence regimens), branding of service delivery sites with free malaria testing and treatment available signs, and recognition through certificates. The core SBC effort comprised a multichannel campaign, Little Mosquito Big Problem (LMBP), that uses context- and culture-specific campaign materials to increase miners' malaria risk perception and self-efficacy to sleep under LLINs, test for malaria, and complete treatment. Materials included: a catchy theme song and accompanying music video; dramatic radio spots; an animated miniseries "Jungle Feevah" based on a fictional mining community; live actor television spots; social media posts; print materials such as posters, banners, and handouts and brochures; flash drives that integrate malaria messages and popular music; and DVDs that contain all the campaign's audiovisual materials. The campaign used a mix of animated characters, mainly Mike the Miner, and live actors and real miners in the local mining context to appeal and relate to miners. The programme team used a participatory human-centred design (HCD) approach for programme design to ensure that the programme was contextually relevant.

The evaluation involved mixed methods to assess the VMT efforts and the complementary SBC campaign and included multiple data sources: VMT monitoring data and data on pre-intervention malaria knowledge, attitudes, and practices and post-intervention changes in them among gold miners in the study areas. The latter data was collected using cross-sectional surveys administered to approximately 1,685 and 1,252 adult miners in 2019 and 2022, respectively. Additional validation came from qualitative interviews with key stakeholders and two SBC capacity assessments in 2018 and 2022. The evaluation was guided by the ideation model, a theory-based framework that incorporates multiple cognitive, emotional, and social constructs from various behavioural theories to examine the effectiveness of SBC interventions. The model includes multiple psychosocial variables, and ideation scores were calculated to examine knowledge, attitudes, self-efficacy, interpersonal communication, and social support associated with malaria behaviours around prevention, testing, and treatment. The analysis included bivariate comparisons and multiple logistic regression controlling for background variables to examine the links between ideation factors and behaviours associated with exposure to the programme.

From the VMT monitoring data from miners who visited a tester during the Breakthrough ACTION Guyana project period of 2020 to 2022, the findings from one region showed that the use of LLINs among miners increased notably from 37% to 82%. This spike corresponded with MOH's LLIN distribution in that region. In another region, LLIN use increased from 15% to 46% within six months, specifically with the involvement of private partners who supported LLIN distribution. In addition, the monitoring data highlight an increase in prompt care-seeking and a decline in self-medication. 

For purposes of the analysis, miners were categorised into three groups according to the extent of their exposure to the intervention: no exposure, exposure to either the LMBP media or VMT, and exposure to both LMBP and VMT. Miners exposed to both LMBP and VMT components of the programme demonstrated a significantly greater mean ideation score around malaria prevention, testing, and treatment than those who were exposed to one or the other of the two components (i.e., LMBP or VMT) or those exposed to neither intervention. The measure for malaria prevention behaviours was the use of LLINs. Even though the LLIN distribution programme was a government initiative not linked directly with the LMBP campaign and VMT, significantly more miners who were exposed to the campaign reported they owned an LLIN. Despite this higher level of ownership, LLIN use did not differ significantly by levels of exposure.

The results showed that over half of the miners had been tested for malaria regardless of exposure to LMBP or VMT. Exposure to both LMBP and VMT was associated with appropriate and prompt care. Self-medication was highest among miners not exposed to either component (66%), followed by the miners who were exposed to both LMBP and VMT (51%), whereas miners exposed to either the LMBP or the VMT were significantly less likely to report self-medication (46%). While most miners (81%) unexposed to malaria interventions were prescribed treatment, prescription rates were slightly higher among miners exposed to either or both interventions (88% each). Almost all miners completed their prescribed medication, regardless of exposure to the interventions.

Multivariable logistic regressions were used to explore the interrelationship between exposure to malaria interventions, malaria-related ideation (prevention, testing, and treatment), and malaria behaviours including LLIN use, prompt care-seeking for fever, nonuse of self-medication, and malaria testing. The regression analysis controlled for miners' sociodemographic characteristics and mining context. Both exposure to malaria interventions and positive ideation were associated with improved malaria-related behaviours among miners. Exposure to malaria interventions was directly associated with prompt care-seeking (adjusted odds ratio [aOR]: 2.18; 95% confidence interval [CI]: 1.14-4.16) and nonuse of self-medication (aOR: 1.80; 95% CI: 0.96-3.36) among miners with fever in the past 12 months. In addition, miners' malaria prevention ideation was associated with increased odds of LLIN use among miners with nets (aOR: 1.44; 95% CI: 1.23-1.69). Miners' malaria testing ideation was associated with increased odds of prompt care-seeking (aOR: 1.17; 95% CI: 1.04-1.33) and malaria testing (aOR: 1.17; 95% CI: 1.03-1.32) among miners with fever in the past 12 months.

According to the report, the quantitative findings were complemented by overwhelmingly positive perceptions regarding the Breakthrough ACTION Guyana project from monitoring data and interviews with various stakeholders. Most participants lauded the SBC campaign, finding the multichannel approach of the project as valuable for reaching diverse audiences. The qualitative data based on participants' reports indicated that the SBC project improved miners' awareness of malaria-related issues such as severity, prevention, and treatment, as well as their malaria-related behaviours. Interviews with camp managers and MOH staff found that SBC communication increased the visibility of the VMT programme, making services more accessible to miners and saving them both time and money, and participants especially noted improved access in remote locations. According to the interviewees, appreciation for and the success of the Breakthrough ACTION Guyana project were evident in the increased number of people interested in becoming VMTs. Despite the many positives, interview participants also expressed concerns about the achievements of Breakthrough ACTION Guyana lasting beyond the lifetime of the project, as well as the lack of SBC-related funding.

The discussion of the results highlights some of the strengths and weaknesses of the programme. For example, given that SBC materials were well received by both testers and miners, the HCD participatory approach appeared to meet the goal of implementing activities that resonated with the intended audiences. The evaluation also showcased the use of entertainment as a useful way to address a public health problem; for example, the creative use of easy-to-remember jingles was mentioned during qualitative interviews and discussions. Despite the overall positive results, several areas of the programme need improvement. While increase in exposure was associated with higher ideation scores, comprising higher knowledge, favourable attitudes, self-efficacy, positive self-image, and availability of social support, the results around the relationship between exposure and malaria prevention, testing, and treatment were "somewhat ambiguous" (most notably, the results around the rate of consistent use of LLIN, which was lowest among miners exposed to both LMBP and VMT (79%) compared with 88% consistent use reported by miners with no exposure). This finding, according to the report, points to areas of the programme that need strengthening.

The report discusses a number of recommendations for the way forward, which include, for example, creating and tailoring activities and messages for secondary audiences, as miners reported being influenced by health workers, family members, and partners who are potential secondary audiences. The evaluation highlighted challenges related to the transient nature of the mining population, which means that messages about prevention, testing, and treatment should, going forward, be repeated constantly to reach different waves of migrant miners who work on a seasonal basis.