Incorporating a New Approach into Dengue Control Programs: Community Participation in Negotiating Be

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Incorporating a New Approach into Dengue Control
Programs Community Participation in
Negotiating Behavior Change
Carlos Alberto Marin Correa M.D. MPH CHANGE
Project Academy for Educational Development AED /
USAID Mayo de 2003
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A Mini-Primer on Dengue
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A Mini-Primer on Dengue

• Transmitted by a mosquito called aedes aegypti
• On first being bitten by an infected mosquito,
  causes a range of flu-like symptoms
• On subsequent exposures, potential for serious
  and potentially fatal dengue hemorrhagic fever
• The only means of control is to control the
  mosquito or avoid bites, there is no vaccine or
  specific treatment
• Most control programs focus on eliminating the
  mosquito or killing the mosquito larva before
  they hatch

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How can a behavioral science approach help with
dengue control?

• Global re-emergence of dengue and DHF
• Reflects the difficulties in maintaining
  effective vertically organized control programs
• Highlights the urgent need to develop
  alternative, sustainable, integrated approaches
  to Ae. Aegypti control

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Problem?
Or Solution ?
Focus on behavior!
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Cover those tanks and get rid of unnecessary
containers!
Why wont those pesky people DO what theyre
supposed to do???
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The Education Approach

• People dont know
• Its our job to provide people with the
  information
• We must be clear and accurate, and
• Provide universal facts for everyone

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A Comprehensive Behavior Change Approach
Policy/Regulation
Institutions
Community
Family/home
Individual
Focus on behaviors!
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What are some of factors that influence
behaviors??

• Knowledge
• Attitudes
• Perceived risk
• Self-efficacy (I can do something)
• Social norms
• Access to services and products
• Policies

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Background
El Salvador
6,341.421 pop. 21,000 Km2 301 pop/Km2
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Background

• Dengue endemic and epidemic (2000 2002) and
  high susceptibility to DHF and mortality
• Water and sewage infrastructure deficient and in
  some cases improper storage habits
• Reactive programs, reactive people

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The starting point

• Despite intensive educational programs to educate
  the public, people continue with detrimental
  practice
• People are motivated to do control behaviors
  that are considered easy .. Although no one
  asked them
• If (when) programs fail, it is those peoples
  fault

An alternative view

• People value options that make sense..
• That consider the costs, benefits and
  consequences of taking that action

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Methods

• Pilot intervention in 3 communities
• Multi-phase formative research
• In-depth Interviews
• Household Observations
• know water sources, storage containers and
  maintenance routines, benefits and personal
  motivations for various actions,
• knowledge of the relationship between water and
  dengue, perceived severity and risk of dengue.

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Methods

• Multi-phase formative research
• Community Trials or Negotiation
• Building on existing practices, identify a few
  actions for control
• Take them to the community
• tested for effectiveness and feasibility
• evaluated their different reactions
• recommendations for modifications
• This methodology builds on previous
• experiences and research results from the
• Dominican Republic and Honduras

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• ... That tire over there.. No way Ill throw it
  out Ill probably use it in the windy season to
  keep the tin roof anchored down.

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Positive Findings

• Households expending effort/money to keep water
  clean, to maintain containers and keep them
  covered
• Cleaning directed to leaves, dust, insects,
  waste, algae not to mosquito eggs or larvae
• Use of household bleach is common, but not in
  quantities strong enough for egg and larvae
  elimination
• Oil drums and large outdoor sinks used for water
  storage were the most prolific breeding sites
• Additional major breeding sites include other
  containers, houseplants, vases, animal dishes and
  tires

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More Findings

• Current practices not effective at reducing
  mosquito breeding
• Limited knowledge about relationship between
  standing water and mosquito breeding, mosquito
  eggs and larvae
• Many containers considered garbage by health
  specialists were valuable resources to
  householders

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NEPRAM Community Negotiations of Improved
Practices

• Developing a comprehensive control strategy
• Short-to-medium term measures
• Cleaning techniques to control breeding sites
• Tightly covering reserve water storage containers
  
• Getting rid of true garbage
• Taking care of useful containers so they dont
  breed
• Including community and commercial spaces

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NEPRAM

• Medium and long-term measures
• Encouraging new designs for water storage
  containers
• Involving the community and private sector to
  produce them
• Supporting community and private sector
  initiatives to replace old containers
• Fortifying community networks

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Inviting the community to join in

• Six possible behaviors (simple, easy and
  effective)
• 3 cleaning behaviors called the Untaditas
• involves wiping the walls of the water drums
  with bleach or bleach detergent to kill
  mosquito eggs
• Shift in emphasis from covering ALL tanks all the
  time, to covering long-term storage
• Putting lime powder inside of spare tires to
  prevent breeding
• Cleaning method for animal dishes

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Inviting the community .

• Tested for feasibility and reduced breeding
• Modifications of behaviors INVITED through home
  visitors from their communities

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Negotiating Change through Volunteer Home
Visitors Support Strategies

• Strengthen linkages with community leaders
• Train volunteers in the new approach of
  negotiating change
• Other social mobilization
• Mass communication
• Incentives for the community and volunteer
  visitors
• Health teams with members from community, MOH and
  municipality

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• Support materials like flipcharts, community and
  technical guides and stickers

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Preliminary Results

• After 9 weeks
• Good level of community participation
• Both communities and institutions responsive to
  the negotitation process
• Incorporation of the improved practices into
  the intervention households
• Overall reduction of entomological indicators
• Adoption of the Untadita cleaning behaviors by
  the National Dengue Control Program of the MOH.

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Lessons Learned from the Integrated Negotiation
Approach

• Although knowledge is not sufficient, certain key
  knowledge is necessary for behavior change
• To close the KAP-gap, we need to address a range
  of other factors
• The community cannot be reached with one single
  approach

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More Lessons

• Intensive, interpersonal interaction is needed to
  effect complex changes
• Mass media helps to support this
• A coherence with national and local policy is
  essential

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More Lessons Learned

• Applying this approach requires changes at many
  levels within institutions, health promotors,
  community and households levels.
• Communities are receptive to the approach of
  negotiating improved behaviors versus imposed
  solutions.
• The community is an under-utilized resource.
• Entomological indicators are going down but have
  not yet met necessary reductions for dengue
  control.

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Para más información
Proyecto CHANGE Academy for Educational
Development e-mail carloschange_at_integra.com.sv
or changeproject_at_aed.org