Figures & Tables
Figures
- FIGURE
Location of Project Districts in Bihar, Jharkhand, and West Bengal States of India, February 2016 to March 2017
Tables
Focal Areas Current Situation/Issue Barriers/Challenges Components for BCC to Address Interdependenciesa Knowledge and attitudes among communities and opinion leaders about causes, symptoms, and severity of VL Unaware/not completely aware of the cause
Inability to differentiate between malaria and VL in terms of causes and causative vectors
Insufficient/incorrect information about causative vector in transmission of VL Knowledge about causes of VL and differences between malaria and VL Building capacities of FLWs in IPC and effective use of BCC toolsb Not aware of all the symptoms and the modes of transmission of VL Insufficient/incorrect information about symptoms and modes of transmission Knowledge about symptoms and modes of transmission Building capacities of FLWs in IPC and effective use of BCC toolsb Awareness and perception that VL is severe and can be fatal if not diagnosed and cured on time Late diagnosis due to lack of information about symptoms
Lack of identification of symptoms, leading to late diagnosis and delayed treatment
Knowledge that delayed diagnosis leads to high transmission of parasite by vector, thereby increasing the case load within a household Building capacities of FLWs in IPC and effective use of BCC toolsb Knowledge, attitudes, and practices among communities and opinion leaders about diagnosis and treatment of VL Analysis of health-seeking behavior of community at the onset of fever reveals that most sought home remedies or visited the local healer (ojha)
Very few prefer going to government health facilities due to various service-delivery reasons
Community is not fully aware about the Rk39 test and about where it can be done
Lack of awareness about diagnosis and treatment and about where to go
Lack of timely diagnosis due to unavailability/inadequate quantity of Rk39
Lack of or poor access to government health facilities due to distance and transportation costs
Low credibility of public health service providers (including FLWs) and the perception/experience of people that there are no/insufficient medicines available at these health facilities
Low levels of motivation and knowledge among FLWs and other providers regarding diagnosis and treatment
Health-seeking behavior for early diagnosis and prompt treatment through public service delivery channels, emphasizing that it is of high quality and free of cost
Informing the community about the various services available and how they can be accessed
Increased credibility, confidence, and satisfaction among community on public health service delivery channels at the PHC and at Sadar district hospital
Increased credibility, trust, and confidence in FLWs, so the community feels motivated to seek help from them
Building capacities of FLWs in IPC and effective use of BCC toolsb
Ensuring sufficient stock of Rk39 diagnostic kits and AmBisome vials, as well as complete and appropriate treatment at Sadar district hospital
Advocating with policy makers regarding implementation of guidelines on incentives for patients and FLWs for treatment
Addressing ‘softer’ aspects like behavior and treatment toward patients by PHC/Sadar district hospital staff
Knowledge, attitudes, and practices among communities and opinion leaders about prevention of VL Less knowledge on prevention measures of VL to prevent breeding of sand fly. Despite incomplete knowledge, VL perceived to be a preventable disease Incomplete knowledge on the methods of prevention Knowledge on preventive methods for Kala-azar (VL) Building capacities of frontline functionaries in IPC skill building and effective use of BCC toolsb Limited knowledge of IRS as one method of prevention
Insufficient information provided to households well in advance of the date of the spray
Practices related to covering the entire house through IRS, including inside the house and cowsheds and in the surroundings and outside the house
IRS has not been done in the recent past in the village
Perceive the spray to affect the walls of the house and contaminate the food because of the bad smell and the stains it leaves behind
Spray workers taking bribes/food grains in exchange for spraying
IRS perceived to be ineffective in the long run
Allergy to the smell (causes headache, cough, etc.)
Face difficulty while emptying the house prior to IRS (which is related to prior communication of the IRS dates)
Absence of male member in the house when spray workers arrive
Delay and continuous changes in dates of IRS
Complete knowledge about IRS and its intended benefits
Advantages of SP and the improvement over DDT
Key influencers and opinion leaders (ward members, Mukhiya, etc.) to play an active role in demanding complete spray
Building capacities of FLWs in IPC and effective use of BCC toolsb
Training of spray workers on technical and soft skills
Ensuring dates of IRS are communicated well in advance, and adhered to by the spray squad
Coordinating with other development partners like CARE
Lack of basic awareness on maintaining cleanliness and keeping the surroundings clean as preventive methods for VL Limited knowledge of importance/benefits of keeping household, cowsheds, and surroundings clean and dry Knowledge and awareness of maintaining proper hygiene and cleanliness especially in damp areas Building capacities of FLWs in IPC and effective use of BCC toolsb Knowledge, attitudes, and practices among communities and opinion leaders about PKDL or relapse of kala-azar Inadequate awareness about PKDL and importance of treatment among patients and their families
Lack of sufficient information that PKDL is a reservoir of infection, which would increase transmission and the case load
Delayed reporting of PKDL cases due to lack of knowledge
Insufficient knowledge about PKDL among community members Knowledge about PKDL and importance of getting it treated immediately Building capacities of FLWs in IPC and effective use of BCC toolsb
Increasing awareness and motivation about PKDL among Medical Officer In-Charge
Abbreviations: BCC, behavior change communication; FLW, frontline health worker; IPC, interpersonal communication; IRS, indoor residual spraying; PHC, primary health center; PKDL, post-kala-azar dermal leishmaniasis; VL, visceral leishmaniasis.
↵a Intervention focused primarily on BCC at the community level while recognizing that achieving the overall goal of VL elimination depends also on structural factors such as availability of timely and quality services.
↵b The intervention used BCC facilitators to implement the BCC activities but also involved FLWs in the BCC activities; no formal communication capacity building of the FLWs, however, was done.
Level Type of Audience Specific Audience Village/tola/community level Primary audience:
Will be carrying out the intended action and therefore the prime target for BCC interventionsPatients and families in the endemic areas
Communities and clusters living in damp humid areas and near vegetation, especially certain vulnerable sections of the population (excluded communities and marginalized groups)
Workers in agricultural fields and in cowsheds
Pregnant women and families with children residing in the endemic areas
Village/tola/community level Secondary audience:
Responsible for facilitating the desired action toward successful behavior changeCommunity-level key influencers and opinion leaders such as PRI members, religious leaders, SHGs/AGGs/youth groups, school teachers/headmasters
Children in middle and secondary schools
Village/block level Secondary audience:
Responsible for facilitating the desired action toward successful behavior changeMoICs, frontline health workers (if any), and active SHG women
District, state, and national level Tertiary audience:
Responsible for providing an enabling environment for sustained behavior changePolicy makers and program managers
Abbreviations: AGG, adolescent girls' group; BCC, behavior change communication; MoIC, Medical Officer In-Charge; PRI, Panchayati Raj Institution; SHG, self-help group.
- TABLE 3.
Mapping of Key Audiences to Communication Objectives, BCC Activities, and BCC Tools
Level Audience Communication Objectives Description of BCC Activity BCC Materials/Tools Village/tola/community level Primary audience: Patients and families in the endemic areas
Communities and clusters living in damp humid areas and near vegetation
Workers in agricultural fields and in cowsheds
Pregnant women and families with children residing in the endemic areas
Increase awareness about VL and PKDL causes, symptoms, and mode of transmission
Ensure timely identification and reporting of fever and PKDL cases to avoid delays in diagnosis and treatment (which increases chances of transmission and case load)
Ensure IRS within complete household (including cowsheds, cracks, holes)
Maintain cleanliness and hygiene within household and surroundings and keep them dry
Increase in awareness regarding:
Location and accessibility of the nearest PHC and Sadar district hospital
Duration, costs, side effects regarding treatment
Provision of incentives for treatment
Group communication sessions using the VL film
IPC using the flip-book
IPC activities such as simple and participatory games, which can be carried out without any specific BCC tool
Miking during IRS (only in Bihar)
Munadi (drum beating) during IRS (only in Jharkhand)
VL film
Flip-book
Posters and stickers displayed at the PHC and Sadar district hospital
Display posters on rickshaws, tempo, and other vehicles plying in rural areas
SMS alerts
Village/block level Secondary audience:
Frontline health workers at village level; MoIC and KTS at the block levelEnsure timely diagnosis and treatment of Kala-azar patients
Ensure active case finding and identification during Kala-azar fortnights and passive case finding during home visits (both Kala-azar and PKDL)
Increase community awareness on causes, symptoms, diagnosis, treatment and prevention of Kala-azar and PKDL
Provide identification and motivation of patients and their families for seeking timely diagnosis and treatment for fever and PKDL (through IPC and counselling during home visits)
Provide information about incentives/other entitlements for Kala-azar patients
Ensuring active participation of FLWs in group communication sessions using the Kala-azar film (to ensure continuity and sustainability)
IPC using the flip-book
Interactions/meetings using FAQ booklet
Capacity building on IPC and communication skills
VL film for GC sessions
Flip-book for IPC sessions
FAQ booklet
Module on IPC and effective communication
SMS alerts
Village/tola/community level Secondary audience:
Opinion leaders, PRI/Gram Sabha members, religious leaders, SHGs/AGGs/youth groups, school teachers and headmastersIncrease awareness about VL and PKDL causes, symptoms, and mode of transmission
Timely reporting of fever and PKDL cases
Ensuring IRS of complete village in each and every household (including cowsheds)
Mobilize and motivate the community to timely report PKDL cases
Mobilize and motivate the community to access and demand various services
Provide information and assist patients in getting incentives after treatment
Provide support during active case finding in Kala-azar fortnights
Ensuring active participation in group communication sessions using the VL film
IPC using the flip-book
Interactions/meetings using FAQ booklet;
Screenings of VL film at the school
Miking during IRS (only in Bihar)
Munadi (drum beating) during IRS (only in Jharkhand)
VL film
Flip-book
FAQ booklet
Posters and stickers distributed to the community, the PHC, and Sadar district hospital
Display posters on rickshaws, tempo, and other vehicles plying in rural areas
SMS alerts
Village/block level Secondary audience:
Private practitioners/traditional healersEnsure timely diagnosis and treatment of VL patients
Informing the patients about causes, symptoms, diagnosis, treatment, and prevention of VL and PKDL
Provide information about diagnosis and treatment processes as well as procedures for referral to Sadar district hospital
Ensure proper recording and reporting of cases
Inform the patients about the nearest accessible and functional health facility
Sensitization workshops FAQ booklet
Posters and stickers for display and distribution in clinics, hospitals
SMS alerts
Workshop kit
District, state, and national level Tertiary audience:
Policy makers and program managersProvision of quality and timely resources (human, equipment, and finances)
Provision of timely and regular supply of diagnostic kits and medicines
Ensure proper planning and implementation to ensure complete coverage through IRS
Devise a plan for capacity building of health care service providers and spray staff on technical and soft skills to enhance their motivation and awareness levels
Coordinate with other departments to ensure concerted efforts toward elimination
Ensure periodic review of the VL elimination program by senior officials at state and district levels
Advocacy by KalaCORE with support Advocacy Abbreviations: AGG, adolescent girls' groups; BCC, behavior change communication; FAQ, frequently asked questions; IPC, interpersonal communication; IRS, indoor residual spraying; KTS, Kala-azar Technical Supervisor; MoIC, Medical Officer In-Charge; PHC, primary health center; PKDL, post-kala-azar dermal leishmaniasis; PRI, Panchayati Raj Institution; SHG, self-help group; VL, visceral leishmaniasis.
- TABLE 4.
Estimated Reach of BCC Activities in Bihar and Jharkhand, India, February 2016 to March 2017
BCC Activities No. of Activities No. of Contacts Madea Group communication sessions 24,572 982,880 VL film screenings 3,090 185,400 Interaction with frontline health workers through FAQ booklet and with KI using leaflet 64,484 64,484 IPC sessions through flip-book 74,452 595,616 Posters (on treatment, IRS, PKDL) 91,228 456,140 Wall stickers (on treatment and PKDL) 215,697 1,078,485 TOTAL 3,363,005 Abbreviations: BCC, behavior change communication; FAQ, frequently asked questions; IPC, interpersonal communication; IRS, indoor residual spraying; PKDL, post-kala-azar dermal leishmaniasis; VL, visceral leishmaniasis.
↵a These do not necessarily represent unique contacts because there may have been overlap in the people exposed to different BCC activities.
- TABLE 5.
Demographic Characteristics of Households Included in the Survey, Bihar and Jharkhand States of India, 2016
Variables Bihar Jharkhand Total Control (n=250) Intervention (n=500) Control (n=100) Intervention (n=200) Control (N=350) Intervention (N=700) Population of villagesa 112,522 394,497 12,590 37,516 125,112 432,013 Total no. of householdsa 24,431 63,944 2471 7620 26,902 71,564 Distance to nearest PHC, mean (km) 11.0 9.0 14.3 12.6 11.9 10.1 Average no. of family members in the surveyed households 10.1 9.5 6.0 5.6 8.9 8.4 Caste group, % General 12.8 13.4 0.0 0.5 9.1 9.7 Other Backward Caste 42.0 43.6 10.0 13.0 32.9 34.9 Scheduled Caste 31.2 27.2 9.0 3.5 24.9 20.4 Scheduled Tribe 6.4 8.2 78.0 82.0 26.9 29.3 Mahadalitb 6.8 5.8 1.0 0.0 5.1 4.1 Not disclosed 0.8 1.8 2.0 1.0 1.1 1.6 Religious affiliation, % Hindu 85.2 83.8 37.0 41.5 71.4 71.7 Muslim 13.6 15.0 0.0 0.5 9.7 10.9 Christian 0.8 0.4 35.0 33.5 10.6 9.9 Sikh 0.0 0.0 0.0 0.0 0.0 0.0 Jain 0.0 0.0 0.0 0.0 0.0 0.0 Buddhist 0.0 0.0 1.0 0.0 0.3 0.0 Sarna 0.0 0.6 27.0 23.5 7.7 7.1 Not disclosed 0.4 0.2 0.0 1.0 0.3 0.4 Major occupation, % Agriculture 32.4 31.3 95.0 87.5 50.3 47.4 Labor 44.8 44.1 1.0 2.5 32.3 32.2 Service 5.6 5.2 2.0 2.0 4.6 4.3 Business 10.0 11.2 1.0 2.0 7.4 8.6 Other 7.2 8.2 1.0 6.0 5.4 7.6 Income category, % Below the poverty level 74.0 70.6 90.0 86.5 78.6 75.1 Above the poverty level 22.0 25.4 9.0 12.5 18.3 21.7 Don't know 4.0 4.0 1.0 1.0 3.1 3.1 - TABLE 6.
Exposure to the VL Messages Among Intervention and Control Households, Bihar and Jharkhand States of India, 2016
Intervention (%) (N=700) Control (%) (N=350) OR 95% CI P Value Have heard/seen anything about VL in the last 12 months? 68.7 21.1 8.4 (4.41, 15.90) <.001 Where did you hear/see anything about VL?a Radio 0.3 0.7 0.3 (0.01, 8.20) .50 TV 6.4 1.3 6.3 (0.75, 53.48) .09 Newspaper 0.5 0.7 1.0 (0.06, 16.21) 1.00 Poster 10.5 0.9 12.2 (1.55, 96.68) .02 Health meeting at PHC 0.2 0.4 1.0 (0.02, 50.89) 1.00 Community meeting 2.9 0.4 7.2 (0.37, 141.53) .19 Religious place/religious leaders 0.3 0.0 1.0 (0.02, 50.89) 1.00 Community leaders 0.0 0.1 1.0 (0.02, 50.89) 1.00 Friends/neighbor 1.9 1.4 2.0 (0.18, 22.65) .57 Miking/drum beating 6.5 4.4 1.5 (0.42, 5.60) .52 ASHA, ANM, AWW, or other health staff 3.5 2.1 1.5 (0.25, 9.27) .65 Door-to-door meeting 5.7 0.0 13.8 (0.77, 248.81) .07 Other 0.0 0.4 1.0 (0.02, 50.89) 1.00 BCC project activities 24.5 0.3 67.9 (4.02, 113.00) <.001 Don't know/not heard or seen 36.8 87.0 0.1 (0.04, 0.18) <.001 Did you get prior information about IRS of your house?b Yes 66.9 30.3 4.7 (2.61, 8.61) <.001 No 25.3 51.4 0.3 (0.18, 0.58) <.001 Don't know 7.9 18.3 0.4 (0.16, 0.96) .04 Abbreviations: ANM, auxillary nurse-midwife; ASHA, Accredited Social Health Activist; AWW, Agaanwadi Worker; BCC, behavior change communication; CI, confidence interval; OR, odds ratio; PHC, primary health center; PKDL, post-Kala-azar dermal leishmaniasis; VL, visceral leishmaniasis.
↵a Respondents were asked open-ended questions and their first response was recorded.
↵b Refers to information through miking on the day of or before the IRS spray to announce arrival of the spray team. In intervention villages, miking was conducted by the BCC project, whereas in control villages it was conducted by the government.
- TABLE 7.
IRS Refusal Rates During the Second Spray Round Among Intervention and Control Households, by District and Block, Bihar and Jharkhand States of India, 2016
District Block % IRS Refusal ORa 95% CI P Value Intervention Control Bihar 6.20 20.90 0.24 (0.09, 0.62) <.001 Araria Forbesganj 5.63 51.39 0.06 (0.02, 0.15) <.001 Gopalganj Baruali 3.16 15.08 0.18 (0.05, 0.63) .01 Katihar Kadwa 3.68 4.62 0.79 (0.21, 3.04) .73 Muzaffarpur Paroo 11.96 16.65 0.67 (0.30, 1.48) .32 Purnia Kaswa 5.18 1.67 2.58 (0.49, 13.62) .26 Samastipur Sarairanjan 12.72 26.11 0.43 (0.20, 0.89) .02 Saran Dariyapur, Garkha 9.08 32.84 0.20 (0.09, 0.45) <.001 Sitamarhi Dumra 5.63 37.79 0.10 (0.04, 0.26) <.001 Siwan Barhariya 3.96 12.44 0.31 (0.10, 0.98) .05 Vaishali Mahua 1.44 10.12 0.09 (0.01, 0.72) .02 Jharkhand 12.20 33.40 0.28 (0.13, 0.58) <.001 Dumka Ramgarh 1.18 34.72 0.02 (0.00, 0.14) <.001 Godda Sundarpahari 18.76 44.73 0.29 (0.15, 0.54) <.001 Pakur Littipara 19.07 25.07 0.70 (0.36, 1.38) .31 Sahibganj Borio 9.82 29.09 0.27 (0.12, 0.60) <.001 Total (Bihar and Jharkhand) 7.95 24.45 0.27 (0.11, 0.62) <.001 Abbreviations: CI, confidence interval; OR, odds ratio; IRS, indoor residual spraying.
↵a OR estimated based on assumption that the percentage of households that accepted IRS in the intervention areas would have refused IRS had they not been exposed to the BCC intervention. For example, in Araria district, 5.63% of households exposed to BCC activities still refused IRS. Therefore, we assume that 94.37% of households would have refused IRS if they had not been exposed to the BCC intervention, keeping aside confounders and outliers.
- TABLE 8.
Knowledge, Attitudes, and Practicesa Related to Prevention of VL Among Intervention and Control Households, Bihar and Jharkhand States of India, 2016
Intervention(%) (N=700) Control(%) (N=350) OR 95% CI P Value KNOWLEDGEb What causes VL? Insects 3.6 4.9 0.8 (0.21, 3.04) .73 Mosquitos 20.3 63.1 0.1 (0.08, 0.28) <.001 Sand fly 68.4 7.4 28.2 (11.76, 67.77) <.001 Other 3.3 1.7 1.5 (0.25, 9.27) .65 Don't know 4.3 22.9 0.1 (0.05, 0.42) <.001 Is VL contagious and spread by touching? Yes 21.0 23.4 0.9 (0.46, 1.74) .73 No 66.7 44.6 2.5 (1.41, 4.40) <.001 Don't know 12.3 32.0 0.3 (0.14, 0.60) <.001 What are the symptoms of VL? Fever >2 weeks 25.4 10.5 3.0 (1.36, 6.64) .01 Loss of appetite 15.5 7.1 2.5 (0.99, 6.45) .05 Enlargement of spleen 14.8 5.5 2.8 (1.03, 7.45) .04 Weakness and anemia 11.4 4.2 3.0 (0.91, 9.66) .07 Don't know 29.4 68.1 0.2 (0.11, 0.35) <.001 Do you know IRS prevents VL? Yes 82.3 41.7 6.3 (3.29, 12.01) <.001 No 7.4 19.7 0.3 (0.12, 0.75) .01 Don't know 10.3 38.3 0.2 (0.08, 0.39) <.001 What is effective treatment of VL? Local/traditional treatment 6.4 12.6 0.4 (0.15, 1.17) .10 Malarial medicine 8.1 14.6 0.5 (0.19, 1.22) .13 1-day medicine that is given in government hospital 64.7 13.1 12.4 (6.09, 25.36) <.001 No need for medicine 0.6 0.0 3.0 (0.12, 75.28) .50 Other 1.6 7.7 0.2 (0.05, 1.13) .07 Don't know 18.4 52.0 0.2 (0.11, 0.39) <.001 Do you know that complete treatment of VL is available? Yes 88.3 62.0 4.5 (2.17, 9.29) <.001 No 3.9 14.0 0.3 (0.08, 0.81) .02 Don't know 7.9 24.0 0.3 (0.12, 0.65) <.001 Do you know that complete treatment of VL is free? Yes 81.0 39.1 6.7 (3.51, 12.66) <.001 No 6.9 26.9 0.2 (0.08, 0.49) <.001 Don't know 12.0 34.0 0.3 (0.13, 0.55) <.001 When to treat a patient with VL? Immediately 38.0 20.3 2.5 (1.31, 4.63) .01 Within 1 week 11.3 5.7 1.9 (0.68, 5.46) .21 Within 2 weeks 22.6 6.0 4.7 (1.81, 12.07) <.001 When the patient has a fever 10.4 12.6 0.7 (0.31, 1.78) .51 Other 1.7 3.4 0.7 (0.11, 4.04) .65 Don't know 16.0 51.4 0.2 (0.09, 0.36) <.001 ATTITUDES To whom do you advise patients with VL symptoms to go for diagnosis and treatment? PHC 77.0 39.4 5.2 (2.83, 9.69) <.001 Private doctor 7.3 27.1 0.2 (0.08, 0.49) <.001 RMP/Quack 1.1 6.3 0.1 (0.01, 1.04) .05 Traditional healer 0.4 0.3 1.0 (0.02, 50.89) 1.00 Other 1.3 2.3 0.5 (0.04, 5.55) .57 Don't know 12.9 24.6 0.4 (0.21, 0.94) .03 Will you motivate/help community members to accept IRS? Yes 78.6 44.6 4.6 (2.47, 8.56) <.001 No 14.9 31.1 0.4 (0.19, 0.79) .01 Don't know 6.6 24.3 0.2 (0.09, 0.58) <.001 Will you help community members to identify suspected cases of VL? Yes 72.3 30.9 5.7 (3.11, 10.52) <.001 No 18.4 44.3 0.3 (0.15, 0.53) <.001 Don't know 9.1 24.9 0.3 (0.13, 0.67) <.001 PRACTICES Did you allow spraying of SP last timec in your house? Yes, all rooms 77.3 54.6 2.7 (1.49, 5.04) <.001 Yes, partially 16.3 27.4 0.5 (0.26, 1.03) .06 No 1.1 4.0 0.2 (0.03, 2.21) .21 My house was locked 1.9 2.9 0.7 (0.11, 4.04) .65 Unaware about day of IRS 3.4 11.1 0.3 (0.06, 0.93) .04 Abbreviations: ANM, auxillary nurse-midwife; ASHA, Accredited Social Health Activist; AWW, Anganwadi Worker; CI, confidence interval; OR, odds ratio; PHC, primary health center; PKDL, post-Kala-azar dermal leishmaniasis; RMP, registered medical practitioner; SP, synthetic pyrethroid; VL, visceral leishmaniasis.
↵a Respondents were asked open-ended questions and their first response was recorded.
↵b Correct answers are shown in italics.
↵c Refers to the first IRS round.
Supplemental material
Files in this Data Supplement:
- Download Supplement 1 - Mapping of Communication Channels to BCC Activities, Materials, and Audiences
- Download Supplement 2 - Implementation Plan for BCC Intervention in Bihar, India
- Download Supplement 3 - Organogram of the Bihar and Jharkhand Project Teams
- Download Supplement 4 - Instructions for Field Implementation
- Download Supplement 5 - Project Management Information System
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