TABLE 1.

Situational Analysis According to Focal Areas of the BCC Intervention

Focal Areas	Current Situation/Issue	Barriers/Challenges	Components for BCC to Address	Interdependencies^a
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 tools^b
	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 tools^b
	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 tools^b
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 tools^b 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 tools^b
	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 tools^b 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 tools^b
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 tools^b 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.