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Achieving Behaviour Change For Dengue Control: Methods, Scaling-Up, And Sustainability

30 Nov 2007

Source: WHO/TDR

John Elder ¹ , Linda S Lloyd ²

¹Department of Behavioral Sciences, Graduate School of Public Health, San Diego State University, San Diego, CA 92182, USA
²3443 Whittier St., San Diego, CA 92106, USA

Working paper for the Scientific Working Group on Dengue Research, convened by the Special Programme for Research and Training in Tropical Diseases, Geneva, 1–5 October 2006

Full text source: Scientific Working Group, Report on Dengue, 1–5 October 2006, Geneva, Switzerland, Copyright © World Health Organization on behalf of the Special Programme for Research and Training in Tropical Diseases, 2007, http://www.who.int/tdr/publications/publications/swg_dengue_2.htm

Introduction

With the global resurgence of dengue and its more severe form, dengue hemorrhagic fever (DHF), the disease has re-emerged as a major threat to public health. Typical approaches to dengue control and vector control involve vertical programmes to reduce the source of transmission. Physical (e.g. destruction or other physical manipulation of water-holding containers), biological (e.g. use of fish), and chemical (e.g. use of larvicides, spraying with systemic insecticides) control methods can be successful if substantial administrative and political support is provided. However, such efforts often result in short-term control as the areas become reinfested in a fairly short period of time. Vertical vector control programmes may be ineffective because communities are not active partners in the control actions but rather are passive participants or recipients of the control efforts [13]. In light of the restructuring efforts by ministries of health to decentralize services, and of the generalized chronic underfunding of dengue control programmes, and in order to provide effective control measures, it is critical to address issues such as: (1) how to maintain quality of control in a decentralized system where decision-making takes place at regional, state, provincial or municipal levels; (2) how to ensure that funding is adequate to maintain programme infrastructure; and (3) how to ensure, where traditionally staff have been under the purview of the ministry of health (e.g. communications, entomology) rather that the regional or municipal health department, that there are trained staff in technical areas at the local level.

Dengue may present as a mild illness episode, leading many people to underestimate its seriousness and therefore the importance of controlling the mosquito vector. Some residents may be unaware of how dengue is transmitted, and some may be unaware of the source of the vector mosquito; others however may know where the Ae. aegypti mosquito is produced and how the breeding sites can be controlled or eliminated but are not motivated to take preventive action. Even those who do follow the recommended actions may still have Ae. aegypti or other mosquitoes in their houses and, worse still, may suffer dengue infections if their neighbours do not participate in controlling domestic breeding sites, or they may get bitten by an infected mosquito at their place of work or study. Therefore, the issue for vector control is not whether source reduction is effective, but whether and how community participation can be a part of that source reduction effort [14,19] Regardless of whether the dengue control efforts take place through a centralized or decentralized system of care, the issues are (1) how to meaningfully engage residents in sustained control actions; (2) how to effectively communicate with residents in ever-expanding urban and semi-urban areas in light of reduced vector control staffing and chronic budget shortfalls; and (3) how to measure the impact of residents' actions on Ae. aegypti breeding sites. This paper is divided into two sections. The first will examine behaviour change and dengue control efforts and the second will examine delivery mechanisms for behaviour change interventions in the community.

Behaviour change and dengue control

Although experts agree that community participation and modification of human behaviour at the household level are crucial to effective control of Ae. aegypti, the specific form that control efforts should take continues to present a challenge to public health officials. As the context for the present paper, a review was conducted of research studies in community-based dengue control efforts published since 1995. This review was carried out through Internet search engines (PubMed, Google Scholar, etc.) and through reviews of existing paper files and library-housed journals. Given the nature of these searches, most literature identified was published in English.

All behaviour change and/or health communication-oriented papers were reviewed with respect to the following characteristics or variables:

country/setting
planning tool or approach used
level at which the intervention was directed (i.e. household, school and other organizations, or entire communities or regions)
person(s) who was(were) the source of communication or agent of change
dependent measure or outcome variable
research or evaluation design of the study or programme evaluation
results, and conclusions drawn by the authors.

The studies presented here were those for which most of this information was evident in the article, especially with regard to whether any evaluation of the dengue control effort had been undertaken. A summary of these studies (or programme evaluations) is presented in table 1.

In 2005, an evaluation of 11 WHO-supported dengue communication and mobilization programmes using the communication for behavioural impact (COMBI) planning tool [26] was conducted in six South Asian and Latin America/Caribbean countries [7]. The conclusions below are derived from this evaluation, as well as from the review of recent programmes (table 1).

Progress and challenges in community-based behaviour change efforts

Multi-level behaviour and community change

As can be seen in table 1, all programmes included behaviour change efforts at the household level, and some targeted the broader community and other partners (schools were the most common partner). However, vector control cannot be effective (or at least, very effective) if carried out only on an individual basis. Thus, if mosquito breeding sites are eliminated in one household but not in a neighbour's or in public areas, the individuals in that cleaner household are likely to receive some but little added protection against dengue. At some point, however, a critical mass may be reached where a sufficient number of vectors are eliminated in an area or region, thereby reducing everyone's risk for contracting dengue. Thus, multi-level, vertically and horizontally integrated programmes offer the best solution to dengue control. For optimal effects, such programmes would include not only community-wide (e.g. mass media) and house-by-house efforts, but also those efforts of schools, worksites and other organizations within the community.

At the community and regional levels, responsible agencies may need to identify ‘programme champions’ in order for their efforts to succeed, while at other levels, groups of individuals may share responsibility for maintaining programme momentum and integrity. An assessment of different leadership modalities from the WHO evaluation revealed that roughly half of the programmes were led by strong, forceful individuals, while the others seemed to be more ‘committee driven’, with two to several individuals sharing responsibility and decision-making. Neither model seemed to have an advantage over the other. In one case, the group of individuals responsible for the effort seemed not to agree on its key aspect, impeding progress towards COMBI goals. In another, the programme champion was such a strong individual that one would worry about the future of the programme after leadership turnover. But in most other cases, the model that was chosen by the country or community seemed to be the best one for them, a phenomenon consistent with recent research on tailoring health communications. The advantages of a programme champion are that their investment of energy and enthusiasm will often achieve more results in the short term, while the downside relates to the unclear implications for longer term sustainability and generalizability to regions without such individuals.

In any case, enthusiasm will at some point die out, especially among non-paid volunteers, thus threatening sustainability. Setting limited periods of commitment or allowing the workers to move on at some point to other health issues or even other communities (perhaps helping new neighbourhoods to start their own front-line worker teams) could be among the methods used to optimize commitment. Second, plans must be developed to fade an effort out once progress has been sufficient or nearly so. Booster (or spot-check) home visits, for example, should be increasingly infrequent, thus avoiding both health worker and homeowner burn-out. Should entomological, epidemiological or behavioural data indicate a need to renew a full intervention, this could then be accomplished on a shorter-term scale, reverting to spot-checks when needed.

While much has been written about social marketing and many examples of successful social marketing have been projects that took place over several years, there are few examples of incorporation of social marketing principles in dengue prevention and control programmes. According to the UK National Social Marketing Centre (2006) [22], social marketing is ‘the systematic application of marketing concepts and techniques to achieve specific behavioural goals, for a social or public good’. In a comprehensive white paper on how to create a ‘people-centred’ public health strategy, the authors examine how to improve disease prevention and health promotion within the British National Health System, and they assess the potential of social marketing to move beyond the prevention models currently in practice. The authors state that social marketing ‘can support efforts to achieve an appropriate and effective balance between the role of individuals and the role of the state and relevant bodies’. Although an assumption might be that, in resource-rich countries, such approaches would be systematically developed and supported, in reality the public health and the health care systems generally function as two separate entities with differing views on what prevention is and who the target audience should be. It is important to clarify that a national media campaign is not social marketing, although it might be part of a social marketing programme. Regardless of the framework, the following issues have been identified as essential to understanding prior to the development of any community-based approaches.

Operationalization of behaviours

Few programmes provide clear definitions of specific human actions that can improve control as part of the planning phase of community programmes, and those that do often leap ahead to an examination of indications of mosquito breeding in the evaluation effort (table 1). A key element in any health behaviour change or disease prevention programme comprises the initial step of ‘operationalization’ of target behaviours. Operational definitions of behaviours or the environments surrounding them emphasize an objective observation of the physical aspects of the behaviours. Thus, a behaviour can be observed directly and reliably by examining the frequency, duration, or strength of the behaviour (e.g. the frequency of applying larvicide, the duration of cleaning used to reduce algae in a 55 gallon drum, the intensity with which an individual appears to scrub a cement basin), or the physical by-product of that behaviour (e.g. the number of tyres left unprotected in a backyard vs. the number filled with dirt or placed under a roof). Operational definitions, therefore, go hand in hand with the nature of the assessment used to arrive at those descriptions of behaviour. Thus, phenomena such as ‘knowledge of breeding cycles’ or ‘fear of mosquito contamination’ are not behaviours per se but inferred inner causes of these behaviours. In practice it is often difficult for health education or vector control professionals to arrive at specific operational definitions of behaviours, as they have frequently been trained to emphasize these internal mechanisms.

In Ae. aegypti control efforts, it may be difficult to observe the nature of the behaviour, and therefore for monitoring purposes it is often necessary to select physical by-products of the behaviour rather than an observation of the behaviour. Nonetheless, behaviours must still be operationally defined even if their direct performance cannot be observed. It is only through the operationalization of each behaviour that indicators can be developed to measure whether or not the behaviour has taken place and to what extent it has been carried out.

The operationalization of behaviour starts with the selection of one or more specific target behaviours. These behaviours are selected on a variety of criteria, the most important of which is whether the behaviour itself seems to have an impact on the specific health problem. Nevertheless, many different behaviours may potentially have such an impact and the target behaviour must be narrowed down to a manageable single or small group of behaviours. Therefore, programme planners should also address the following in the selection of target behaviours:

Feasibility: To what extent would the performance of the target behaviour result in negative consequences for the individual performing it (e.g. changing the taste of drinking water by adding temephos or fish)? Is the behaviour compatible with the person's current practice and with sociocultural norms in the community? Does the potential target behaviour require an unrealistic rate or frequency or duration in order to be sufficient? What are the costs of the target behaviour in terms of time, energy or other community-identified expenditures?
One step at a time: Are there any existing ‘approximations’ to the target behaviour? Is the behaviour already being performed perhaps at a substandard but detectable level? Can this behaviour be ‘shaped’ to meet criteria? Are there monitoring systems (see below) in place that could be used to provide feedback to household residents, health staff, and others who may gradually provide evidence of improvement in behaviour [12]?
Some confusion about how to operationalize target behaviours derives from an inability to distinguish between whether the target behaviour exists at all, or whether it does not exist in adequate strength due to ‘performance deficit’ or ‘skill deficit’. ‘Performance deficit’ refers to a situation in which individuals may actually possess an existing skill but either do not receive the reinforcement necessary for performing the behaviour or receive inadequate reinforcement and hence do not engage in adequate practice. As part of the performance deficit analysis, understanding the functions served by containers (not just their type and capacity) that are potential breeding sites in the home is key to determining the actions that can be implemented [19,9]. In contrast, a ‘skill deficit’ is simply that the individual does not have the knowledge and practice associated with adequate performance of a skill regardless of whether he or she is motivated to engage in that behaviour. Health communication and social mobilization efforts take very different forms depending on whether the bulk of the population evidences skill or performance deficit with respect to the control of mosquito breeding.
Context of the behaviour: To further complicate the definition and selection of target behaviours, general community needs and capacity must be examined simultaneously. In most studies, both the target behaviours and the communities selected evidence a range of ‘difficulty’. When using the COMBI planning tool, programme planners must focus on target behaviours that will have a measurable impact on the specific component of dengue prevention and control being addressed through the communication/social mobilization plan; the target behaviours, however, are the result of a community-based process through which the target population and the programme planners identify and test behaviours for feasibility and effectiveness. Other programmes have used other models or processes to define behaviours within a participatory community process (table 1). The target areas also evidence a range of characteristics in socioeconomic status and accessibility, ranging from communities enjoying schools, roads in good condition, utilities, general municipal services, and employment, to others with high crime and low employment, and buildings and roads in poor physical condition. Some communities may be within a few kilometres of their health centres while others are in remote locations. In other words, some communities are relatively easy to work with, while others are more difficult.
These independent dimensions of behavioural and community ‘difficulty’ may lead one to conclude that generally, when planners select a difficult community (e.g. poorer, with higher crime), they may want to begin with an ‘easier’ target behaviour (e.g. hermetic covering of containers). Should more accessible and prosperous communities be selected, planners can be more ambitious with respect to the choice of target behaviours (e.g. frequent emptying and scrubbing of containers). It is axiomatic that poorer communities need more resources to achieve an equivalent result. Planners should focus on what is truly practical for modest or resource-poor environments (resource-poor referring to both the programmatic environment and the target community).

The monitoring-feedback loop

Related to the integration of efforts and the operationalization of specific, observable target behaviours is the need for an emphasis on information sharing and feedback loops through monitoring and evaluation. Few studies reported in the literature (table 1) indicate that systematic monitoring and evaluation have been carried out, and perhaps only a few have used ongoing monitoring to improve or reinforce efforts. Vector control and health education/communications staff seem to understand in general what evaluation is, but how to conduct routine programme monitoring, and how to use those data for programme adjustments throughout the year, do not seem to be clearly understood. While many national programmes can show that data are collected for calculating entomological indices, few can describe how these data are used during household visits since Aedes breeding sites are not prioritized, leading to the ongoing promotion of general behavioural messages that have limited impact on mosquito breeding as evidenced in continued high larval indices.

Understanding of and enthusiasm for the COMBI interventions among residents seems to be largely a function of health workers giving individual, specific feedback at the household level. In fact, health workers and volunteers seem to be more cognizant of and capable when they use specific behaviourally-based feedback rather than more general exhortations to the community. Monitoring and evaluation data must be accessible and apparent at higher levels as well. In the Nicaragua programme, maps with colour-coded pins used to track neighbourhood outbreaks of dengue and malaria provided feedback to all staff and community health volunteers regarding epidemiological markers for programme progress, and pinpointed specific blocks in the neighbourhoods where more intensive education and behaviour change work were needed. Staff and volunteers met each month to discuss the neighbourhoods and specific challenges, so that staff and volunteers received continuous feedback and reinforcement for their work, just as residents had received through the self-retaining of records.

A weakness of all programmes examined to date is the lack of behavioural indicators that have been tested and validated for routine field use within the context of national dengue programmes. Although indicators have been created and tested in some studies (e.g. in Mexico, Honduras), these indicators have not been operationalized within a dengue prevention and control programme setting. There is lack of staff with specific expertise in this area within ministries of health, leading to ongoing, inappropriate use of entomological indicators as proxies for human behaviours.

Delivery of behavioural interventions to target populations

To date, special community-based projects may use ministry of health staff, a combination of ministry of health/externally funded staff, or may be completely externally funded. The ongoing challenge is how to take promising results from a special project and deliver them on a national scale, taking into consideration differences in vector ecology and in local level capacity to manage programmes, lack of local level staff with behaviour change expertise, political changes that impact programme services from national to municipal level, staffing changes at all levels, and chronic funding and staffing shortages.

Because most behaviour interventions have been delivered through the existing structure of dengue programmes, for the most part, after a certain period, the programme reverts to its original focus and programming, that is, to entomological surveying and source reduction conducted by vector control staff. This is not only the case for behavioural interventions, but laboratory and case management also tend to function independently, even though the need for integration of the five essential components has been highlighted over the past years [23–24,33] In order to address this issue, the Regional Program Office for Dengue Prevention and Control of the Pan American Health Organization developed a Strategy for Integrated Dengue Management (EGI-Dengue), a process by which countries functionally integrate the five key components of a dengue prevention and control programme (epidemiology, entomology/vector control, community participation, laboratory, case management) [25] The EGI-Dengue process convenes a national technical expert group with two to three experts in each of the five components to prioritize actions for each component area and then to prioritize actions across the five areas. The national group of experts monitors the implementation of the national integration strategy via the logic framework (marco logico) developed as part of the process. The EGI-Dengue process has been under way in the Americas since 2004.

Behavioural risk indicators

Good programme planning is based on understanding who needs what service(s), when, and where. Unfortunately, we do not have indicators by which we can measure dengue behavioural risk, such as blood pressure is used to indicate heart disease and blood sugar to indicate diabetes. We need to be able to stratify areas using epidemiological, entomological and behavioural risk indicators in order to develop and then deliver an intervention mix that will respond to the priority risk indicators of that area.

Key issues for consideration in behaviour change interventions

Programme leadership and planning for sustainable community participation and involvement.
Transfer of technical knowledge and skills in planning participatory behavioural interventions to health workers, community volunteers and other partners at the local level.
Creation and maintenance of monitoring and feedback systems at the local and national levels, including the development of behavioural indicators.
Judicious mix of communication channels (interpersonal, mass media, publicity, etc.) to support programme behavioural goals over time, based not just on available funding but also on effectiveness for the local context.

Priority research questions

How can indicators that measure behaviour change, and the extent of this change, be operationalized?
What are the indicators of behavioural risk and how can these indicators be part of a stratification process based on epidemiological, entomological and behavioural risk indicators?
Can the current, entrenched programme delivery model, which is not, for the most part, achieving the goals and objectives of controlling dengue fever/DHF, be revamped, or do we need a new programme model?
How can cost effectiveness be measured? Do we need to measure the added benefit of each individual component since we don't have a fully integrated model that can be used as a reference point?
How can we go to scale from pilot models of community-based communication/mobilization efforts?

References

1. Arostegui J, etal Impact of evidence-based community-derived interventions for the control of the dengue virus vector Aedes aegypti in Managua, Nicaragua .

2. Bera A, etal (2004) The value of social science research during the implementation of dengue fever prevention and control activities in Fiji. Dengue Bull 28S: 26-29.

3. Chan AS, etal (1998) Development of an indicator to evaluate the impact, on a community-based Aedes aegypti control intervention, of improved cleaning of water-storage containers by householders. Ann Trop Med Parasitol 92: 317-329.

4. Clark GG, Halstead SB, Gomez-Dantes H, (1992) Aedes aegypti community-based control programmes in the Americas: Puerto Rico. Dengue: a worldwide problem, a common strategy Mexico City:Mexican Ministry of Health and Rockefeller Foundation 217-223.

5. Clark GG, etal (2004) Development of pilot programmes for dengue prevention in Puerto Rico: a case study. Dengue Bull 28S: 48-52.

6. Espinoza-Gómez F, Hernández-Suárez CM, Coll-Cárdenas R, (2002) Educational campaign versus malathion spraying for the control of Aedes aegypti in Colima, Mexico. J Epidemiol Community Health 56: 148-152.

7. Elder JP, (2005) Evaluation of communication for behavioural impact (‘COMBI’) efforts to control Aedes aegypti breeding sites in six countries Tunis:WHO Mediterranean Centre for Vulnerability Reduction .

8. Fernández E, Martinez M, Sherman C, (2004) Social mobilization for dengue control in Honduras. Dengue Bull 28S: 30-34.

9. Galván JM, Gutiérrez LR, (2004) Dengue prevention in Mérida, Yucatán, Mexico: Use of formative research to refine an education/communication intervention targeting household management of key Aedes aegytpi-producing containers. Dengue Bull 28S: 44-47.

10. Gordon AJ, (1988) Mixed strategies in health education and community participation: an evaluation of dengue control in the Dominican Republic. Health Educ Res 3: 399-419.

11. Gordon AJ, Rojas Z, Tidwell M, (1990) Cultural factors in Aedes aegypti and dengue control in Latin America: a case study from the Dominican Republic. Int Q Community Health Educ 10: 193-211.

12. Graeff J, Elder J, Booth E, (1993) Communications for health behavior change: a developing country perspective San Francisco:Jossey-Bass .

13. Gubler DJ, (2002) Epidemic dengue/dengue hemorrhagic fever as a public health, social and economic problem in the 21st century. Trends Microbiol 10: 100-103.

14. Gubler DJ, Clark GG, (1996) Community involvement in the control of Aedes aegypti. Acta Tropica 61: 169-179.

15. Kusriastuti R, etal (2004) “Together Picket”: Community activities in dengue source reduction in Purwokerto City, Central Java, Indonesia. Dengue Bull 28S: 35-38.

16. Leontsini E, etal (2004) NEgociación de PRÁcticas Mejoradas - NEPRAM (Negotiation of Improved Practices): The development of a national behaviour change strategy for community-based prevention of dengue fever in the Dominican Republic. Dengue Bull 28S: 22-25.

17. Leontsini E, (2000) Insumos para diseñar una estrategia integral de prevención de dengue en República Dominicana. Negociaciones de Prácticas Mejoradas con relación al control de criaderos domésticos de Aedes aegypti US:Universidad de Johns Hopkins . (CENCET/SESPAS/USAID/AED/JHU/CDC/OPS)

18. Lloyd L, etal (1994) The design of a community-based health education intervention for the control of Aedes aegypti. American Journal of Tropical Medicine and Hygiene 50: 401-411.

19. Lloyd L, etal (1992) Results of a community-based Aedes aegypti control program in Merida, Yucatan, Mexico. American Journal of Tropical Medicine and Hygiene 46: 635-642.

20. Luna JE, etal (2004) Social mobilization using strategies of education and communication to prevent dengue fever in Bucaramanga, Columbia. Dengue Bull 28S: 17-21.

21. Nam VS, etal (2004) Community mobilization, behaviour change and biological control in the prevention and control of dengue fever in Viet Nam. Dengue Bull 28S: 57-61.

22. National Social Marketing Centre, Its our health!. Realising the potential of effective social marketing. A report to the Department of Health, United Kingdom, c2006 . Available from: http://www.nsms.org.uk

23. Pan American Health Organization, (1994) Dengue and dengue hemorrhagic fever in the Americas: guidelines for prevention and control Washington DC, PAHO:Scientific Publication no. 548 .

24. Pan American Health Organization, (1999) The blueprint for action for the next generation: dengue prevention and control Washington DC, PAHO .

25. Pan American Health Organization, (2003) Resolution CD 44.R9 . Available from http://www.paho.org/spanish/gov/cd/cd44-r9-s.pdf also http://www.paho.org/spanish/gov/cd/cd44-14-s.pdf

26. Parks W, Lloyd L, (2004) Planning social mobilization and communication for dengue fever prevention and control: a step-by-step guide Geneva:WHO/TDR/PAHO (TDR/STR/SEB/DEN/04.1) . Available from: http://www.paho.org/English/AD/DPC/CD/den-step-by-step.htm

27. Socheat D, etal (2004) The development and testing of water storage jar covers in Cambodia. Dengue Bull 28S: 8-12.

28. Suhaili MR, etal (2004) Applying Communication-for-Behavioural-Impact (COMBI) in the prevention and control of dengue in Johor Bahru, Johore, Malaysia. Dengue Bull 28S: 39-43.

29. Toaliu H, Taleo G, (2004) Formation of community committees to develop and implement dengue fever prevention and control activities in Vanuatu. Dengue Bull 28S: 53-56.

30. UBS Optimus Foundation, (2006) External evaluation of the ‘Evidence-based, community-derived interventions for prevention and control of dengue in Nicaragua’. A report to the UBS Optimus Foundation, Zurich, Switzerland . (internal document)

31. Whiteford LM, (1997) The ethnoecology of dengue fever. Med Anthropol Q 11: 202-223.

32. Winch PJ, etal (2002) Community-based dengue prevention programs in Puerto Rico: Impact on knowledge, behavior, and residential mosquito infestation. Am J Trop Med Hyg 67: 363-370.

33. World Health Organization, (1999) Strengthening implementation of the Global Strategy for Dengue Fever/Dengue Haemorrhagic Fever Prevention and Control: Report of the informal consultation, 18–20 October 1999 Geneva:World Health Organization .