Addressing COVID-19 Rumors and Behaviors Using Theory in Guyana: A Program Case Study.

INTRODUCTION: To manage the rapid rise of misleading information on the coronavirus disease (COVID-19) during the pandemic, the Breakthrough ACTION project developed a theory-based rumor-tracking system to inform Guyana's COVID-19 communication campaign. METHODS: The rumor-tracking project used the extended parallel processing model (EPPM) to identify and categorize rumors reflecting perceived high versus low vulnerability to COVID-19 and high versus low efficacy of engaging in recommended COVID-19 prevention behaviors. The project designed contextually relevant social and behavior change messages, called "MythBusters," responded to rumor categories with the following objectives: (1) high perceived vulnerability and high efficacy rumors included a call to action; high perceived vulnerability and low efficacy rumors educated about effective and achievable solutions; (3) low perceived vulnerability and high efficacy rumors educated about risk; and (4) low perceived vulnerability and low efficacy rumors educated about risk and effective and achievable solutions. RESULTS: Most rumors emanated from regions 4 and 8 (29%). Over two-thirds of the rumors (71%) recurred. Rumors were typically related to COVID-19 treatment or prevention (40%) and transmission (35%). Most rumors (48%) reflected low perceived vulnerability and low efficacy, 29% reflected high perceived vulnerability and low efficacy, 13% reflected low perceived vulnerability and high efficacy, and 10% reflected high perceived vulnerability and high efficacy. The project rapidly developed 12 MythBusters from June through December 2020 and integrated them into the national COVID-19 communication campaign, disseminated via radio, television, and Facebook. Estimates indicate that they have reached most of the target Guyanese population. DISCUSSION: The EPPM was a particularly useful tool, giving direction to countering myths with appropriate messaging to affect relevant behaviors. The COVID-19 MythBusters provided the Guyanese public with valid and verifiable information and promoted preventive and protective behaviors.

Malaria care-seeking and treatment ideation among gold miners in Guyana.

BACKGROUND: Although miners are a priority population in malaria elimination in Guyana, scant literature exists on the drivers of malaria-related behaviour. This study explores the relationship between gold miners' malaria-related ideation and the adoption of malaria care-seeking and treatment behaviours including prompt care-seeking, malaria testing, and self-medication. METHODS: Data are from a cross-sectional quantitative survey of 1685 adult miners between the ages of 18-59 years who live in mining camps in Regions 1, 7, and 8. The analysis focused on miners who reported an episode of fever in the past year (n = 745). Malaria care-seeking and treatment ideation was defined as a composite additive score consisting of the following variables: general malaria knowledge, perceived severity, perceived susceptibility, beliefs, perceived self-efficacy, perceived norms, interpersonal communication, and perceived response efficacy. Multivariable logistic regressions explored the relationship between ideation on care-seeking/treatment behaviours, controlling for confounding variables. RESULTS: Most miners with a recent episode of fever had perceived risk (92%), self-efficacy (67%), susceptibility (53%) and high malaria knowledge (53%). Overall, miners' care-seeking/treatment ideation score ranged from 0 to 8 with a mean of 4.1. Ideation scores were associated with higher odds of care-seeking for fever (aOR: 1.19; 95% CI 1.04-1.36), getting tested for malaria (aOR: 1.22; 95% CI 1.07-1.38) and lower odds of self-medication (aOR: 0.87; 95% CI 0.77-0.99). CONCLUSIONS: A national community case management initiative is using study findings as part of its scale-up, using volunteers to make testing and treatment services more accessible to miners. This is complemented by a multi-channel mass media campaign to improve miners' ideation. Communication messages focus on increasing miners' knowledge of malaria transmission and symptoms, encourage positive beliefs about malaria testing and volunteer testers, promote evidence about the effectiveness of testing, and reminders of how quick and easy it is to get a malaria test with the community case management initiative. Study findings also have implications for efforts to eliminate malaria across the Guiana Shield.

Human-centered design process and solutions to promote malaria testing and treatment seeking behavior in Guyana hinterlands.

BACKGROUND: Malaria is a persistent public health challenge among miners and other hard-to-reach populations in Guyana's hinterland, specifically in Regions 1, 7, 8, and 9. Despite an overall decrease in malaria prevalence throughout Guyana, it remains common among mining populations whose work conditions both contribute toward malaria transmission and make it difficult to seek timely, Ministry of Health (MoH) approved malaria testing and treatment services. In an effort to develop innovative approaches to address this public health challenge, an interdisciplinary team of public health professionals, designers, and mining organizations collaborated using a human-centered design (HCD) process facilitated by the USAID-funded Breakthrough ACTION Guyana project in partnership with the MoH. METHODS: This paper describes two phases: [1] Define and [2] Design & Test. In the Define phase, following a literature review, we conducted 108 qualitative interviews with miners, camp managers, trained malaria testers, health workers, and other key stakeholders to understand experiences and challenges when seeking malaria testing and treatment services. These interviews were synthesized into 11 insights on issues such as risk perception, malaria knowledge, preventive behaviors, traditional and self-treatment, adherence to the correct treatment, testing, and coordination and communication gaps. From these insights, during the Design & Test phase, we developed 33 "How might we…?" questions which led to 792 ideas, of which eight emergent concepts were prototyped and refined in the field with 145 miners, camp managers, and stakeholders. RESULTS: The five final prototypes included: "Little Mosquito, Big Problem" social behavior change campaign; rapid counseling cards; branded malaria testing and treatment services; innovations in treatment adherence; and a participants, content, and logistics approach. CONCLUSION: When applying HCD to public health issues, there are both opportunities and challenges to reconcile gaps that may exist between the two disciplines. However, HCD provides additional tools and mindsets to generatively work with migrant and mobile mining communities to encourage malaria testing and treatment services.

Malaria prevention and care seeking among gold miners in Guyana.

Despite being a priority population in malaria elimination, there is scant literature on malaria-related behavior among gold miners. This study explores the prevalence and factors influencing malaria prevention, care seeking and treatment behaviors in Guyana gold mining camps. A cross sectional survey was conducted among adult gold miners living in mining camps in the hinterland Regions 1 (Barima-Waini), 7 (Cuyuni-Mazaruni), and 8 (Potaro-Siparuni). Multivariable logistic regressions explored factors associated with miners' self-report of mosquito net use, prompt care-seeking; self-medication; and testing for malaria. A third of miners used a mosquito net the night preceding the survey and net use was higher among those who believed that net use was the norm in their camp (aOR: 3.11; 95% CI:1.65, 5.88). Less than half (45%) of miners had a fever in the past 12 months, among whom 36% sought care promptly, 48% tested positive for malaria while 54% self-medicated before seeking care. Prompt care-seeking was higher among miners with high malaria knowledge (aOR: 1.44; 95% CI: 1.01, 2.05). Similarly, testing rates increased with secondary education (aOR: 1.71; 95% CI: (1.16, 2.51), high malaria knowledge (aOR: 1.45; 95% CI: 1.02, 2.05), positive beliefs regarding malaria transmission, threat, self-diagnosis, testing and treatment, and, trust in government services (aOR: 1.59; 95% CI (1.12, 2.27) and experience of a prior malaria episode (aOR: 2.62; 95% CI: 1.71, 4.00). Self-medication was lower among male miners (aOR: 0. 52; 95% CI: 0.32, 0.86). Malaria prevention and care seeking behaviors among miners are somewhat low and influenced by mosquito net usage, perceived norms, malaria knowledge and prior episode of confirmed malaria. Study findings have implications for malaria interventions in the hinterland regions of Guyana such as the mass and continuous distribution of insecticide treated nets as well as community case management initiatives using trained malaria testing and treatment volunteers to curb malaria transmission among remote gold mining populations. These include efforts to identify and address gaps in distributing mosquito nets to miners and address miners' barriers to prompt care seeking, malaria testing and treatment adherence. Targeted social and behavior change messaging is needed on net acquisition, use and care, prompt care-seeking, malaria testing and treatment adherence. Additional efforts to ensure the overall sustainability of the community case management initiative include increased publicity of the community case management initiative among miners, use of incentives to promote retention rates among the community case management volunteer testers and public private partnerships between the Guyana Ministry of Health and relevant mining organizations.

Digging for care-seeking behaviour among gold miners in the Guyana hinterland: a qualitative doer non-doer analysis of social and behavioural motivations for malaria testing and treatment.

BACKGROUND: Although Guyana has made significant progress toward malaria control, limited access to malaria testing and treatment services threatens those gains. Mining activities create breeding environments for mosquitoes, and the migrant and mobile mining populations are hard to reach with information and services. The Ministry of Public Health (MoPH) has trained volunteers to test and treat malaria cases in remote regions. However, it remains unclear how miners perceive these testers, the services they provide, or what their malaria care-seeking behaviour is in general. To better address these challenges, Breakthrough ACTION Guyana and MoPH conducted qualitative research from October to November 2018 in Regions 7 and 8 in Guyana. METHODS: A total of 109 individuals, 70 miners, 17 other mining camp staff, and 22 other key stakeholders (e.g. community health workers, pharmacists, and regional leadership), participated in semi-structured interviews and focus group discussions. Results were derived using a framework analysis, with an adjusted doer and non-doer analysis, and organized using the integrated behaviour framework. RESULTS: Miners sought MoPH-approved services because of close geographic proximity to testing services, a preference for public service treatment, and a desire to correctly diagnose and cure malaria rather than just treat its symptoms. Those who chose to initiate self-treatment-using unregulated medications from the private and informal sector-did so out of convenience and the belief that self-treatment had worked before. Miners who completed the full MoPH-approved treatment understood the need to complete the treatment, while those who prematurely stopped treatment did so because of medication side effects and a desire to feel better as soon as possible. CONCLUSION: Reasons why miners do and do not pursue malaria testing and treatment services are diverse. These results can inform better MoPH programming and new solutions to improve malaria outcomes in Guyana.

"Love me, parents!": impact evaluation of a national social and behavioral change communication campaign on maternal health outcomes in Tanzania.

BACKGROUND: Despite marked improvements over the last few decades, maternal mortality in Tanzania remains among the world's highest at 454 maternal deaths per 100,000 live births. Many factors contribute to this disparity, such as a lack of attendance at antenatal care (ANC) services and low rates of delivery at a health facility with a skilled provider. The Wazazi Nipendeni (Love me, parents) social and behavioral change communication campaign was launched in Tanzania in 2012 to improve a range of maternal health outcomes, including individual birth planning, timely ANC attendance, and giving birth in a healthcare facility. METHODS: An evaluation to determine the impact of the national Wazazi Nipendeni campaign was conducted in five purposively selected regions of Tanzania using exit interviews with pregnant and post-natal women attending ANC clinics. A total of 1708 women were interviewed regarding campaign exposure, ANC attendance, and individual birth planning. RESULTS: Over one third of interviewed women (35.1%) reported exposure to the campaign in the last month. The more sources from which women reported hearing the Wazazi Nipendeni message, the more they planned for the birth of their child (ß = 0.08, p = .001). Greater numbers of types of exposure to the Wazazi Nipendeni message was associated with an increase in ANC visits (ß = 0.05, p = .004). Intervention exposure did not significantly predict the timing of the first ANC visit or HIV testing in the adjusted model, however, findings showed that exposure did predict whether women delivered at a health care facility (or not) and whether they tested for HIV with a partner in the unadjusted models. CONCLUSIONS: The Wazazi Nipendeni campaign shows promise that such a behavior change communication intervention could lead to better pregnancy and childbirth outcomes for women in low resource settings. For outcomes such as HIV testing, message exposure showed some promising effects, but demographic variables such as age and socioeconomic status appear to be important as well.

Sustainable Cost Models for mHealth at Scale: Modeling Program Data from m4RH Tanzania.

BACKGROUND: There is increasing evidence that mobile phone health interventions ("mHealth") can improve health behaviors and outcomes and are critically important in low-resource, low-access settings. However, the majority of mHealth programs in developing countries fail to reach scale. One reason may be the challenge of developing financially sustainable programs. The goal of this paper is to explore strategies for mHealth program sustainability and develop cost-recovery models for program implementers using 2014 operational program data from Mobile for Reproductive Health (m4RH), a national text-message (SMS) based health communication service in Tanzania. METHODS: We delineated 2014 m4RH program costs and considered three strategies for cost-recovery for the m4RH program: user pay-for-service, SMS cost reduction, and strategic partnerships. These inputs were used to develop four different cost-recovery scenarios. The four scenarios leveraged strategic partnerships to reduce per-SMS program costs and create per-SMS program revenue and varied the structure for user financial contribution. Finally, we conducted break-even and uncertainty analyses to evaluate the costs and revenues of these models at the 2014 user volume (125,320) and at any possible break-even volume. RESULTS: In three of four scenarios, costs exceeded revenue by $94,596, $34,443, and $84,571 at the 2014 user volume. However, these costs represented large reductions (54%, 83%, and 58%, respectively) from the 2014 program cost of $203,475. Scenario four, in which the lowest per-SMS rate ($0.01 per SMS) was negotiated and users paid for all m4RH SMS sent or received, achieved a $5,660 profit at the 2014 user volume. A Monte Carlo uncertainty analysis demonstrated that break-even points were driven by user volume rather than variations in program costs. CONCLUSIONS: These results reveal that breaking even was only probable when all SMS costs were transferred to users and the lowest per-SMS cost was negotiated with telecom partners. While this strategy was sustainable for the implementer, a central concern is that health information may not reach those who are too poor to pay, limiting the program's reach and impact. Incorporating strategies presented here may make mHealth programs more appealing to funders and investors but need further consideration to balance sustainability, scale, and impact.