What is the Malaria Behavior Survey?

What is the Malaria Behavior Survey?

The Malaria Behavior Survey (MBS) is a standardized, validated tool developed and refined through an iterative process. The MBS is powered to assess malaria-related behaviors and a range of factors that influence those behaviors. The survey indicators are based on the RBM Partnership to End Malaria SBC Indicator Reference Guide. Multiple countries have implemented the MBS.

The conceptual model that underlies the MBS is the ideation model, which explores the psychosocial factors (called ideational factors) associated with behavioral outcomes. Understanding these factors of behaviors helps malaria program planners determine the most strategic focus of social and behavior change (SBC) activities and can also be useful for planning malaria service delivery and vector control programs. The survey is based on and builds off previous similar surveys conducted in Liberia, Madagascar, Mali, and Nigeria.

How is the MBS structured and implemented?

The MBS is a cross-sectional survey with structured questionnaires administered to a random sample of women and men of reproductive age and heads of households. The survey is fielded in the rainy season or shortly afterward, with a representative sample selected from defined study zones in each country (see Methods).

How can the results of the MBS be used?

The results of the MBS are used to develop evidence-based malaria programs and strategies by national malaria programs and other partners to increase insecticide-treated nets (ITN) use and care, prevention of malaria in pregnancy, prompt care seeking for fever, adherence to malaria test results, and where applicable, support seasonal malaria chemoprevention (SMC) adherence and indoor residual spraying (IRS) acceptance. Results can also be used to inform Global Fund to Fight AIDS, Tuberculosis and Malaria concept notes, and in countries that receive funding from the U.S. President’s Malaria Initiative (PMI), to inform Malaria Operational Plan SBC priorities. While primarily a formative assessment tool, if implemented every five years, the MBS can be used in baseline-endline assessments and capture trends over time.

At what level can the MBS data be interpreted?

The MBS sampling approach divides the survey area into two or more zones combining several contiguous subnational areas. Geographic zones are determined with country stakeholders and informed by the key considerations they agree are important for grouping areas, such as malaria transmission patterns and major ethnic/linguistic groups.

In most cases, the MBS is fielded nationally and designed to make national-level inferences. Making inferences at lower levels depends on the sampling strategy, which will vary according to country priorities and scope. Each country MBS report provides details of the geographic areas represented by the MBS in that country. Other large national surveys, such as the DHS, MIS, and MICS, often sample according to administrative units with larger sample sizes that can allow for more granular interpretation.

Why is the MBS needed? Don’t other household surveys, such as the MIS and DHS, provide information about malaria-related behaviors?

Many countries have data gaps around the factors that motivate (or de-motivate) people’s use of malaria prevention and treatment interventions. Programs are often designed in the absence of such insights resulting in activities that fail to fully address the needs of individuals and, as a result, the country. Demographic Health Surveys (DHS), Malaria Indicator Surveys (MIS), and Multiple Indicator Cluster Surveys (MICS) measure some behaviors but do not assess associated ideational factors. Other one-off data collection activities, such as many knowledge, attitudes, and practices (KAP) surveys, are not standardized and may rely on unvalidated survey questions and tools, which challenge data interpretation and use.

The boxes below illustrate three types of information collected by the MBS. Many items in the boxes labeled ‘Ideational Characteristics’ are absent in DHS, MIS, and MICS.

Where MBS data are available, a more comprehensive array of cognitive, emotional, and social factors influencing behavior is studied. This can enable program planners to have a much better understanding of how to craft and frame key messages and identify the factors most likely to influence priority audiences and behaviors. The MBS also explores certain structural factors, such as access to sufficient nets in households, distance to the nearest health facility, urban and rural residence, and wealth quintile. Further, the MBS explores experience with health services, including perceptions of health workers and perceptions of the availability of supplies in health facilities.

Which behaviors do the MBS measure?

The table below outlines what the MBS does and does not measure.

How can MBS data be used with other survey data?

Surveys, such as the DHS, MIS, and MICS, are complementary to the MBS, and taken together, provide malaria programs with a broader picture of malaria behaviors in context and the individual and social factors that motivate specific groups. This can also be a way to follow trends over time. However, there are differences between the surveys that should be accounted for in the interpretation of the data. Because other surveys provide robust coverage estimates of malaria interventions or rates of fever, this is not the intended use of the MBS. When making direct comparisons of shared indicators between the MBS and other surveys, geographic representativeness can vary, so we recommend that such comparisons use national MBS data. For making subnational comparisons, we recommend discussion by country stakeholders on a case-by-case basis to best understand how to accurately interpret and triangulate MBS results with other surveys.

When triangulating data, bear in mind that all surveys produce point estimates within a range of uncertainty (confidence interval), so data points may not be exactly the same across surveys but may still be aligned within a range.

Can questions from the MBS be integrated into other surveys?

The MBS is a standardized theory-based, field-tested tool developed and refined through an iterative process over several years. Questions included in the MBS are designed and asked in a specific manner and order. In some instances, entire groups of questions have been carefully developed to measure a specific construct or to create indices that can then be used to determine the predictiveness of the theoretical constructs (perceived risk, self-efficacy, social norms, etc.) on the behaviors of interest. Picking and choosing individual questions from the MBS questionnaire for use in other surveys is therefore not recommended as it can undermine the validity of the individual questions.

When implementing the MIS, countries are also strongly encouraged to include the optional SBC module, developed by the RBM Partnership to End Malaria SBC Working Group, in any planned MIS. The module ensures that a small set of SBC questions included in the MIS are standardized, grounded in behavioral science, and backed by evidence. In addition to the behaviors measured in the standard MIS, the SBC module provides data on exposure to malaria messages, knowledge, perceived risk, self-efficacy, attitudes, and norms. Because there are only a few questions in the MIS SBC module, it does not substitute for the MBS, but the two can be used complementarily.

What is involved in conducting the MBS?

The decision to conduct an MBS, including the timing, scope, and cost, should be led by the government bodies overseeing malaria programming, as well as any relevant donors and implementing partners with the following factors in mind:

Timing: The MBS is a major data collection activity requiring country buy-in and investment of time, budget support, and a skilled research partner for implementation. Once funding is secured, the MBS requires approximately one year to complete from initial planning discussions to the finalization and dissemination of the report.

Cost: Costing information of other surveys similar in size or scope can inform the potential costs of the MBS. Highly variable costs include research firm rates, transportation during the rainy season, and translation of the survey into multiple languages.

Geographic Scope: Final decisions about the scope of an MBS will often be guided by the budget available. For countries interested in implementing a nationwide MBS, the PMI SBC Team recommends a sampling approach that provides estimates based on the major malaria transmission zones of the country, where important differences in behavioral determinants may exist. Other sampling approaches may include a focus on PMI target areas or geographic zones of programmatic interest. To maximize MBS coverage, co-financing with other donors may be an option.

For PMI, the MBS is currently implemented through Breakthrough ACTION. Countries interested in fielding an MBS should contact the Interagency SBC Technical Team at PMI Headquarters to discuss sampling, budgeting, and planning for an MBS. Additional information about implementing the MBS can be found in the MBS Implementation Guidelines.

When should the MBS be fielded? Should it be done at the same time other household surveys are being conducted?

The ideal time to plan for and implement the MBS may be before a periodic national strategy revision; a reorientation or shift in national goals; stagnation or lack of progress in the uptake of malaria behaviors; the design phase of a new large-scale project; and/or any other transition point where behavioral data are needed to guide programmatic decision making, whether at the formative, implementation, or evaluative program stage. Decisions about the timing of an MBS should be led in close collaboration with host country governments, as well as any relevant donors and implementing partners. Two important considerations to keep in mind are that the MBS is designed to be conducted during or very shortly after the rainy season during high malaria transmission months and that once funding is secured, the survey requires approximately one year from planning discussions to finalization and dissemination of the report. PMI FY2024 Technical Guidance recommends that the MBS should not be conducted at the same time as the MIS, the MICS, or the DHS, with a minimum of eighteen months between the MBS and any of these other large household surveys, due to the intensive nature of these surveys.