What is the Malaria Behavior Survey?
The Malaria Behavior Survey (MBS) is used to understand ideational factors associated with malaria-related outcomes. Understanding these drivers of behavior helps countries and program planners determine the appropriate focus of social and behavior change (SBC) programmatic activities to reduce the burden of malaria.
How is the Malaria Behavior Survey 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, as well as a household questionnaire. The survey is fielded in the rainy season or shortly afterwards, with representative sampling across defined study zones in each country.
How can results of the Malaria Behavior Survey be used?
The results of the MBS are used to develop evidence-based malaria SBC programs and strategies by national malaria programs and other partners working in malaria SBC 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 3-5 years, the MBS can be used in baseline-end line assessments and capture trends over time.
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 behaviors but do not assess associated ideational factors. Other one-off data collection activities, such as many knowledge, attitudes, and practices surveys, are not standardized and may rely on unvalidated survey questions and tools which, in turn, challenge data interpretation and use. The MBS is a standardized, validated tool developed and refined through an iterative process. The survey indicators are based on the RBM Partnership to End Malaria SBC Indicator Reference Guide and multiple countries have implemented the MBS. The boxes below illustrate three kinds of questions included in the MBS. Many of the questions in the boxes labeled ‘Ideational Characteristics’ and ‘Other’ are absent in DHS, MIS, and MICS. It is important to note that the MBS is not designed provide intervention coverage estimates, and other data sources are recommended for that.
Countries are, however, encouraged to include the recently developed optional SBC module in any planned MIS. The optional module, which was developed by the RBM Partnership to End Malaria Social and Behavior Change Working Group, ensures that SBC questions included in the MIS are standardized, grounded in behavioral science, and backed by evidence. Adding questions to the MBS is generally not recommended, but when necessary, the checklist at the end of the Implementation Guidelines should be consulted. The MBS is a relatively standard survey, intended to be implemented in much the same fashion across countries. This allows for comparisons across countries and time, and also ensures optimal use of survey questions that have been previously field tested. It is a lengthy survey, and the questions it contains have been pre-tested and refined over a number of years in many sub-Saharan countries.
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. 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.
What is involved in conducting the MBS?
The decision to conduct an MBS, including the timing and scope, should be negotiated with the host country government, 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, budget support, and a skilled partner for implementation. As previously mentioned, the MBS will take approximately one year to complete. Planning should start six to seven months before data collection, eight weeks should be allowed for data collection, and three months for data entry, cleaning, and draft report writing. The country should ensure sufficient time to submit and receive approval from an in-country ethical review board. More information on timing can be found in below.
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. In order 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 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 around a periodic national strategy revision; a reorientation or shift in national goals; stagnation or lack of progress in 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 made 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 from initial discussions to finalization and dissemination of the report, the survey requires approximately one year.
PMI FY2020 Technical Guidance recommends the MBS be implemented every five years in all transmission settings, and highlights 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.