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.

Behavioral Outcomes

Behaviors related to:
Use and care of mosquito nets
Care seeking for children with fever
Prevention of malaria in pregnancy
Acceptance of household IRS and SMC interventions

(Specific behavioral indicators are in the table below)

Ideational Characteristics

Attitudes
Knowledge
Perceived threat
Perceived response efficacy
Descriptive norms
Communication about malaria with others
Decision-making participation
Perceived self-efficacy
Perceptions of health workers and health services
Gender attitudes

Other

Sociodemographic characteristics
Media consumption
Exposure to and recall of malaria SBC interventions
Access to sufficient nets in households and the net use to access ratio
Distance to the nearest health facility
Urban and rural residence
Wealth quintile

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.

Behavioral outcomes measured by the MBS

Prompt care-seeking: The proportion of index children under five years old with fever in the two weeks prior to the survey for whom treatment was sought the same or next day after the onset of fever
Appropriate care-seeking: The proportion of index children under five years old with fever in the two weeks prior to the survey for whom treatment was sought at a facility or community health worker the same or next day after the onset of fever
Use of nets: The proportion of existing bed nets in the home that were used for sleeping under the night before the survey
Consistent net use: The proportion of respondents who report they sleep under a bed net every night of the week preceding the survey
Nets tied or folded up over sleeping space: The proportion of existing nets in the home that were found tied or folded up over the sleeping space at the time of the survey
Net overwashing: The proportion of nets that were washed more than twice in the past 6 months
Drying of nets in the sun: The proportion of nets dried in the sun after the last wash
Nets washed with harmful products: The proportion of nets that were washed with bleach or detergent during the last wash
Tying or folding up nets when not in use: The proportion of respondents who reported tying or folding up their nets when not in use
Early ANC attendance*: The proportion of women who gave birth in the two years prior to the study who attended ANC in the first trimester of their pregnancy
Recommended ANC visit attainment*: The proportion of women who attended their country’s recommended number of ANC visits
ANC4 attendance*: The proportion of women who gave birth in the last 2 years who reported attending at least four ANC visits during their last pregnancy
Recommended IPTp dose attainment*: The proportion of women who gave birth in the two years prior to the study who received their country’s recommended number of IPTp doses
Receipt of IPTp3*: The proportion of women who had at least one child in the last 2 years who reported receiving three or more doses of IPTp during their last pregnancy

*The survey data are self-reported and not meant to substitute for data from the HMIS when available. If HMIS data are lacking, the MBS can provide a snapshot or limited proxy of some HMIS-type indicators.

Indicators for intent measured by the MBS

Early ANC intent: The proportion of women who plan a future pregnancy that reported intent to seek ANC during the first 3 months of their future pregnancy
IPTp intent: The proportion of women who plan a future pregnancy that reported intent to take IPTp during their future pregnancy

The MBS does NOT measure

Incidence of malaria in the surveyed population (parasitaemia)
Rates of malaria testing or antimalarial prescriptions
Rates of antimalarial treatment
HMIS indicators such as the number of health facility visits, number of fever cases seen at the health facility, number of cases of severe malaria, etc.
Indoor residual spraying coverage
Seasonal malaria chemoprevention coverage
Inferences below the survey zone level (the MBS is powered to make inferences at the national and survey zone level, as described above)

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.

What will I find on this website?

Malaria Behavior Survey Toolkit

The Malaria Behavior Survey toolkit consists of a set of standard survey questionnaires (women’s, men’s, household), templates, and tools to guide implementation of the survey. New resources are added to this toolkit as they are developed.

Malaria Behavior Survey Toolkit

Country Results

Country-specific pages contain reports detailing the MBS results and include the survey tools used, as well as external links to datasets on the USAID Digital Data Library, as they become available. These pages are updated regularly.

Country Results