FoQus for Qualitative Segmentation Study Design

PAPUA NEW GUINEA (2009): Development of Communications to Support Delivery of ACT/RDTs/LLINs for

Global Fund Round 8

Sponsored by:

PSI’s Core Values Bottom Line Health Impact * Private Sector Speed and Efficiency * Decentralization, Innovation,

and Entrepreneurship * Long-term Commitment to the People We Serve

1

Research & Metrics Population Services International

1120 Nineteenth Street NW, Suite 600 Washington, D.C. 20036

Development of Communications to Support Delivery of

ACT/RDTs/LLINs for Global Fund Round 8

PSI Papua New Guinea 2009

© Population Services International, 2009

Contact Information:

Cynde Robinson Section 52, Lot 18, Varahe Road Gordons, NCD Papua New Guinea Tel: (675) 311 2190 Fax: (675) 311 2199 c.robinson@psipng.org

Esther Saville Regional Researcher – Asia and Eastern Europe Population Services International 4th Floor, Tower A Building No.10 DLF Cyber City, Phase II Gurgaon – 122 001, Haryana, India Tel: 91 – 124 - 4726200 ext: 296 Mob: 91 - 9810054408 esther@psi.org.in

2

Introduction

Background of Health Problem Papua New Guinea (PNG) is a patchwork of different ecological zones, inhabited by human populations of exceptional cultural and linguistic diversity. This results in complex variations in vector ecology and Malaria epidemiology. Malaria is the main cause of morbidity in many health facilities in lowland areas, but it is absent in much of the highlands. All four human Malaria species occur, but endemicity varies widely, with Plasmodium falciparum locally reaching holo-endemic levels that are rarely found outside sub-Saharan Africa. The high frequency of Plasmodium vivax is an important difference to most African situations. Papua New Guinea is planning for the introduction of artemether-lumefantrine (Coartem®), a highly efficacious artemisinin-based combination therapy (ACT), as the new national 1st line treatment with the aim to significantly reduce the burden of Malaria in the country. Nationwide implementation of ACT along with already introduced long-lasting insecticide-treated mosquito nets (LLIN) is expected to lead to a reduction in Malaria parasitaemia, gametocytaemia, and clinical disease (Bhattarai et al. 2007). However, the magnitude of the effect of ACT depends on several factors, including drug efficacy, coverage, compliance and to a considerable degree on the simultaneous introduction of complementary and supporting control strategies, such as LLIN, indoor residual spraying (IRS) or other vector control methods as well as improvements in the health system (Bhattarai et al. 2007; Barnes et al. 2005; Van et al. 2005). Effective behaviour change communications are essential in ensuring compliance with ACT as well as promoting other complementary and supporting control strategies such as LLIN use. There is very little existing population –based, behavioural research on Malaria control behaviours in PNG to inform the development of communication materials. Program Description and Objectives

Program Description Population Services International (PSI) is a non-profit non-governmental organization (NGO) that specializes in social marketing of AIDS prevention, family planning and maternal and child health products and services. PSI/ Papua New Guinea has been operating in Papua New Guinea since 2008. The National Department of Health (NDoH) in Papua New Guinea and its partners have made considerable progress in recent years scaling up Malaria control interventions, notably long-lasting insecticidal nets (LLIN), primarily with GFATM (Round 3) financial support. In order to maintain the current positive momentum and continue the process of scaling up with effective evidence-based interventions, the government of Papua New Guinea is scheduled to receive GFATM funds from Round 8. A continuation of funding for the national effort is vital as the government has recently changed first-line treatment to Artemisinin-based Combination Therapy (ACT) , introduced a Rapid Diagnostic Test - RDTs; and has yet to reach and maintain internationally agreed targets for intervention coverage (for LLIN and ACT).

- 3 -

The overall strategic plan for Malaria is to be implemented by three partners (NDoH, RAM and PSI) who will implement a 5-year project to improve health seeking behavior and correct and consistent usage of quality assured artemisinin-based combination therapy (ACT), Rapid Diagnostic Tests (RDTs) and LLINs. Ultimately, the aim of the GF Round 8 strategy is to improve up-take and demand for proven, evidence-based interventions for Malaria control among the population. The overall program goal is to reduce Malaria morbidity and mortality in PNG by increasing demand for an appropriate use of preventive and curative Malaria among at-risk populations in PNG. At an impact level the programme aims to: 1. Reduce the percentage of children aged 6-59 months with Malaria infection (confirmed

parasitemia 2. Reduce the number of Malaria cases confirmed by microscopy detected per 1000 population

from 244 in Year 1 to 122 in Year 5 3. Reduce the number of deaths due to Malaria (confirmed Malaria diagnosis) per 1000

population from 8.97 in Year 1 to 2.5 in Year 5 Standard GF outcome indicators apply to this programme and include: 1. Increase the % pregnant women (in net-owning households) who slept under an LLIN

(utilization) the previous night 2. Increase the % children under 5 years of age (in net-owning households) who slept under

an LLIN (utilization) the previous night 3. Increase % of caregivers of children under 5 years of age with fever during the past 2 weeks

who sought treatment with an appropriate ACT within 24 hours of fever symptoms (treatment-seeking behaviour

4. Increase % of children under 5 years of age with fever during the past 2 weeks who,

according to reports from caregivers, completed ACT treatment as directed (treatment compliance)

One of the stated objectives of the national Malaria strategic plan is “Improving knowledge, behavior and participation of communities and individuals in the national Malaria control effort.” Under the Global Fund proposal Population Services International-PNG is charged with demand generation and consistent correct usage of proven Malaria control methods through behaviour change communications. PSI/PNG is responsible for designing and implementing mass media and interpersonal communication campaigns for advocacy and behavior change related to Malaria control.

Relevant Research In 2000, formative research was conducted by staff from the NDoH Health Promotion Branch (HPB), with support from the Health Services Support Project (HSSP), to inform the development of health promotion activities for Malaria control, specifically the distribution of insecticide-treated nets (ITN) and the implementation of a new case management treatment policy (at that time, chloroquine with sulfadoxine–pyrimethamine). Prior to this work, relatively little research had been conducted in the area of behavior change communication for Malaria

- 4 -

control in Papua New Guinea. Even where materials and tools had been developed, effectiveness was rarely measured. “A review of existing health communication materials suggests that the materials have not been evaluated for their comprehension by target audiences or their impact. A rapid review of the WHO comic during this research study revealed weaknesses in the design and misunderstanding of content which reflect the lack of pre-testing that is typical of much health promotion materials.” In short, the study revealed a relatively high level of knowledge regarding Malaria. Malaria was identified as the number one public health concern by most respondents, signs and symptoms were readily identified and the source of Malarial disease (mosquito bites) well understood by the majority. However, some important gaps in knowledge and misunderstandings remain. For example, there was limited understanding about the effects of Malaria in pregnancy (miscarriage, low birth weight in newborns etc.), misunderstandings about certain methods of Malaria vector control (grass cutting or bush clearing for example; proven ineffective in 1946), and a clear problem with prompt treatment-seeking behavior (with respondents stating that effective treatment through health facilities is often only sought after symptoms have worsened and home-based remedies – including faith healers and left-over medicines etc have proven ineffective). There is a need to build upon the findings of this research and further explore gaps in knowledge and misunderstandings that need to be addressed through PSI’s behaviour change campaign.

Study Rationale

Designing the concept for a social marketing activity requires familiarity with the target audience and the context in which behavior change takes place. The purpose of this study is to provide information that can be used to develop the message or campaign personality for ACT, RDT and LLIN communications.

Data from this study will also be used to inform the development of scale items for the baseline TRaC study. Tracking Results Continuously (TRaC) is a quantitative population-based study performed at regular intervals to provide timely information for program management. Data analysis permits PSI to segment target audiences, and monitor and evaluate program performance. A TRaC baseline survey will take place in October 2009. The TRaC questionnaire will include scales consisting of multiple items or statements. Scales are developed to provide an understanding of complex opportunity, ability and motivational determinants of behaviour. The generation of scales is guided by PSI’s Behavior Change Framework. Data from this FoQus for Qualitative Segmentation Study will be used to identify important determinants that may influence behavior change among the target audience. In PNG, where no prior Malaria TRaCs have been undertaken and virtually no behavioural research on Malaria has been conducted qualitative data is essential in informing the development of scales for the baseline TRaC questionnaire.

PSI/Papua New Guinea seeks to gain an in-depth understanding of the population including:

- health providers’ knowledge, attitudes and practices to position RDT/ACTs and LLINs by developing a campaign to increase timely and correct use of ACT for

- 5 -

uncomplicated Malaria treatment, correct diagnosis of Malaria using RDTs for ages above 5 and syndromic management of U5

- caregivers/HOHs of CU5 treatment seeking behaviour to design a campaign to promote correct and consistent usage of ACTs for children U5, in all endemic and epidemic areas in PNG

- caregivers (including pregnant women)/HOHs of CU5 net use, to design a campaign to promote correct and consistent usage of LLIN, especially by pregnant women and children U5 in all endemic and epidemic areas in PNG.

As stated above, no TRaC study has been conducted with this group and little is known about what motivates caretakers of children under 5 to use (or not use) anti-Malarials or LLINs. Little is currently understood about how knowledge, social support, beliefs, severity and self-efficacy function as behavioral determinants amongst caretakers in these areas. Furthermore, little is known about what motivates or creates barriers for health providers to correctly diagnose and treat Malaria of those who present at a health facility (Health Centers or Aid Posts). It has therefore been decided to use the FoQus for Qualitative Segmentation process to build a relevant evidence base to design a marketing concept and strategy based on OAM determinants. PSI will use the results of this FoQus for Qualitative Segmentation study to develop a new behavior change communication intervention, including a media campaign, to reach this population to improve knowledge, behaviour and participation of communities, individuals and health providers for effective Malaria control. The behaviour change campaign will consist of a mass media component as well as IPC materials/communication toolkits for use by health providers and directly to the communities. PSI is responsible for all communication efforts to encourage people to seek treatment quickly if they suspet malaria as well as consistent and correct use of LLINs particularly by pregnant women and CU5. Health providers will be crucial interlocutors with the communities in understanding the case management and prevention of malaria. The core part of this project will involve generic communications campaigns to improve awareness of the benefits of ACT, RDTs and LLINs in general, and to improve their correct and consistent usage in endemic and epidemic areas.

FoQus for Qualitative Segmentation FoQus for Qualitative Segmentation is the process of discovering and refining an idea into a complete description for guiding intervention design and branding a product, service, or behavior. It uses qualitative research to facilitate more effective social marketing activities and give voice to the target audience.

FoQus for Qualitative Segmentation is conducted when no segmentation results are available through quantitative research (TRaC studies). In some cases, the descriptive output produced through the FoQus for Qualitative Segmentation process will serve as a surrogate for a quantitative segmentation “dashboard” table. In other cases, FoQus for Qualitative Segmentation results will be used as input into a TRaC study design and questionnaire.

The six-step process listed below is used to design “the concept.” For steps one through four, qualitative methods are used to generate insight and understanding relevant for designing social marketing communication activities. The last two steps involve application of these findings to create specific social marketing outputs.

- 6 -

1. Identify beliefs to reinforce and beliefs to change

2. Build a person profile by:

a. creating one or more character archetypes

b. identifying successful strategies used to behave

3. Understand the current brand position and associations

4. Describe the target group’s openness to and skill to process messages related to the product, behavior, or service being targeted

5. Draw a Category Map that identifies the frame of reference--the competing products, behaviors, or services--that forms the context in which the archetype makes decisions regarding adoption of the desired behavior

6. Identify likely determinants and create one or more Qualitative Segmentation Diagrams to guide marketers toward determinants most likely to maximize intervention impact

Through this process, PSI is developing a common language and set of tools for prioritizing intervention areas and developing concepts. FoQus for Qualitative Segmentation enables country programs to learn from the target audience, build capacity to develop concepts based on evidence, and develop brands, campaigns, and messages that are consistently effective at influencing health-related behavior.

This document describes the objectives, methods and anticipated outputs relevant for the steps described above.

Research Objectives This study aims to gather data useful for designing the following eight elements of the concept for communications campaigns to improve correct and consistent usage of ACTs/RDTs and LLINs aimed at caregivers and heads of households with children from age zero up to four years, pregnant women as well as the general population. Health providers will also be a target audience given their key role in case management of Malaria.

Specifically, the study objectives are to:

a. Identify beliefs to reinforce and beliefs to change related to: timely use of first line ACTs (combined with RDTs for ages 5 and above and syndromic diagnosis of CU5); promotion of LLIN usage by health care providers who are responsible for delivering BCC and treatment in the communities (from Health Centers and Aid Posts) and use of LLIN by caregivers of CU5 and pregnant women.

b. Build one or more character archetypes

c. Identify current strategies used by target audience members to overcome obstacles to the desired behavior

d. Describe the openings – when, where, and by whom target audience members can be communicated with

e. Describe target audience members’ past experiences with the desired behavior and alternative behaviors in the category

- 7 -

f. Describe the level of knowledge and sophistication with which target audience members approach decisions about the desired behavior

g. Understand current prevention and treatment perceptions related to Malaria control

Timeline

A summary of timelines is contained in Appendix A. The research process involves study design preparation, identification and training of research assistants, data collection, transcription and translation, data analysis, narratives, preparation for interpretation session, interpretation session and finalizing dashboard and session documents.

The Regional Researcher and Country Representative will prepare the study design in consultation with the PSI Malaria team between April 1st and May 5th 2009.

The Regional Researcher and Country Representative will recruit community based researchers in the study areas to undertake interviewing in the four regions of Papua New Guinea. Care will be taken to ensure that only community residents with at least secondary education and preferably with experience in community research are recruited.

PSI’s FoQus consultant will lead this study and will deliver a FoQus for Qualitative Segmentation workshop for the Research team and all programmers to be followed by thorough training in research objectives and methodology between 18th May and 1st June 2009. Data collection will be conducted by two teams of fieldworkers and supervised by the Research Manager through June 2009. Transcription and translation will take place through June until 10th July 2009. Coding will be done between 13th July and 31st July while narratives will be done 31st July to 14th August 2009. Preparation for the interpretation session will take place from 17th August and the interpretation session will take place during the last two weeks of August. Final analysis and narrative of dashboards will be done by PSI research department. Drafted results and additional recommendations will be ready by September 14th.

Methodology

Study Type Between April and September of 2009 PSI Papua New Guinea will conduct a FoQus for Qualitative Segmentation study to gather information in the above mentioned areas. Qualitative research, emphasizing spoken narratives, will be used to collect data. This method was chosen for its ease of use and the rich data that emerge when study participants are given an opportunity to share their personal stories. Spoken narratives allow researchers (and marketers) to make an emotional connection with the target audience and help create a picture of the “typical” experience. Storytelling is a fundamental human way of relaying information, so data collection feels “natural” to both moderators and participants. The method is also relatively simple for inexperienced moderators to implement. Visual images further enhance this process – how best to integrate photographic images into data collection will be discussed and agreed during the training workshop. Feedback from an anthropologist who has worked in PNG for several decades has confirmed the suitability of using photography in PNG communities. It is essential that this is not perceived to be intrusive by the communities

- 8 -

we visit. It is anticipated that photographs will be taken by the interviewers. Precautions will be taken to ensure that no one will be harmed in the effort to acquire visual data. Picture takers will gain verbal permission to take photos and respondents will be informed that for external dissemination faces will be blurred to preserve anonymity.

Study Population The study will be conducted among primary caregivers and HOHs of children aged under 5 years and with health care providers serving the local community from which caregivers/HOHs are selected. The study population will be split into timely users of anti-Malarial treatment (within two days of onset of last fever in CU5)[‘treaters’], and ‘non-treaters’, described as persons who did not treat Malaria with anti-Malarial medicines within two days of last onset of fever in CU5. Respondents whose CU5 slept under a net the previous night (consistent net-users) and those whose CU5 didn’t sleep under a net the previous night (inconsistent net-users) will also be captured within this sample of respondents. One pregnant caregiver will also be recruited in each of the ‘treater’ and ‘non-treater’ sub-groups. Interviewers must be able to distinguish between these two types so that they can recruit study participants to form a balanced sample. Secondly, health care providers from Health Centers and Aid Posts will be interviewed to better understand the barriers to proper diagnosis and treatment that confront them and what communication tools would be most useful to them to reinforce proper case management of Malaria and use of LLINs when a patient or caregiver presents to them. A screening questionnaire to determine levels of compliance with guidelines will be used to select group participants. A sample of health care providers who are more compliant with guidelines versus those who are less compliant with guidelines will be recruited. It is important to note that level of compliance with guidelines is due to both circumstantial and individual factors and it is essential that health providers don’t feel judged or stigmatized as a result of this screening process (see Appendix F for draft Screening Questionnaire). At a community level a screening questionnaire will only be used for interview where there are more than two health providers present. If there are only two health providers both will be interviewed.

Sample size and sampling strategy Purposive sampling method will be used to select study participants from the four regions of Papua New Guinea (see map attached at Appendix G with site locations). The criteria for site selection includes:

o Coverage of the four regions o Coverage of highland and coastal areas o Inclusion of epidemic and endemic areas o Reasonably easy to access o Nets have been distributed o Includes a pilot RDT site (Madang district) o As far as possible captures diversity of population o Has Malaria o Includes an area that has had a recent epidemic o Excludes areas that have had high levels of exposure to educations/health

campaigns on Malaria in recent years o Only rural areas have been selected with the exception of Rabaul which is peri-

urban

- 9 -

Locations selected include:

o Rabaul (Islands) o Bogia (Momase) o Lufa (Highlands) o Kwikila (Southern)

Back-up areas have also been selected – see map attached for locations

The study sample will be split into two groups (see diagrams attached for proposed sampling selection):

• Group 1: caregivers of children (including pregnant women) and heads of household The criteria for recruiting the study participants include: primary caregivers (including pregnant women) and heads of households with children under five, low socio-economic status, living in rural areas who have received a secondary education or below.

• Group 2: health care providers

The criteria for recruiting the study participants include: health care providers who work in the field of Malaria control in Health Centers and Aid Posts and will be responsible for delivering communications on ACT (combined with RDTs) as part of the GF programme. While for the most part health care providers will not be responsible for the distribution of LLINs except during ante-natal activities, they can provide effective communication to those who come to the health facilities for Malaria treatment to prevent repeated Malaria episodes.

Sample size In each district, ten spoken narrative interviews with caregivers/HoHs will be conducted and two small focus groups/interviews with Health Providers including those working in Health Centers as well as those working in Aid-Posts. Where it is not possible to conduct a group at the community level due to small numbers of health providers present, interviews will be undertaken. Two groups will be conducted in Madang district where RDTs have been piloted. If necessary, further discussion groups will be conducted in peri-urban locations such as Rabaul to seek further views from a range of health providers.Table 1.1 provides summary statistics of the sample size by respondent category and region. Table 1.1: Sample Size Distribution Category Islands Highlands Momase

Southern

Spoken Narratives Primary caregivers of children under five (including pregnant women)/HoH

10 10 10 10

Health care providers 2 groups/ Interviews

2 groups/ Interviews

2 groups/ Interviews

2 groups/ Interviews

- 10 -

Sample selection process

In each location, 10 caregivers of children under five (including pregnant women)/HoH will be purposively selected to represent rural characteristics. A selection guide will be used to ensure that only respondents who meet the study criteria are included in the study. Eligible respondents will be interviewed in their households or place of work. It is anticipated that the primary behaviour criteria for selection will be ‘treater’ and ‘non-treaters’. The target number of non-behavers [‘non-treaters’] in each location will be 7 [5 caregivers and 2 HoHs] and 3 behavers [3 caregivers]. It is intended that consistent net-users and inconsistent net-users will be captured within this sample. National and regional data on treatment seeking behaviour and net-use suggests that we should be able to meet our sample requirements although considerable variation at a local level is highly plausible. As a result our sampling strategy will need to be monitored closely on implementation to ensure flexibility and responsiveness to capture our sample requirements. Health providers will be identified either through district level contacts or at a community level through the community leader and Tok Save.

- 11 -

Data Collection Process A PSI consultant (Nick Lehnertz) will provide technical assistance for the research process and significantly and directly support the three major stages; (i) the development of the study design, (ii) training for community-based researchers, (iii) data analysis including a FoQus for Qualitative Segmentation interpretation session. Mexy Kakazo, a Senior Lecturer at Divine Wood University (Madang) will act as a ‘scientific collaborator’ providing advice and guidance on Malaria and on issues to consider when undertaking qualitative research in PNG. Mexy is currently undertaking his PhD and will be using the data gathered through this study as the basis for one of the three papers he is required to submit. Mexy and Manuel Hertzl from the Institute of Medical Research (research collaborators for Malaria TRaC) will both attend the training and interpretation workshops and will provide valuable insights to inform the research process. PSI Research team (RM Malaria, RM HIV, RR, FoQus Consultant and Mexy Kakazo) will oversee the data collection process, including management and supervision of field teams and debriefing with community-based researchers and participate in the data analysis workshop. There will be two fieldwork teams – one based in Port Moresby and the other based in Madang at Divine Wood University. The Port Moresby team will be managed by the Malaria RM and the Madang team will be recruited and supervised by Mexy Kakazo. The Malaria RM will have overall management responsibility for delivery of the research and will establish regular reporting mechanisms with the supervisor and data collection team in Madang. The interviews will be conducted by community-based researchers, who will be recruited based on selection criteria, enumerated in the following section. Before conducting actual interviews in the field, the community-based researchers will take part in a workshop facilitated by the PSI consultant that will cover research objectives, research method and interviewing skills. All interviews will be audio recorded. Recorded interviews will be transcribed in Pidgin/Muto and then into English as soon as possible by two teams of two transcribers/translators who will cross-check each other’s transcripts, including back-translation, before submitting them to the supervisor.

- 12 -

Data collection procedures

The research will be conducted in the four regions of PNG. Spoken narrative interviews will take place in private locations within natural settings to ensure comfort and ease of respondents during the interviewing process. Four community-based researchers (CBRs) will be recruited (to conduct interviews with caregivers/HoHs), two for each team, based on the following criteria;

(a) Same age cohort as the study population, both sexes, speak local language and English (either Pidgin or Motu) with at least secondary education and above. (b) MUST be nonjudgmental about Malaria drugs and health seeking behavior in all its

forms (c) Reassurance that the study participants will perceive the community-based researchers

as allies (d) Community-based researchers feel comfortable talking to community members about

their issues (e) Personality characteristics will be considered in the selection of community-based

researchers. • Makes other people feel comfortable • Great listener • Likes talking to people • Smart and quick thinker • Responsible • Can handle logistics, for example tape recording • Confident • Able to ask hard questions with sensitivity • Sense of humor • Good eye contact • Does not interrupt other people when they talk • Speak the language of the interviewer. For ease of transcription will try to

interview in communities where Pidgin is fluently spoken. (f) Community-based researchers will not necessarily be caregivers or heads of households

with children under five Community-based researchers will recruit study participants using the criteria outlined in the sampling size and sampling section. Mexy Kakazo, who trained as a nurse and is an expert on Malaria, will undertake the interviews/groups discussions with the health providers. Health Boards at Provincial and District levels will be informed of the research and it is anticipated that they will facilitate access to local health providers. Tok Saves (community meetings) are required to take place with the community leader and members of the community before the interviews are conducted in each study location. CBRs will be fully briefed to undertake these meetings although where possible the Malaria RM or Mexy Kakazo will also attend. Informed consent will be obtained for both interview and analysis. Anonymity of responses will be assured by use of pseudonyms. Tapes and transcriptions of the interviews will be maintained

- 13 -

under lock and key for only PSI/Papua New Guinea researchers and Mexy Kakazo (Divine Wood University) to access. Data collection tool Researchers will prepare a discussion guide in collaboration with people with experience in Malaria prevention and treatment both from within and outside PNG including Malaria experts at IMR (Goroka PNG) and PSI Malaria team. They will be subjected to a very short questionnaire to solicit ideas necessary for the development of a study design. These include: What does PSI-PNG need to learn about the target audience that we currently don’t know? What do you want to learn about the care takers of children under five in the study areas through the upcoming study? What 2-3 questions do you think we absolutely must ask them? It will contain simple prompts and probes and will address the following components of the FoQus for Qualitative Segmentation framework; beliefs to reinforce and beliefs to change; archetype characteristics; strategies used to behave; and opportunity, ability, and motivation to process information, acquisition stories, openings, category experiences and brand associations. The discussion guide for each of two-parted interviews will itself be divided into two halves. The first half of each discussion guide will be narrative in nature: 1) “Please tell us the story of how you managed a situation when your child fell ill”. The second half of each discussion guide will be comprised of conversational prompts covering the study themes.

The guide will be first written in English and then translated into Pidgin (and Motu if necessary for Southern region). It will be tested during pilot interviews during the community-based researcher training and modified as necessary for the field interviews.

Data collection timeline and procedures

Data will be collected during a 2-4 week period. Each study participant will be asked to tell a story about the last time their CU5 had a fever and what action was taken. Spontaneous and anticipated probes will be used to collect as much detail about this event as possible.

Data Analysis Digital audio recordings will be transcribed in English and Pidgin and then translated into English. Transcripts will be hand coded and coding will be verified by assigning the same codes to two researchers. In FoQus on Segmentation, coding uses the 9 components of the framework to sort the data. For beliefs to reinforce and beliefs to change, additional codes will be assigned to emergent themes. Once coded by hand, electronic chunks of code will be stored in Word files or in an Excel spreadsheet. The research team will verify their coding scheme with the regional researcher and modify coding as necessary.

A common narrative will be developed by using recurring themes identified during data analysis. This narrative will be presented to marketers and used to ground additional data analysis that will take place during the interpretation session.

- 14 -

Data Interpretation After finishing the data collection and coding, the research team including community-based researchers will have an initial 2-day data processing and theme development session. The focus of this session will be to explore emergent themes and to develop methods for best presenting the data to the programme team at the start of the interpretation workshop. The use of photographs and drama should be explored. The next step is the Interpretation Workshop where two days will be spent with all members of the program team, and relevant stakeholders working with PSI on Malaria in PNG including IMR and Divine Wood University. The workshop will use the expertise gained by the community-based researchers to explore the set of emergent themes in the data.

The first day will start with the research team presenting an experiential introduction to the data – in the form of unified narratives. These should include photographs, if possible, and a drama. Both devices will provide an entry point into the study findings and ground the rest of the data analysis and interpretation process.

Coded portions of transcript text will then be presented in a manner that allows session participants to analyze them in small groups. The coded data will be posted on the walls so that session participants can “shop” and compare different sub-groups of the target audience.

On day two, the team will identify statements in the data that are prospective determinants of behavior and complete the dashboard instrument. They will create one or more archetypes based on the photonarratives and study transcripts. The remaining 7 components of the dashboard will reference the archetype by name. A category map will complete the activities in the interpretation session

After the completion of the interpretation session, the research team will produce Qualitative Segmentation Diagrams to guide programmers and marketers towards determinants most likely to maximize intervention impact.

Human Subjects Ethical Consideration This study has been determined to be “research” and will be initiated only after receiving written approval or written exemption from the PSI Research Ethics Board. Those implementing this study will comply with all policies and procedures of the PSI Research Ethics Board. Local IRB approval has been submitted to Divine Wood University, PNG. We request that this study be approved pending approval from the local IRB. This study methodology has been designed to address the following ethical principals: respect for persons, beneficence and justice. Efforts are made to protect individual autonomy, minimize harm and maximize benefits and equitably distribute risks and benefits by using procedures which are consistent with sound research designs that take these issues into consideration. This study will not pose the physical risks associated with a physical procedure or intervention, such as obtaining tissue or blood samples. Respect for persons and individual autonomy:

- 15 -

Interviewers will be carefully trained in human subjects’ protection, especially the importance of protecting privacy and confidentiality. No personal identifying information will be collected, i.e. name or initials, address, birth date (although age is acceptable), etc.

Feedback from an anthropologist who has worked in PNG for several decades has confirmed the suitability of using photography in PNG communities. It is essential that this is not perceived to be intrusive by the communities we visit. It is anticipated that photographs will be taken by the interviewers. Precautions will be taken to ensure that no one will be harmed in the effort to acquire visual data. Picture takers will gain verbal permission to take photos and respondents will be informed that for external dissemination faces will be blurred to preserve anonymity. Interviewers for this survey shall be recruited at local level in PNG. However, they shall not be recruited from the study localities or communities. Interviewers shall be identified from an existing pool of interviewers who are have worked with Divine Wood University or from University of PNG based in Poet Moresby. The training of interviewers shall be conducted in Port Moresby. The RM and Scientific Collaborator will monitor data collection to ensure that appropriate sampling and interview methodologies are being applied. Respondents will be informed that they are allowed to skip questions or to stop the interview altogether if they wish to do so. Interviewers will be given additional training on confidentiality issues, and no identifying information will be recorded as part of the main questionnaire. After finishing the interview, the respondents will be given informational brochures about the studied health problem. After the survey, respondents will also be provided contact information for a PSI employee who will be available to answer any questions about health problems or problems related to the participation.

The only record linking the subject and the research will be the consent/assent document and the principal risk will be potential harm resulting from a breach of confidentiality. A written consent/assent will not be used. The interviewer signs a summary of the information. Verbal responses to research questions will be considered to imply consent/assent. Interviewers will fully brief potential participants on the research. Interviewers will also explain to respondents that by completing the interview they are giving verbal consent/assent.

As stated above, participants will not be linked to their responses via a signed informed consent/assent form. Participants will not be identifiable via the transcripts. Quotations used in reports will not be attributed to the participants using the participants’ names. Instead, speakers will be identified with broad demographic characteristics. The contents of consent form shall be loudly read out to them in a language which they understand. Subsequently, upon receiving the verbal consent from respondent the form shall be signed by the interviewer. Interviewers will read statements regarding the research to respondents and provide them with written copies. Interviewers will also explain to respondents that by completing the interview they are giving verbal consent. See Appendix E for consent document. No subjects will be interviewed without their informed consent.

- 16 -

The only records linking the subject and the research will be the mapping listing and identification sheet and the principal risk will be potential harm resulting from a breach of confidentiality. As stated above, participants will not be linked to the data collected in the interview via these records. The forms will be stored in a separate location from the transcripts. Participants will not be identifiable via the data. Interviewers would assure the respondents that all the information collected through this interview would remain confidential in nature. The name of the respondent shall not be used in the transcript. Interview recordings will be destroyed after the interview has been transcribed.

Beneficence (maximize benefits and minimize harm):

There is unlikely to be any benefit to participants themselves; however, knowledge about behavioral trends and the determinants of these behaviors will be directly applied to the design and planning of prevention or treatment interventions. This will improve future interventions. For this reason, the potential benefits to society as a whole outweigh the risks.

The research manager/advisor will periodically review the data collection to ensure that no information is included that could identify the participant.

Justice (equitable distribution of research benefits and risks):

As described in the sampling section above, subjects will be selected with assistance from community leaders to meet the quota for each group. All relevant subgroups (age, ethnicity, sex, etc.) for whom results are expected to vary will have the opportunity to participate.

Compensation:

It is not planned to give any compensation to the respondents during the survey. Provision of study results: When it is feasible the results of this study will be made available to participants.

- 17 -

Appendix A – Timeline for FoQus for Qualitative Segmentation study using spoken narratives Activity Dates Person responsible Finalize research study design April 1st -20th April Regional Researcher &

Country Representative Conference call with CR, Nick Lerhertz (consultant) and Region al Researcher

April 17th – 27th April

Regional Researcher, Country Representative & Consultant

Submit study design to local IRB & PSI REB

April 20th – 6th May Regional Researcher & Country Representative

Recruit Malaria Research Coordinator April 1st – 1st May Regional Researcher & Country Representative

Recruit community-based researchers in two research sites

1st May – 20th May Country Representative & Research Manager

Nick Lerhertz meets Country Representative

May 19th Country Representative & Consultant

Seminar on FoQuS on CD and Segmentation

May 25th Consultant, Research team and Sales, Marketing and Communication

Train community-based researchers of COASTAL and HILLS

May 26th – 28th Consultant and Research Manager

Recruit participants and conduct interviews in the two study areas

May 31st – 26th June

Community-based researchers and Research Manager

Quality control data collection and feedback to community-based researchers

May 31st -3rd June Consultant and Research Manager

Transcription tapes June 29th - 10th July Community-based researchers and Research Officer

Coding July 13th - July 31st Research Manager & TBC

Data analysis and create narratives August 3rd – 17th August

Research Manager

Preparation for interpretation session August 21th Consultant, Regional Researcher, Research team and Sales, Marketing and Communication

Session with Community-based Researchers

August 24th (2-3 hours)

Consultant, Regional Researcher, Research team, CBRs

Interpretation Session August 25th - 26th Consultant, Regional Researcher, Research team and Sales,

- 18 -

Marketing and Communication

Finalize dashboard and session documents

By September 7th Research Manager & Consultant

Appendix B – Background information used to inform FoQus for Qualitative Segmentation Study IMPROVING KNOWLEDGE, BEHAVIOR AND PARTICIPATION OF COMMUNITIES AND INDIVIDUALS IN THE NATIONAL MALARIA CONTROL EFFORT – PSI/PNG (extracts from concept paper written for PSI’s application to GF Round 8). This concept note first summarizes previous formative health promotion research related to Malaria conducted in Papua New Guinea in 2000 by staff from the NDoH Health Promotion Branch (HPB), with support from the Health Services Support Project (HSSP). The research was undertaken to inform the development of health promotion activities for Malaria control, specifically the distribution of insecticide-treated nets (ITN) and the implementation of a new case management treatment policy (at that time, chloroquine with sulfadoxine–pyrimethamine). Prior to this work, relatively little research had been conducted in the area of behavior change communication for Malaria control in Papua New Guinea. Even where materials and tools had been developed, effectiveness was rarely measured. “A review of existing health communication materials suggests that the materials have not been evaluated for their comprehension by target audiences or their impact. A rapid review of the WHO comic during this research study revealed weaknesses in the design and misunderstanding of content which reflect the lack of pre-testing that is typical of much health promotion materials.” The aims of the 2000 study were as follows:

• To document local understandings of Malaria and Malaria-related treatment-seeking behavior including diagnosis and treatment compliance

• To explore socio-cultural, economic and behavioral factors influencing bed net

ownership and usage as well as knowledge, attitudes and behavior regarding household spraying

• To make recommendations for health communication, partnership building and

advocacy to support the national Malaria program (e.g. social marketing strategy for bed nets, improved clinic-based diagnosis, and the new treatment regime)

The following subject areas were explored:

• the relative importance of Malaria; • names used for Malaria and fever; • signs and symptoms of Malaria; • causes and spread of Malaria; • perceptions of mosquitoes; • prevention of Malaria; • Malaria and pregnancy;

- 19 -

• treatment of Malaria; • caring for children and treatment decision-making; • and the packaging of medicines.

Knowledge:

• A relatively high level of knowledge regarding Malaria. • Malaria identified as the number one public health concern by most respondents, ,

followed by TB, diarrhea and cough • Signs and symptoms were readily identified. There did not appear to be any significant

differences between males and females and between adults and teenagers in the type or range of signs and symptoms given

• Both rural and urban respondents showed widespread knowledge and understanding of the common signs and symptoms of Malaria.

• Source of Malarial disease (mosquito bites) well understood by the majority. However, the knowledge that Malaria is caused by mosquitoes exists within a cleanliness model of health / illness. Environmental and personal hygiene are considered causes because it is widely believed that poor hygiene and environmental health create conditions conducive for mosquito breeding

• Local names reflect a tendency of naming illnesses by their symptoms. In Tok Pisin, Malaria is commonly referred to as hot sik or kol sik. When people use the term Malaria or the local name, they may simply mean the symptoms of Malaria – fever or feeling cold. Many local names for Malaria were used by respondents

However, some important gaps in knowledge and misunderstandings remain:

• limited understanding about the effects of Malaria in pregnancy (miscarriage, low birth weight in newborns etc.)

• misunderstandings about certain methods of Malaria vector control (grass cutting or bush clearing for example proven ineffective in 1946)

• a clear problem with prompt treatment-seeking behavior (with respondents stating that effective treatment through health facilities is often only sought after symptoms have worsened and home-based remedies – including faith healers and left-over medicines etc.- have proven ineffective).

Perceived threat:

• All age groups were thought to be vulnerable to Malaria, particularly those who do not sleep under a mosquito net. Because the Highlands are thought to be too cold for mosquitoes and Malaria, many people there considered only those who live in towns and cities or travel to the coast to be vulnerable

• Mosquitoes were perceived as being a big problem, especially in warmer regions and in larger population centers. People who travel to the coast were identified as a major risk group. Increases in mosquito abundance noted during the rainy season

• Although the need to protect pregnant women was understood by many respondents, prophylaxis is not always linked to the prevention of Malaria. The risks of Malaria in pregnancy (miscarriage, low birth weight etc.) are not well known

Outcome expectation:

• Mosquito nets are the most well known method of prevention, followed by coils and repellent. In terms of environmental prevention, cutting grass was cited as an effective and well known method, as was cleaning the house and surroundings

- 20 -

• The majority of respondents indicated that treatment for fever was first sought at household and community level, with formal health facilities utilized only when symptoms worsened

Brand attributes:

• There was a clear preference for blister packaging (with instructions indicating timing of treatment etc.)

Recommendation: it is clear that more attention must be given to behavior change communication, advocacy and social mobilization. Specifically, the population of Papua New Guinea (especially those in remote, rural areas) needs to better understand:

• the main biological risk groups • the need for prompt treatment seeking behavior (within 24 hours of the

onset of fever) • treatment compliance • improved attendance by pregnant women of ANC facilities • the most effective methods of reducing Malaria vector-human contact (LLIN/IRS).

Some of the behavioral indicators to be tracked over time might include:

• % of respondents who cite LLIN and IRS as the most appropriate preventive interventions for Malaria

• % of respondents who cite the importance of prompt treatment-seeking behavior with ACT within 24 hours of the onset of symptoms

• % of respondents who understand the importance of adherence to the ACT treatment regimen

• % of pregnant women and ante-natal care providers who understand the impact of Malaria in pregnancy and the importance of accessing IPT at least twice during the course of any one pregnancy

The concept paper recommended the following activities to improve LLIN utilisation and demand:

• Picture and discussion-driven participatory communication tools, particularly during free LLIN delivery through rolling campaigns supported by Rotarians Against Malaria (RAM) and the respective district teams

• Discussion guides for staff at ante-natal clinics tasked with delivering LLIN to pregnant women

• A series of media tools that would support efforts by the private sector to market LLIN in the long-term, including mass-media and point of sale communications

• Radio spots, community theatre, mobile video, TV (urban areas), printed materials • Other tools as deemed necessary to improve LLIN up-take and correct utilization among

other risk groups, such as People Living with HIV/AIDS, orphans, children in boarding schools, hospital patients

• Child-to-Child or Child-to-parent programs through the schools in collaboration with the Ministry of Education

• Use of immunization campaigns to deliver targeted nets to children under 5, where feasible considering vaccination coverage constraints currently faced in PNG

• Targeted training tools/discussion guides for religious leaders/church groups to ensure their congregations are well informed about the benefits of LLIN usage

- 21 -

The concept paper recommended the following activities to improve treatment seeking behaviour and treatment compliance:

• A picture and discussion-driven participatory communication toolkit for use by Village Health Volunteers that improves both treatment seeking behavior (including RDT use) and treatment compliance (building on current work with the Healthy Island initiative.

• Discussion aids and treatment logarithms for peripheral health facility staff that explain the new ACT treatment regime to patients and the role of RDTs

• Low-literacy, pictorial wallets for ACT treatment blister packs that would improve • treatment compliance. Coartem® packaging will be adapted to the PNG context (per

PSI’s agreement with Novartis). The blister-pack will have a unique color-coded foil, text and design to facilitate adherence to the regimen. PSI will provide PNG specific artwork for secondary packaging and low-literacy instructions, consistent with MCP and national guidelines for anti-Malarial packaging

• Radio spots, community theatre, mobile video, TV (urban areas), printed materials • Child-to-Child or Child-to-parent materials discussing the importance of prompt

treatment seeking behavior and compliance The concept paper recommended the following activities to improve IPT up-take through ANC facilities:

• A picture and discussion-driven participatory communications toolkit for use by Village Health Volunteers (and/or Traditional Birth Attendants, TBAs)

• ANC attendance (i.e. encourages more than one visit) • Radio spots, community theatre, mobile video, TV (urban areas), printed materials etc. • Discussion aids for ANC staff who need to explain the impact of Malaria in pregnancy

and the importance of more than one dose of IPT • Targeted IEC materials for men/husbands which encourage them to have their wives

attend ante-natal clinics and sleep under LLIN

- 22 -

Appendix C: Draft Discussion Guide – Caregivers (including pregnant women)/HOH CU5 INTERVIEW Warm-up

a. Where do you work?

b. Who do you live with?

c. What do you like about your community?

d. What do you normally do during your free time?

e. Please describe your family?

f. Please describe your friends?

Narrative Prompt: Please tell me about the last time your child got fever. Start from the time when you noticed the child was sick and describe how you handled the situation. How did you know the child was sick? What did you do? Did you use any medicines to treat the child? Did you go anywhere for treatment? What happened thereafter? Please describe the situation from the beginning to the end. Take a few moments to think about it and then talk as long as you like. What happened thereafter?. Life circumstances, aspirations, and fears

g. What are you proudest of?

h. What are your hopes for your children’s future?

i. What do you hope your life is like in five years?

j. What will you have to overcome to make your life like that?

k. How much money do you earn in a month and how do you earn it?

l. If you suddenly got 300,000 shillings what would you do with it?

m. What is your favorite possession? Why?

n. What three things could you not do without? o. What new activity have you adopted this year? p. And if any how/why did you have you start doing it?

Health seeking and treatment behaviors

q. What does it mean to have a fever?

r. How do you usually manage cases of high fevers in children?

s. How do you decide where to go for treatment?

- 23 -

t. Describe a trusted place where to go for treatment.

u. What health services are provided at that place?

v. Which of these services have you used?

w. Which places would you not go to for treatment? Why?

x. At what point do you think parents should seek treatment for a feverish child?

y. For what reasons would you not seek treatment for fever for your child?

z. What would you do when you notice that a child has a high temperature?

Narrative Prompt

• Any other reason you used medicine after waiting X amount of time. • Who did you make the decision with and what was the decision you made? Was the

person experienced in the type of antiMalarial used? What was said to convince you or prevent you from using that drug? What were your fears or hopes for using the drug?

aa. What symptoms do you notice that make you think that a young child has Malaria?

bb. When does a case of Malaria require treatment?

cc. What antiMalarial medicine have you used to treat your children? dd. If you’ve used an antiMalarial medicine to treat your child, what or who influenced

you? What did they say? ee. How would you describe a parent who treats their child’s Malaria with drugs? ff. What are your worries and fears about antiMalarial medicines? gg. What antiMalarial medicines have you used and how did you decide which drug

to buy? hh. How many times did you use the antiMalarial drug the last time to treat your

child? Narrative prompt Please tell me about what others think of a person who treats a child as soon as they detect signs of Malaria (Beliefs). Describe any conflicts you feel between the messages you receive from your environment. Remember the last time your child got fever, what did others say? How did this influence the decision you took regarding your child’s illness? A2P/M2P/BP

a. What are the most important features you look for in a child with Malaria? b. What are some challenges you face using antiMalarial medicines to treat your children? c. How do you complete a course of treatment of Malaria for your child? d. What are the obstacles you face in providing antiMalarial treatment for you child? e. What do you do when facing those challenges to make sure your child receives

appropriate treatment? f. What kind of caregivers treat their young children as soon as they see signs of Malaria? g. If you knew a medicine worked well, but it took several days before it worked, how would

you persuade a friend with a sick child to use it?

- 24 -

h. If you used a medicine and it cured your child’s Malaria, how would you feel? i. What causes Malaria? j. How can you prevent Malaria? k. Who should sleep under an LLIN? l. Do you know how to hang an LLIN? m. What challenges exist to use an LLIN every day? O2P-openings a. Where do you get important information?

b. What source of information do you trust most? Why?

c. What do you like to listen to on the radio?

d. What programs do you like most?

e. What do you like about it/them?

f. What do you enjoy reading?

g. What about that do you like?

h. What special community events do you participate in?

a. Can you tell me about an advert that you remember liking? Please describe it.

b. What did you like about it?

c. Has any advert ever persuaded you to make a purchase? Which one?

d. What about that advert made you want to buy the thing it was advertising?

i. Who do admire in your community? Why?

j. Who do admire in the country? Why?

- 25 -

Appendix E: Draft discussion guide – Health Care Providers INTERVIEW Warm-up

1. How long have you worked here?

2. Who do you live with?

3. What do you like about your community?

4. What do you like about your job?

5. What do you normally do during your free time?

6. Please describe your family?

7. Please describe your friends?

Narrative Prompt: Please tell me about the last time you had to treat a child with fever. Please describe how you handled the situation. What did you do? How did you diagnose the child? Did you use any medicines to treat the child? What questions did you ask the caregiver of the child? What advice did you give to the caregiver of the child? Please describe the situation from the beginning to the end. Take a few moments to think about it and then talk as long as you like. Life circumstances, aspirations, and fears

a. What are you proudest of?

b. What are your hopes for your [children’s] future?

c. What do you hope your life is like in five years?

d. What will you have to overcome to make your life like that?

e. If you suddenly got 300,000 shillings what would you do with it?

f. What is your favorite possession? Why?

g. What three things could you not do without? h. What new activity have you adopted this year? i. And if any how/why did you have you start doing it? j. What activities have they adopted to achieve their aspirations? k. What role do you play at the HC or Aid Post? l. What makes is easy to do your job? m. What makes it difficult to do your job?

Health seeking and treatment behaviors

n. What does it mean to have a fever?

o. How do you usually manage cases of high fevers in children?

- 26 -

p. How do you decide how to treat a child with fever?

q. How do you make a diagnosis?

r. What are the additional signs and symptoms you are looking for?

s. What health services are provided at the health facility?

t. Where else do people go for treatment in the local area other than here?

u. At what point do you think parents should seek treatment for a feverish child?

v. For what reasons would you recommend not seeking treatment for fever for your child?

w. When does a case of Malaria require treatment?

x. What symptoms do you notice that make you think that a young child has Malaria?

y. What antiMalarial medicines would you prescribe to treat a child? Why do you use these drugs? What effects your decision what to prescribe?

z. Have you heard of RDTs? Do you use RDTs? When would you use an RDT? Are they easy to use?

aa. What advice to give to the caregiver when you prescribe antiMalarials? What are the three key pieces of information you tell the caregiver?

bb. How do you persuade people to complete the full course of medicine? Is non-completion of treatment a common problem?

cc. How do you think antiMalarial drugs are perceived by the community? dd. What are their worries and fears about antiMalarial medicines? ee. How effective do you think antiMalarial drugs are when treating children? Are

there any drugs that you are reluctant to prescribe? Any drugs which people are resistant to?

ff. How do you think people can control Malaria in their communities? What control strategies can they use? Which ones do you think are most effective? What about LLINs?

gg. When people present with Malaria symptoms do you provide any information on Malaria? On control strategies? Net use?

hh. What do you tell them about net-use? Knowledge/ Sophistication

ii. Where do you get information about the prevention and treatment of Malaria?

ii. Is there anything more you’d like to know about prevention and treatment of Malaria?

jj. What do you perceive to be the level of knowledge and understanding in the local community about Malaria and its prevention and treatment?

- 27 -

Appendix E INFORMED CONSENT

Hello my name is ……………………….. I work with PSI/PNG. We are conducting a study on Malaria treatment and experiences. PSI/PNG together with Ministry of Health would like to introduce a new and effective Malaria medicine. Before we do that, we would like to understand your experiences, practices and opinions concerning treatment of Malaria. Participation in the study is voluntary. You are free to join this study or not. Regardless of your choice, everyone will continue to have access to the new medicine. If you would like to participate in this study, we will spend some time talking together one-to-one to share information about yourself and your experiences. This conversation has little risk. You may feel uncomfortable in telling us about some of your stories and routines but, please do not worry, your honesty is very important for us to know how to improve the introduction of new medicines for Malaria treatment. By participating in this study, you may help us find ways to improve the treatment of Malaria in your community and the whole country. All information provided will remain confidential and will be used only for the purpose of the study. Your name and the names of family members will not appear anywhere. We will keep the records in locked files and only study staff will be allowed to look them. Your name or other facts that might identify you will not appear when we report the findings of this study. Your results will be combined with those of 40 people. The only cost to you for being in the study is your time. There is no payment for being in the study. Do you have any questions? If at any time you have questions or concerns about the study, or you may speak to the following persons at PSI head office: Cynde Robinson Country Representative Section 52, Lot 18, Varahe Road Gordons, NCD, PNG Tel: +675 670 2190 Would you like to take part in this study? Interviewer signature: Date:

- 28 -

Appendix F: FoQus for Qualitative Segmentation – Definitions of Nine Codes Desired behavior: __________________________________

1. Archetype (ARCH): • Statements that describe the personality and circumstances of target audience members • Demographic facts • Habits • Values • Aspirations • Needs • Worries • Fears

2. Beliefs to Reinforce (B2R): • Statements by target audience members that express the benefits of desired behavior • Statements by target audience members that express positive attitudes toward desired

behavior • Drivers of desired behavior

3. Beliefs to Change (B2C): • Statements by respondents that express the costs/disadvantages of desired behavior • Statements by respondents that express negative attitudes toward desired behavior • Barriers to desired behavior

4. Strategies to Behave (S2B):

• Techniques or tactics that members of the target audience use to overcome barriers to desired behavior (which include purchasing and using products, enacting desired behaviors, and utilizing services)

• Three elements are necessary: intent to behave; an obstacle; an action to overcome the obstacle

• Examples of such techniques include locating social support, managing peer pressure, accessing money, or juggling schedules

5. Acquisition Stories (AqS): • How members of the target audience acquire (buy or receive) products or services under

study • This includes how non-behavers acquire alternatives to the desired behavior • There do not need to be any particular obstacles to acquisition (as with S2B)

6. Openings (O):

• When and where we can reach target audience members • How we can communicate to them effectively (channels and media preferences) • Who target audience members listen to and trust (trusted referents)

7. Knowledge/Sophistication (K/S):

- 29 -

• Statements by target audience members that indicate their ability to distinguish between the behavior and competing behaviors (comparisons between behaviors)

• Statements that reveal the level of sophistication target audience members have about the desired behavior

• For example, do they understand the mechanism through which a product functions; the biological facts of a health problem; the purpose of a service?

8. Category Experiences (CatEx):

• Target audience members’ past experiences of the desired behavior • Target audience members’ past experiences with competing behaviors

9. Brand Associations (BA):

• Consumers’ emotional attachment to a brand (or behavior) • Consumers’ ideas and attitudes about the brand (or behavior) as it exists today

- 30 -

Appendix G: Proposed Locations for FoQus for Qualitative Segmentation – Malaria PNG

- 31 -

- 32 -

Appendix D – Qualitative Segmentation Graphs (sample)

Benefit

Barrier

(U)

B2R “IUD can cause regular menstruation”

(N)

Degree of significance:Medium.

Frequency

Intensity 

- 33 -

- 34 -

Appendix F: Draft Screening Questionnaire for Health Providers

A brief tick-box questionnaire will be used to filter Health Providers into two groups determined by level of compliance with guidelines for quality of care for Malaria. Questions on the following topics will be included:

• Role at Health Facility

• Training received on guidelines

• Use of RDTs

• On what basis are anti-Malarials prescribed to patients (CU5, pregnant women)

• What medicines are prescribed to patients presenting with Malaria symptoms

• What information is provided to patients on correct use of medicine

• Dose prescribed for pediatric patients

• Any information provided on other Malaria prevention strategies including net-use