September 2022 — This brief explores behavioural and community dynamics related to plague outbreaks in Madagascar. The aim is to support actors involved in plague response to acquire a deeper understanding of behavioural and cultural practices and structural inequities that may exacerbate plague transmission. It also provides suggestions on how to improve communications and community engagement as part of a context-adapted plague response. This brief is the responsibility of Social Science In Humanitarian Action (SSHAP) with contributions from Institut Pasteur Madagascar, the Institute of Development Studies, Rutgers University, the IFRC and UNICEF.

Key findings and considerations include:

• The plague in Madagascar is primarily a problem of structural inequality, poverty, and social neglect. An effective response requires addressing problems related to public health reach and basic healthcare access as well as housing and infrastructure. This may include efforts to improve living conditions and support for improved sanitation at the household and community level. Strategies to minimize contact between humans and rodents should also be tailored to poorer households and those settling in previously uninhabited areas, enabling them to store food safely and to house livestock outside of living spaces.

• People in Madagascar generally have a clear understanding of what plague is, though they may not fully understand its causes and transmission patterns or the difference between bubonic and pneumonic plague. Their response to the plague may be influenced by the high burdens of other infectious diseases and competing priorities in their communities. There is a need to reinforce knowledge to encourage early treatment seeking.

• Adoption of plague prevention and containment measures may be affected by information gaps and by mis- and dis-information. Lack of community engagement and of accurate, timely and reliable information can erode public trust in the government and health authorities. Both historical experience and rumours can contribute to mistrust of authorities. Response actors should provide up-to-date, complete and accurate information in language that communities can easily understand.

• A plague diagnosis can be stigmatizing, especially in urban areas. Stigma may be exacerbated by response teams whose actions announce to the community that they are attending a suspected plague case. This may make people less likely to seek diagnosis or treatment and less likely to report contacts. Public health teams should be discreet when arriving at a home, and public health campaigns should destigmatize plague and take care not to speak in a manner that associates plague with poverty or lack of hygiene.

• Communication approaches should use carefully considered language and avoid framing the situation in pejorative terms, which can increase stigma. Top-down communication approaches can be counterproductive; two-way communication with active listening and dialogue is preferred by the community and thus is more effective.

Kindly read the full Brief here.