Case Study, Part 1
Segmentation of Pregnant Women at Risk of Malaria
![Four women waiting with their infants at a health facility.](https://learning.breakthroughactionandresearch.org/wp-content/uploads/Women-Waiting.jpg)
Case Study
Malaria in pregnancy remains a major health problem with critical risks for pregnant women and their babies. While antenatal care (ANC) services and trained personnel are vital for preventing and treating malaria among pregnant women, counseling during ANC services does not always cater to the unique needs of the many different sub-groups of women who seek this care, including, for example, adolescent and/or single mothers. Often ANC counseling is seen as one size fits all, or at best, women are given varying levels or types of counseling based on their age. But a more precise and potentially impactful counseling will be tailored to the woman’s actual beliefs, attitudes, and feelings towards pregnancy, malaria, ANC, intermittent preventive treatment during pregnancy (IPTp), whether she has had other pregnancies or if she feels supported by her community.
These are all examples of needs, beliefs, etc., attributes that can be used to develop a psychosocial segmentation of pregnant women. This audience segmentation can then guide more personalized counseling.
The following case study reviews the segments that emerged from an analysis of pregnant women at risk for malaria in Cameroon, Côte d’Ivoire, and Malawi. The insights presented serve as the foundation for tailored interventions and recommendations developed for each segment, which are described in detail in Session 3.
Key Questions & Analysis
The Breakthrough ACTION project utilized Malaria Behavior Survey datasets from Cameroon (2019), Côte d’Ivoire (2018), and Malawi (2020) to conduct a psychosocial segmentation analysis to understand pregnant women’s ANC attendance and IPTp acceptance and use behaviors.
Scope of the Malaria Behavior Survey data used for the ANC segmentation
![Cameroon](https://learning.breakthroughactionandresearch.org/wp-content/uploads/Cameroon-252.png)
Cameroon
2019 survey
2 survey zones
2,756 households
4,514 respondents
![Côte d’Ivoire](https://learning.breakthroughactionandresearch.org/wp-content/uploads/Cote-d-Ivoire-252.png)
Côte d’Ivoire
2018 survey
4 survey zones
5,969 households
8,675 respondents
![Malawi](https://learning.breakthroughactionandresearch.org/wp-content/uploads/Malawi-252.png)
Malawi
2021 survey
3 survey zones
3,862 households
5,485 respondents
FOCUS: Women with a live birth in the last two years = 4,646
Breakthrough ACTION reviewed the datasets and selected variables for the analysis that provided insights into three main research questions related to pregnant women and women who had a live birth within the last two years:
- How many times did women go for antenatal care during their pregnancy? (Outcome variable 1: ANC attendance)
- Do women believe that ANC service providers in their community generally treat pregnant women with respect? (Outcome variable 2: Perception of health providers)
- How many times did pregnant women take the medicine to prevent them from getting malaria during pregnancy? (Outcome variable 3: IPTp uptake)
Approach
Click each phase to learn the three-step process Breakthrough ACTION followed to conduct the analysis and determine the segment personas.
Phase I – Identify factors that influence ANC attendance and IPTp acceptance and uptake
Phase I
Identify factors that influence ANC services, experience, and IPTp uptake among pregnant women and women who had a live birth within the last two years.
Women’s responses were analyzed across the three MBS datasets in Cameroon, Côte d’Ivoire, and Malawi through a Chi2 correlation analysis to identify which factors showed a strong correlation with the three research questions. This resulted in uncovering five key drivers of attendance to ANC and IPTp uptake.
- Perception of providers
- Trust in malaria treatment and insecticide treated nets (ITNs)
- Spouse/partner discussion
- Social norms
- Perception of the risk of malaria
A description of each key driver is presented in the section titled, Factors Influencing ANC Attendance & IPTp Uptake.
Phase II – Conduct a quantitative analysis and identify opportunities
Phase II
Conduct a quantitative segmentation analysis and identify opportunities for positive behavior change.
Then, a psychosocial segmentation analysis was conducted using a latent-class analysis (see Introduction to latent class analysis to learn more). Five segments emerged from the analysis and are presented below in the section titled, Meet the Segments.
Once the segments were finalized, we then developed the segment identification tool. More information is presented below in the section title, How to Identify Segments in a Given Population.
Phase III – Develop a malaria-focused ANC counseling tool for health providers
Phase III
Develop a malaria-focused ANC counseling tool for health providers.
Following that, a pretest of the Malaria ANC counseling tool was conducted in Malawi. The pretest workshop uncovered additional insights into the behavior of the segments regarding ANC and helped refine the design and messages of the tool. More information regarding the counseling tool is available in Session 3.
Factors Influencing Uptake
5 Factors
The five key factors associated with women’s ANC attendance and IPTp uptake are: perception of providers, trust in ITNs & treatment, partner/family discussion, social norms, and risk perception. Flip each card to learn more.
Perception of Providers
Women’s perception of providers and how she believes she will be treated by the provider (e.g., if she thinks she will be treated with respect, or sent away if she arrives without her husband).
Trust in ITNs & Treatment
The level of trust pregnant women and women with a live birth in the last two years have regarding insecticide treated nets (ITNs) and malaria treatment obtained at the health facility.
Partner/Family Discussion
The frequency that each segment spoke with their spouse or family member about attending ANC, and their involvement in the decision to attend ANC visits.
Social Norms
Whether women believe that other women in the community also attend ANC and take IPTp.
Risk Perception
How each segment perceives the threat of contracting malaria during pregnancy, whether it is of little, moderate, or of great concern.
Meet the Segments
Pregnant Women at Risk of Malaria
Five segments of pregnant women at risk of malaria emerged across Cameroon, Côte d’Ivoire, and Malawi. Each segment differs in their level of ANC attendance and IPTp uptake, as well as the 5 factors described above, which help us understand what drives those behaviors. This section summarizes the key characteristics of each ANC client segments personas. Click the thumbnail image for a downloadable table.
Segment 1
Active Modernists
ANC Attendance
5+ visits
IPTp Adherence
Uptake is moderate
Perception of Providers
Mostly positive
Trust in ITNs & Treatment
High
Partner/Family Discussion
Discuss ANC with spouse
Social Norms
Believes other women go to 4+ ANC visits
Risk Perception
Believes malaria is a moderate threat
Segment 2
Unhurried Informed
ANC Attendance
1-4 visits
IPTp Adherence
Uptake remains low to moderate
Perception of Providers
Mostly positive
Trust in ITNs & Treatment
High
Partner/Family Discussion
Sporadically discusses ANC with spouse
Social Norms
Believes women should wait before going to ANC visits
Risk Perception
Believes malaria is a moderate threat
Segment 3
Cautious Moderates
ANC Attendance
1-4 visits
IPTp Adherence
Uptake remains low to moderate
Perception of Providers
Believes she will be sent away without spouse
Trust in ITNs & Treatment
High
Partner/Family Discussion
Extensively discusses ANC and jointly decides with spouse
Social Norms
Believes few women go to 4+ ANC visits
Risk Perception
Believes malaria is easy to treat and not a threat
Segment 4
Uncertain New Mothers
ANC Attendance
0-4 visits
IPTp Adherence
Uptake remains low to moderate
Perception of Providers
Believes she will not be treated with respect
Trust in ITNs & Treatment
Moderately high
Partner/Family Discussion
Decides alone or is influenced by a family member
Social Norms
Believes other women go to 4+ ANC visits
Risk Perception
Believes malaria is a moderate threat
Segment 5
Seldom Adopters
ANC Attendance
Rarely attends ANC
IPTp Adherence
Unlikely to receive or to take IPTp
Perception of Providers
Neutral
Trust in ITNs & Treatment
Moderate trust in ITNs and malaria treatment
Partner/Family Discussion
Least likely to discuss ANC with spouse
Social Norms
Believes few women go to 4+ ANC visits
Risk Perception
Believes malaria is a moderate threat
Representative Quotes
The following quotes were developed based on the key factors, beliefs, and behaviors of each segment. These stories were refined based on stakeholder experiences during workshops in Malawi.
Active Modernists
“My spouse and I are aware of ANC benefits during my pregnancy. I go to ANC early and as many times as I can, as do other women in my community.”
Unhurried Informed
“I know ANC is useful but I’m not in a hurry to go to my first visit. I’m less convinced about IPTp.”
Cautious Moderates
“I discuss key decisions with my spouse, such as going to ANC visits. I’m not too worried about malaria, and people in my community don’t really go to ANC visits.”
Uncertain New Mothers
“I’m a single mother. i don’t have much experience with ANC providers but I’m not sure they will treat me with respect.”
Seldom Adopters
“My partner generally decides for me. I don’t go to ANC visits or take IPTp.”
After reviewing the percentage of segment per country, click to learn more about key parameters by segment.
Percentage of segment per country
The same five segments exist across the two countries but with different distributions within the populations, reflecting each country’s local context. The proportion of each segment across Cameroon, Côte d’Ivoire, and Malawi is found below.
Some segments comprise a smaller percentage in some countries (e.g., Cautious Moderates in Côte d’Ivoire (1%) and Malawi (3%). When developing programs and interventions, it is important to account for the size of the segment in the country and prioritize segments not only based on the opportunity to improve specific behaviors (e.g., IPTp uptake), but also the size of the segment in the population and how easy it will be to reach them and change behavior. Click the figure for a downloadable PDF.
![Segment percentage by country](https://learning.breakthroughactionandresearch.org/wp-content/uploads/Segment-Percentage-By-Country-1030.png)
Key parameters by segment
Below you see a visual representation of the segment across the five key factors influencing the behavior of pregnant women and women who had a live birth in the last 2 years. Each segment is mapped across the five axes in the spider-chart below and represented by their name and their color. The spider chart enables us to visually identify areas of strengths and weaknesses for each segment and is complementary to the text description provided above on each segment. For example, the Cautious Moderates (yellow), have a good perception of health workers and high trust in ITNs, as represented by their high score on the chart below. However, they have a low score on “Risk Perception” of malaria (severity) and “Social Norms” reflecting their underestimation of the risk of malaria and their perception that other women in the community do not go to ANC visits. For more details on each axis you can refer to the text on the left side of the spider-chart. Click the figure for a downloadable PDF.
![](https://learning.breakthroughactionandresearch.org/wp-content/uploads/Summary-Behaviors-Drivers-Biases.png)
Partner/Family Influence
Represents spousal/family influence in decision-making regarding going to ANC visits (higher = less autonomy to make decision on her own)
Social Norms
Perception of how many women in the community take preventative care and go to at least 4 ANC visits (higher = believe more women goes to ANC and take IPTp)
Trust in ITNs & Treatment
Represents trust level in ITNs and preventive/treatment drugs coming from the health facility (higher = greater trust)
Perception of Providers
Represents the perception of health workers at the facility (higher = more positive perception of health workers)
Risk Perception
Represents perception of the gravity of malaria care and how easily it can be treated (higher = greater awareness of malaria risk)
How to identify the segments in a given population
Now that we have identified segments, it is important to have a tool that can be used to identify them in a given population.
A segment identification questionnaire is a brief set of questions that allows us to determine what segment the ANC client is categorized. These questions were selected using the MBS datasets and a Chi-squared automatic interaction detector (CHAID) model. Download a more detailed PDF of the following segment identification questionnaire.
1.
How many ANC visits should a woman attend during their pregnancy?
How important is attending ANC during pregnancy?
Answers:
- 0-1 visits
- ANC is not important
- Continue to 1a
Answers:
- 5+ visits, as many as possible
- ANC is very important
- Continue to 1b
Answers:
- 4 or less visits, some visits
- ANC is somewhat important
- Continue to 2
1a.
Discuss ANC decision making with her spouse
- If there is little to no discussion, and her spouse largely makes the decision, confirmed Seldom Adopter.
- Otherwise, go to 2
Seldom Adopter
1b.
Discuss ANC decision making with her spouse
- If there is some discussion & she has agency in decision-making, confirmed Active Modernist.
Active Modernist
2.
Who makes the decision to go to ANC in your household?
Yourself, your spouse, or another individual?
Answers:
- Myself
- Mother
- Another individual
- Continue to 2a
Answers:
- Myself and my spouse
- My spouse
- Continue to 3
2a.
Discuss her current marital status
- If she is widowed, separated, divorced, or single, confirmed Uncertain New Mother.
- If she has a partner, go to 3
Uncertain New Mother
3.
Have you ever seen or experienced a pregnant woman that has been sent away or reprimanded when she goes to the health facility without her husband/partner?
Answers:
- No, she has not
- Unlikely
- Doesn’t know
- Continue to 3a
Answers:
- Yes, except in special circumstances
- Yes, at most facilities
- Continue to 3b
3a.
Discuss her perception of malarial threat level
- If she worries about malaria and thinks it is difficult to treat, confirmed Unhurried Informed.
Unhurried Informed
3b.
Discuss her perception of malarial threat level
- If she worries about malaria but thinks it can be easily treated, confirmed Cautious Moderate.
Cautious Moderate
Using this tool allows SBC programmers, providers, or other stakeholders to identify client segments by asking a limited set of questions, with a high level of accuracy. In the next session, you will see how this tool was incorporated into segment-specific counseling cards for ANC clients.
Key Takeaways
Check Your Understanding
Thank you for completing the second session of Audience Segmentation for Malaria. Next is an ungraded quiz to test your understanding of Session 2. Click the Knowledge Check button to get started.