Impact of a Behaviour Change Intervention on Long-lasting Insecticidal Net Care and Repair Behaviour and Net Condition in Nasarawa State, Nigeria

"It is possible for BCC interventions to change both attitudes and behaviours, and to have an important effect on overall median net lifespan. Care and repair messages are easily incorporated into existing malaria BCC platforms, and will help contribute to improved net condition, providing, in principle, more protection from malaria."

This study, conducted in Nigeria, sought to assess how the durability of long-lasting insecticidal nets (LLIN) nets are influenced by behaviour of net maintenance, care, and repair, as well as whether behaviour change communication (BCC) interventions could substantially impact on the average useful life of the net.

The BCC intervention, which was conducted in two phases (from November 2012 to March 2013, and from December 2013 to March 2014) followed the P-Process© (see Related Summaries, below), a 5-step planning process for behaviour change programmes developed by the Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (JHUCCP). The intervention used an evidence-based design that was informed by existing research. Through this process, the intended audience (adults who own and use mosquito nets, with a focus on women), key behaviours, barriers, and motivators related to net care and repair were identified. These findings informed the development of materials and messages, which were designed at a participatory workshop with local malaria stakeholders, scriptwriters, and design experts. The multi-channel BCC strategy, which focused on encouraging small, do-able actions (e.g., tying the net up during the day to keep away from young children and rodents) consisted of:

• Radio: Five 60-second radio spots were produced that were broadcast on Nasarawa Broadcasting Service (NBS). The focus was on providing cues to action and reminder messages to reinforce the interpersonal communication (IPC) activities. In phase two, 14 episodes of a 15-minute radio magazine show were produced and aired to reinforce the main messages, comprised of interviews with community leaders and community members, as well as recordings from community activities.
• IPC: 40 community mobilisers were recruited and trained to conduct activities focused on modelling appropriate care and repair behaviours. They carried out house visits, community dialogues with street theatre, community outreach at weekly markets, and road shows. During these events, community mobilisers shared key messages, demonstrated net care and repair behaviour, and encouraged community members to stitch or patch demonstration nets. In addition, a song contest was organised in which all 20 communities composed and performed an original song about net care and repair in front of a live audience. A panel of judges selected the winning song, which was studio-recorded and broadcast on the radio in phase two.
• Local advocacy: For example, the chiefs of each of the 20 communities were approached during advocacy meetings to explain the BCC campaign and obtain their buy-in prior to conducting any community-level activities.
• Print materials: Intended to reach low-literacy members of the intended audience, 5 poster designs with photographs of community members modelling net care and repair behaviour were created. Other posters used photographs to demonstrate proper washing technique and ways to fold or tie a net when not in use. Posters were placed in public spaces in communities and in health facilities, and were used during public events. A printed job aid for the community mobilisers was also created, which listed frequently asked questions and answers regarding net care and repair, and served as a discussion guide for mobilisers during their IPC activities.

These radio spots, print materials, campaign logos, and key messages were pre-tested in focus groups in rural and urban communities and further refined before launch in the 20 focus communities of the intervention site.

The study was nested within a larger LLIN durability study. Kokona Local Government Area (LGA) was selected as the intervention arm, with BCC activities as described above. Toto LGA, similar in environment and cultural aspects, was selected as the control site. The study used an intervention-control design with before and after assessment through repeated cross-sectional household surveys with 2-stage cluster sampling following Nasarawa State's December 2010 mass campaign. Baseline, midline, and endline surveys were conducted at 1-year intervals: in March 2012, March 2013, and April 2014, respectively. Outcome measures were the proportion of confirmed campaign nets with observed repairs and the proportion in serviceable condition, measured with proportionate hole index (pHI) and according to World Health Organization (WHO) guidelines.

Selected excerpted findings: "For all respondents, exposure to BCC messages was strongly correlated with increased positive attitude towards care and repair, and increases in attitude were positively correlated with observed net repairs, and with the proportion of nets in serviceable condition. In a multivariate regression model, positive care and repair attitude (OR 6.17 p=0.001) and level of exposure (1 source: OR 4.00 p=0.000; 3 sources: OR 9.34 p=0.000) remained the most significant predictors of net condition, controlling for background and environmental factors. Nets that were tied up had 2.70 higher odds of being in serviceable condition (p=0.001), while repairs made to nets were not sufficient to improve their pHI category. Estimated median net lifespan was approximately one full year longer for nets in households with a positive compared to a negative attitude."

With regard to communication tools and strategies, the authors note that, though this study found that exposure to radio was a better predictor of serviceable LLIN condition than IPC ("radio has been shown to be a cost-effective way of changing behaviour, as it reaches many more people than community activities"), "the data also support the central tenet of BCC strategy design that the reinforcing properties of using multiple channels are more effective than using a single channel. The authors suggest that the radio spots, community health worker (CHW) job aids and key messages, and community events "are relatively easily incorporated into existing malaria BCC platforms. Particularly for malaria prevention programmes that already train and support CHWs, the production of simple job aids is inexpensive, and key messages can be added into their routine work. Given the impact of radio-only exposure on serviceable condition of nets, planners may want to consider developing two to three short spots and adding them into the rotation of net use messaging, even if other community platforms are not available."

One conclusion: "While these results show that repairs made to nets did not improve their condition, this does not necessarily imply that BCC messages on repair should be dropped. Certainly the key message for program planners is that care and prevention help the most, but continuing to include some key messages on net repair is unlikely to hurt, and may contribute overall to a positive attitude towards care of the net, as evidenced by specific attitudes about repair remaining significantly predictive of net condition at endline."