Ideational Factors Associated with Consistent Use of Insecticide-Treated Nets: A Multi-Country, Multilevel Analysis

"The findings suggest that a social and behaviour change strategy based on the ideation model is relevant for increasing consistent ITN use and can inform specific strategies for each context."

There is increasing recognition of the role of sociodemographic, ideational (psychosocial), and household factors as significant predictors of use of insecticide-treated nets (ITNs) to prevent malaria. There is evidence that exposure to social and behaviour change (SBC) interventions has led to increased net use in many African countries. This multi-country analysis uses a multilevel analytic approach to describe variations in consistent use of ITN among men and women of reproductive age in Cameroon, Côte d'Ivoire, and Sierra Leone. The goal is to identify the ideational variables significantly associated with consistent net use in the three countries, with the ultimate purpose of informing malaria SBC programmes.

The study uses data from Malaria Behaviour Surveys (MBS) conducted between 2018 and 2019. The analyses presented here focus on survey respondents from households with at least one ITN: 2,995 in Cameroon, 6,164 in Côte d'Ivoire, and 2,730 in Sierra Leone. The independent variables include a range of sociodemographic and ideational factors (e.g., attitudes towards ITNs, interpersonal communication about malaria). The main analytic method was multilevel logistic regression.

Consistent ITN use in Côte d'Ivoire was 65.4%, 72.6% in Cameroon, and 77.1% in Sierra Leone. The findings revealed strong clustering at the household and enumeration area (EA) levels, suggesting similarities in net use among respondents of the same EA and in the same household. None of the socio-demographic variables showed a consistent pattern of association with the outcome across the three countries. In contrast, the results underscore the value of the ideation model for understanding the determinants of malaria-related behaviours. For instance, multilevel logistic regression results showed that perceived self-efficacy to use ITNs and positive attitudes towards ITN use were variables associated with consistent use in all three countries. The perception of ITN use as a community norm was positively linked with consistent use in Cameroon and Côte d'Ivoire but was not significant in Sierra Leone. Perceived vulnerability to malaria was positively linked with consistent use in Cameroon and Sierra Leone but negatively correlated with the outcome in Côte d'Ivoire.

Consistent with other studies, the relationship of exposure to malaria-related messaging with consistent net use was positive in Côte d'Ivoire and Sierra Leone.

• In Côte d'Ivoire, the SBC strategies that were implemented in the 6 months before the MBS included interpersonal communication and community mobilisation activities implemented by community health workers (CHWs) in 42 rural districts. In addition, television spots were disseminated nationally, and radio jingles were played on three faith-based radio stations. The media materials and the CHW activities addressed various malaria-related behaviours including use of ITNs.
• In Sierra Leone, in the 6 months prior to the MBS, SBC activities included nationwide broadcasting of malaria jingles and approaches to identify and use positive deviant volunteers to promote ITN use at the community level. In addition, there were a number of advocacy meetings with paramount chiefs to discuss the implementation of SBC activities during the 2020 mass net distribution campaign.

In Cameroon, the focus of the SBC efforts during the 6 months preceding the survey was threefold: (i) the mass net distribution campaign: explaining how to obtain nets and prepare the new nets for installation through community mobilisers, community radio and town criers; (ii) the seasonal malaria chemoprevention (SMC) campaign: using community mobilisers and community radio to explain the importance, process of administration, and required dosage of the SMC drug; and (iii) using community mobilisers and community radio to explain the importance of sleeping under an ITN every night, along with other malaria-related behaviours. This study showed a surprisingly significant negative relationship of exposure to this malaria-related messaging with consistent use in Cameroon. Per the researchers, the reason for this unusual finding is not clear and warrants further investigation.

"The findings from this study have implications for programming, policy, and future research. For example, the substantial differences in the ideational correlates of consistent ITN use across countries indicate that regarding SBC strategies for promoting this behaviour, one approach does not fit all. Strategies will have to be adapted to country and regional context addressing the ideational variables that are found to be significant correlates of ITN use among households with nets. All the same, the consistent association of perceived self-efficacy with use of ITNs across the three countries underscores the importance of SBC efforts designed to strengthen perceived self-efficacy for ITN use....Modelling can be symbolic using the radio, television and social media to depict consistent use of an ITN by someone similar in attributes to the intended audience."

Among the other suggestions: "Efforts that seek to promote positive attitudes towards ITNs, by identifying and correcting misinformation about ITNs and other ideational barriers to consistent net use, are also recommended."

In conclusion: "This study adds to the large body of evidence on the usefulness of the ideation model for understanding malaria-related behaviours and prioritizing interventions with potential to have a substantial impact on outcomes....Social and behaviour change programmes designed to promote consistent use of ITNs should consider using an approach based on the ideation model."