Social and Behavior Change for Insecticide-Treated Nets 2019

"To maximize their potential for malaria control, social and behavior change programs (SBC) promote households' participation in ITN distribution programs, ensure all household members use them every night, care for the ITNs so they last as long as possible, and use old ITNs in ways that continue to provide some protection from malaria."

This document provides programme planners with evidence-based tools that may help social and behaviour change (SBC) programmes seeking to promote the use of insecticide-treated nets (ITNs) to reinvigorate their approach and optimise net use, longevity, and access. Published by VectorWorks, a five-year global project based at the Johns Hopkins Center for Communication Programs (CCP) and funded by the President's Malaria Initiative (PMI), the guide covers not just SBC around net use, but also looks at other dimensions of ITN use, such as ITN acquisition, care, outdoor sleeping, repurposing, and seasonal variation.

The guide defines SBC as "the coordinated use of a range of approaches to achieve individual and collective behaviour change. While most SBC activities rely on communication-based approaches combining mass and social media, community-level programming, and interpersonal communication; non-communication-based approaches, informed by behavioral economics and design thinking are increasingly incorporated, as well."

Starting with an overview section, the publication gives some general guidance on how to choose the net behaviours to promote. These net behaviours occur across four stages of the net lifecycle:

• Net acquisition (e.g., behaviours related to purchasing and participation in net distribution programmes)
• Net use (e.g., behaviours related to net use in dry and wet seasons, the colour and shape of nets, and use outdoors or indoors)
• Net care (e.g., behaviours around protecting the net from harm, washing and repair)
• Net end of life (e.g., behaviours around the use of nets as screens/curtains or to repair other nets).

The guide demonstrates how available data on population access, net use, net care attitudes, and residual transmission can be used to help programmes assess which of the above areas to focus on in their SBC strategy. They can choose to assess one, two, three, or all areas, depending on the data available. This approach is based on the idea that net SBC strategies should be tailored to the context and, in order to improve resource targeting and strengthen the potential effectiveness of SBC programmes, should be based on data. For example, blanket ITN use messaging may not be needed everywhere when the use-to-access ratio is high. Rather, other dimensions/ITN behaviours may need to be emphasised instead - such as net care when the mean attitude score is less than 1.0, or net acquisition when population access is less than 80%. Those who want to further strengthen ITN use rates are directed to conduct additional analysis to understand areas to emphasise, such as seasonality and managing net use in the hot season or when people sleep outdoors.

This section also looks at the importance of timing of messages when developing a comprehensive SBC strategy, which should include both continuous and discrete elements. "Continuous SBC activities will include promoting ITN use and care throughout the year. Where continuous distribution through routine health services and other channels exists, messaging to promote these services should also be ongoing. Discrete activities will include SBC activities related to the mass campaign, school distribution; and, where needed, communication around net misuse, repurposing, or disposal."

Following the overview, the guide is then divided up into four parts. Part A of the guide is dedicated to discussing communication strategies around net acquisition focusing on large-scale mass distribution campaigns as well as continuous distribution through, for example, health centres, schools, and retail outlets.

Related to mass distribution campaigns, the guide gives guidance on what communication channels should be used before, during, and after distribution. For example, for pre-distribution, it looks at the importance of coordinating partner efforts and allowing enough time for the development of campaign materials. It also highlights the importance of community mobilisation at this stage and what channels, such as radio, can be used. For all the different distribution stages, the document offers guidance on which SBC channels, messages (in many cases offering a list of key messages to consider), and activities to use. It covers strategies using radio, local communicators (such as town criers), radio, print materials, and community gatherings, and it looks at when these are most appropriate to use and what messages or content they should be covering.

Related to continuous distribution, the guide looks at channels, messages, and activities that can be used, such as: antenatal and immunisation services, school distribution, community-based distribution, and the private sector. For school distribution, the guide, for example, notes that messaging should indicate that the ITN is for the household, not necessarily the pupil who received it, as pilot programmes have found that students often feel the ITN they receive is theirs, even if the student already has access to an ITN.

Part B of the guide focuses on ITN use and describes the ITN use-to-access ratio, how it is calculated, and how it can be used to measure behavioural gaps in net use. Trends in the ratio over time, by country, age, and gender, and by season are also presented. "The ITN use-to-access ratio is considered a powerful indicator that helps programme managers identify groups who are not using available nets, and should, therefore, be targeted for net use messaging." Other dimensions of ITN use include net care, as well as outdoor sleeping and management of old nets (whether repurposing or disposal), are discussed in this chapter, in addition to the determinants of these behaviours and implications for SBC.

Part C of the guide looks at specific situational considerations when developing a communication strategy related to: the distribution of next generation nets, situations where indoor residual spraying has been implemented, low-transmission areas, and mobile populations. For example, where next generation nets are being distributed due to resistance to pyrethroid ITNs, underlying factors such as political or religious sensitivities may mean that issuing a different type of ITN to a certain area is seen as favouring one group over another. Messaging around next generation ITNs therefore needs careful consideration. In low-transmission areas, strategies should also consider how declining transmission will affect perceptions of malaria risk and the perceived need for sustained use of ITNs. In these cases, messages may need to focus on the benefits of ITNs beyond malaria protection.

Part D touches briefly on human-centred design (HCD) and behavioural economics (BE), both of which can be applied to the design of SBC programmes. HCD involves learning from and working with the intended population(s) to identify the behaviours that need changing and how best to promote that change. In particular, it enables ideas to be tested early and often to determine utility, so only the most effective ideas are implemented. BE focuses more on how people's behaviour and choices are influenced by subconscious biases, context, and psychological or mental "shortcuts" that benefit them immediately, rather than by rational deliberation of long-term gains. Taking these into account will help programmers create environments, processes, and products that make decision-making for optimal health easier and will also help them understand behavioural patterns.

The final chapter offers a list of resources and guides related to SBC best practices, which should be used together with this SBC guide.