The Role of Ideation on the Effect of an SBC Intervention on Consistent Bed Net Use among Caregivers of Children under 5 Years in Nigeria: A Multilevel Mediation Analysis

"...social and behavior change interventions should employ messaging that not only improves knowledge about bed net use and its consequences, but promotes a positive attitude about bed nets, generates conversation regarding the use of bed nets and also enables the audience to feel right about it."

Malaria remains a significant public health challenge in Nigeria. Social and behaviour change (SBC) interventions have been used to promote adoption and practice of malaria-related behaviours, including use of insecticide-treated nets (ITNs). Many researchers have argued that SBC interventions bring about behaviour change by first changing ideation, which includes three domains of psychosocial factors: cognitive (attitudes, knowledge, perceived risk, subjective norms, self-image), emotional (preferences, self-efficacy), and social (social support, social influence, interpersonal communication, personal advocacy). This paper explores the relationship between mass media SBC interventions, ideation, and consistent use of ITNs (sleeping under a net every night) among residents of three Nigerian states where the Health Communication Capacity Collaborative (HC3) project was implemented.

Among other elements, the United States Agency for International Development (USAID)-funded HC3 project (2012-2017) in Nigeria featured a mass media component that included: radio and TV spots in English, Pidgin, Hausa, and other local languages; weekly radio magazine shows (Play Your Part in Pidgin and English, Taka Naka Rawan in Hausa, and locally produced shows in local languages in selected focal states); a national malaria theme song ("Play Your Part" - see video, below); and the Newman Street television drama series, whose malaria-specific excerpts HC3 also screened during community events.

The project was evaluated using a quasi-experimental design with a pre-intervention (baseline) and a post-intervention (endline) survey conducted in Akwa Ibom, Kebbi, and Nasarawa states. The present study is based on data derived from the endline survey. Data were collected in September 2017 among a sample of men and women of reproductive age with at least one child aged less than five years old; 2,745 respondents from households with at least one bed net were included in the analysis.

Respondents were asked about exposure to any of the 15 different media messages the HC3 project produced and aired. For example, respondents were asked, "In the last six months, did you hear a jingle on the radio or the television with Oga Bulus talking about how people can be free of malaria?" The study found that 39.7% of respondents were able to recall malaria-specific messages, with most (72%) of those having low recall (recalled one to five messages). More than four-fifth (83.35%) of respondents knew that bed net use can prevent people from getting malaria. Close to two-thirds (61.57%) reported they participate in decisions on how bed nets are allocated in their household. Overall, 51% reported consistent bed net use, and 57% thought that at least half the people in their community use a bed net.

Respondents with low, moderate, and high recall were 23%, 32%, and 80% more likely, respectively, to have a higher ideational score in the emotional domain (i.e., perceived self-efficacy to prevent oneself or one's children from malaria, perceived self-efficacy to procure and use bed nets, willingness to pay for nets) compared to those not able to recall. Respondents were more likely to have higher ideational scores in the cognitive domain (e.g., knowledge that use of bed net is a way to prevent malaria) if they had low, moderate, or high recall compared to those with no recall. Similarly, respondents with low, moderate, and high recall were more likely to have a higher ideational score in the social domain (i.e., discussion about bed nets with others, participation in net allocation decisions in the household) compared to those with no recall.

After adjusting for recall of media messages and other potential covariates, all three ideational domains also had a significant positive effect on consistent bed net use. For every unit increase in ideational score, the likelihood of reporting consistent bed net use increased by 5% to 10%. There was a significant indirect effect of recalling malaria-specific messages on consistent bed net use through each of the ideational domains. However, the emotional component appeared to have the largest effect of the three, meaning that people with higher ideational scores in the emotional domain had the highest odds of consistent bed net use. Per the researchers: "Mass media can have extremely powerful social and emotional effects if the messages are designed to do so (e.g., by encouraging and modeling discussion with peers or by creating empathy for people trying to protect their family from malaria)."

In short, this study found that respondents who recalled SBC messages were up to three times as likely to have higher ideational scores compared to their counterparts who were unable to recall the messages. The fact that the odds of higher ideation was consistently highest among those with high recall suggests that exposing respondents to a higher number of messages could lead to stronger ideational changes. Such strategies would be likely to produce larger changes in the mediator variable and larger subsequent changes in the behavioural outcome.

Among the concrete recommendations to emerge from the study: Communication interventions aimed at improving bed net use should consider messages that appeal to the emotional domain (e.g., self-efficacy), such as "It is easy to procure and use bed nets because they are widely available from pharmacies and often are distributed free at health facilities." Furthermore, messages should be designed to promote the fact that bed nets effectively prevent malaria and that most people in the community use a bed net.

In conclusion: "Access to a bed net is a critical first step in the process of bed net utilization. However, psychosocial factors e.g., emotional, cognitive, and social domains of ideation also play a major role in bed net use. Mass media SBC interventions could potentially influence bed net related ideation and consequently improve net use behavior. Future social and behavior change interventions should employ approaches that improve these domains of ideation within their audiences in order to increase bed net utilization."