Ideational Factors Associated with Net Care Behaviour: A Multi-country Analysis

"It's what you hear that helps you begin to change your behaviour. And hearing positive messages about how you can easily care for your nets and how that will increase protection from malaria can make people more likely to do so." - Stella Babalola

Correct and consistent use of insecticide-treated mosquito nets (ITN) is an effective strategy for malaria prevention. Behaviour change messages have been correlated with proper net-care behaviours, including tying or folding ITNs up when they are not in use. Research on health communication for behaviour change positions ideation - psychosocial determinants of behaviour, such as perceived severity of malaria - as a key construct. This study compares the ideational correlates of net care behaviours in three sub-Saharan African countries. The hope is that a better understanding of ideational determinants of tying or folding ITNs up will help malaria control and elimination programmes design SBC interventions that increase the average effective ITN lifespan and may contribute to better sustained ITN coverage between net distribution campaigns.

Between 2018 and 2019, the researchers collected household data nationwide in Côte d'Ivoire, from the North and Far North regions of Cameroon, and from Port Loko and Bo districts in Sierra Leone. The analysis was limited to women of reproductive age and their male spouses/partners from households with at least one ITN: 2,940 respondents in Cameroon, 6,105 in Côte d'Ivoire, and 2,730 in Sierra Leone. More women than men were sampled to better capture malaria prevention behaviours usually performed by women, such as care-seeking for fever in young children. By interviewing men in one-third of the households, the survey also was able to better understand men's views as key household decision-makers.

Among respondents, 50.2% in Cameroon, 52.0% in Côte d'Ivoire, and 75.6% in Sierra Leone reported folding or tying up their net when it was not in use. Gender, geographical, and age differences were reported among the countries, meaning context is key when designing behaviour change messages and activities. Adjusted, multivariable, multilevel logistic regression in each country indicated the following (select) findings:

• In Cameroon, several variables were significantly correlated with folding or tying up a net when not in use. The odds of practicing this behaviour among respondents with positive attitudes towards net use (adjusted odds ratio (AOR) = 2.08, p < 0.001) was doubled compared to similar respondents without this positive ideational characteristic. The same was true among respondents with self-efficacy to use nets consistently (AOR = 2.17, p < 0.001) and those who perceived net use to be a norm (AOR = 2.02, p < 0.001). Respondents who had heard/seen a malaria message recently were 43% more likely to report practicing this net-care behaviour (p < 0.05). Residual clustering at the household level showed that about 66.0% of the variance in the behaviour was attributable to household-level factors. Clustering at the enumeration area (EA) level was about 16.3%.
• In Côte d'Ivoire, the strongest positive ideational correlates were interpersonal communication about malaria, perceived susceptibility to malaria, perceived efficacy of ITN, descriptive norm about ITN use, positive attitudes towards ITN care, and positive attitudes towards ITNs. For example, perceived susceptibility to malaria and positive attitude towards ITN use increased the odds of reporting the behaviour by 92% and 78%, respectively (AOR = 1.92, p < 0.001; AOR = 1.78, p < 0.01). The data revealed significant residual clustering at the household level, with about 75.5% of the variance in the behaviour attributable to household-level factors. Clustering at the EA level was less pronounced but nonetheless significant.
• In Sierra Leone, the odds of performing effective net care were elevated among respondents who had positive attitudes towards net care, were confident in their ability to use nets consistently, and who perceived nets to be effective protection against malaria. The odds of performing net care were almost doubled among respondents with perceived response efficacy of bed nets (AOR = 1.92, p < 0.001) compared to those without response efficacy. Similar results were found for respondents with self-efficacy to use nets consistently (AOR = 2.51, p < 0.001) compared to those without self-efficacy. About 27.2% of the variance in the behaviour was attributable to household-level factors, and clustering at the EA level was about 10%.

The results revealed predictive factors that were common to the three countries and others that were country specific. For example, exposure to malaria-related messages was linked to reporting appropriately caring for a net in Cameroon, but not in Sierra Leone or Côte d'Ivoire. While all three countries reported implementing various SBC activities to promote malaria prevention and treatment in the months preceding the survey, including mass media and community mobilisation interventions, the focus of this SBC on behaviours around net care was not documented.

The researchers suggest that the findings have implications for programming, strategy, and future research, including:

• National malaria SBC strategies that rely on maintaining high levels of ITN coverage and use should include promoting this net-care behaviour, as it has been shown to both extend effective ITN lifespan and increase ITN use. Programme efforts to extend the average effective lifespan of ITNs should include SBC activities that prioritise messages about tying and/or folding ITNs up when they are not in use.
• Observed differences in ideational correlates of net-care behaviours across countries reinforce the importance of tailoring country-specific SBC strategies to local context. SBC strategies that are informed by local formative evidence are more likely to resonate strongly with and be accepted by the population.
• The positive associations between being female and the assessed behaviour in Côte d'Ivoire and Sierra Leone suggests that women may take on this role, or there is a need for special efforts to reach men with relevant messages in these countries.
• Residents seemed more likely to tie or fold their net if others in their community were doing so. This finding indicates the influence of positive community norms around correct net care and the importance of promoting new norms around net care where they aren't strong. Relatedly, significant residual clustering at the household and community (cluster) levels indicates factors operating at these micro levels.

In conclusion: "SBC activities fostering increased consistent use of nets, positive attitudes towards net care, increasing perceived susceptibility of malaria infection, increasing perceived self- and response-efficacy of bed nets, and establishing perceived use of bed nets as a community norm may increase net-care behaviour."