Rats, mats and LLINs: Can SBCC make nets last longer?

Experiences from Nigeria & Uganda

04 Feb 2015

Hannah Koenker, Angela Acosta, Gabrielle Hunter

This presentation is made possible by the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of the presenter and do not necessarily reflect the views of USAID or the United States Government.

Research questions Proof of concept study

• Can a BCC campaign improve net care and repair behaviors?

• Can net care and repair behaviors have an effect on net lifespan?

-Net Care-prevent damage

•Hanging & handling carefully•Storing when not in use•Keeping away from sources of damage•Washing gently at the appropriate frequency

-Net Repair-fix damage (close holes)

•Sewing•Knotting•Patching•Repairing small holes immediately

Why is it important to have a net in good condition?

Conceptual framework for LLIN care & repair

NIGERIA

Nasarawa State, Nigeria

Intervention

Control

20 communities

randomly selected

Formative research findings

• Focus groups, interviews, and questionnaire • Are nets valuable?

– Protect health, children, finances

• What causes damage to nets? – Mainly children and being careless

• Net repair? – Well understood by all, repair = sewing or patching a hole– Repairs can be done by individuals or tailors, the materials are affordable– Repairing nets not common practice (18% had ever repaired a net)

• Net care?– More abstract/complex concept– Most respondents cite proper washing to keep it looking clean– Others mention preventing damage, careful handling, daily storage

Formative research analysis

• Over-washing problem: Reported washing frequency higher than recommended for LLINs and very connected to net care

• Motivators: – Social: cleanliness, neatness

– Health: malaria prevention, save money

• Barriers: – Lack of clarity on C&R behaviors due to lack of practice

– Unclear on how-to (e.g.: net material is “special” and not sure how to repair it or with what materials)

– Behaviors to prevent damage (care) are not top of mind

– Net care and repair is not a priority, however to be effective one must set aside time for it and incorporate into household routines

Strategic design

• Communication objective: To increase the useful life of nets by promoting regular care and repair behaviors among LLIN users in Kokona LGA, Nasarawa (~18 mos)

• Collaboration with CCPN

• Participatory design workshop with stakeholders

• Considerations– Address “How To” for all behaviors– Use mostly images to convey messages– Get buy-in from local leaders– Messages to address care, repair and washing behaviors separately– Emphasize building net care into everyday routines, nets are fragile

• Based on formative research, pre-tested messages and materials before production and deployment

Key messages

• “How To” for repair and washing behaviors• Small, do-able, everyday actions for net care

– Roll or tie up nets when not in use– Do not let children play with nets– Keep food [rats] away from nets– Inspect nets regularly for holes

• Nets are valuable [replacement is uncertain], worth the time investment to care and repair

• Torn net can still be effective if repaired• Repair small holes immediately!

Phase 1: Oct 2012-Mar 20135 months; 20 focal communities

• Advocacy• Community IPC with 40 recruited and

trained mobilizers• Radio spots• Print materials• Song contest

Advocacy

• High profile launch event with the state governor’s wife

• Endorsement by highest traditional leader of Kokona

• Coverage on local media and press

• Buy-in from all 20 community chiefs

The Royal Father, Abaga of Garaku, Kokona

Community IPC

Job aid for mobilizers

Sewing demonstration Community dialogue & street theater

House visits

Radio spots• Due to frequency and reach that radio can offer, it was

selected as the driver of everyday reminders and cues to

action for care and repair behaviors within daily routines

• Nasarawa Broadcasting Service

• During design phase was the only option for radio station

• Limited reach in control site, but increased over course

of campaign

• Four creative concepts for spots (60 & 30 seconds) plus an

endorsement by the Royal Father

• Aired spots 600+ times in 3 months

Print materials

Posters in health facilities and public places for community events, use of images to convey behaviors

Song contest: Make C&R fun!Musical troupes from all 20 communities participated by writing a song about net care and repair and performing it at the live contestPanel of judges scored for message and creativity. Covered by local TV & radio

Midline assessment

• Implementation experience from Phase 1

• Community feedback heard by mobilizers

• Field monitoring data

• Quantitative midline data: moderate exposure

• Stakeholders identify strengths and weaknesses

• Many activities and messages, need to focus efforts and boost exposure

• Conducted radio listenership assessment to refine airtime plan, assess internalization of messages, identify favorite spots

Phase 2 strategy refinement

• Moving from initial exposure of new messages to making behaviors routine

• Refined radio airtime plan for more exposure, reduced # of spots and added magazine show

• Focused IPC on activities with most impact in focal communities

Phase 2 activities

• Professional recording of winning song (www.networksmalaria.org)

• Play on radio and at events• Community dialogues and theater

demonstrate C&R• House visits continue, help people find

holes in nets, repair, tie up• Radio producers interview communities

for radio magazine show

Phase 2: Dec 2013-Mar 2014 4 mos; 14 original/6 new communities

• Aired radio spots ~260 times

• Aired14 episodes of 15-minute radio magazine program

• 60 community dialogues, reaching approximately 6,500 people

• 1,737 house visits, reaching approximately 13,700 people

UGANDA

Net Distribution

Serere District, Uganda

Net Distribution

Sep 2012

BaselineSurvey

Dec 2012

BCCPhase 1

Jun-Nov 2013

BCCPhase 2

Jan-May 2014

Endline Survey

May 2014

Qualitative Midline

Sep 2014

• Control (Kaliro) and intervention site (Serere)

• Younger nets - 3 to 19 months post-campaign

• 30 clusters in Serere District

Formative research results are very similar to Nigeria

• Recall: Low recall of C&R messages from the 2012 distribution (30%); complained did not get C&R information.

• Causes of damage: mainly rats (65%) and children.

• Repair: Few repairs (5%) Barriers: net too damaged (44%), no time (24%). Motivators: Preventing malaria, stopping mosquitoes. NOT a barrier: Lack of repair supplies.

• Care: Most associate care with washing and less with deliberately keeping nets away from causes of damage.

• Washing: Confused about proper washing behaviours and whether retreatment is needed. Most did not seem aware that overwashing damages nets.

Phase I strategy

Primary: Mothers Secondary: school children

Key Messages: •“How to” do net care and repair•If you take care of your net, it will last longer and protect you and your family from malaria

Activities•Home visits by VHTs•Compound dialogues •Song contest •Radio spots & mentions•Classroom demos•Posters •Tone: humorous, educational, family activity

Radio• 72% of Serere households

listen to the radio.• Used two leading stations• Ran two 60-second “slice-of-

life” radio spots and four DJ mentions in English and Ateso

• 1-hour talk show featured community events, champions, testimonies, songs, quizzes, and district political and health leaders.

Print

Song Contest: village “face-offs”

Midline qualitative• Almost all had heard of the campaign. More specific

and unprompted recall when exposed to IPC. • Respondents approve of the messages and believe

they will motivate community members • Most said they would use a repaired net – but most

also preferred to buy a new net if possible• More information on social norms• More info on motivators to tying up net daily

There is this [radio spot] of Thomas …before people never knew that you can stitch a net. They actually thought that when a net grow old, you just throw it away. But from the time they started putting those adverts, seeing proper care, people stitch their nets.

You can imagine Thomas with his head sticking out of the net.

49 yo M, husband

40 yo F, wife

Phase II strategy• Increase focus on repair – overcome inertia• Leverage social norms: being a responsible person• Continued activities:

• Household visits by VHTs• Refreshed radio spots and radio show (Thomas v2,

testimony)• New activities:

• Communal Sewing – schools• Music, Dance, and Drama Competition - schools• Uncle Ben’s song• Forum Theater performances – villages

Forum theater: Nabwire’s friends are giving her conflicting advice about her torn net. What should she do?

Household visit: A VHT invites Martha, a primary school student, to show her grandparents how to patch holes in a net.

Process Data: Phase I & II• 3,230 radio spots, 2,188 DJ mentions and 19 radio

talk shows • 34 song contest events: 30 village level, 3 cluster

level, 1 district level• 45 forum theater performances• 30 schools participated in the music, dance and

drama competition, reaching 23,208 students• 1219 household visits and 598 compound dialogues.

EVALUATION

Study design largely similar – control and intervention sites

Nigeria• Mass Campaign (Dec 2010)

• Baseline (Mar 2012)

• Midline (Mar 2013)

• Endline (Apr 2014)

• n=600 households at baseline, 770 at endline

• Nets 3.3 years old at endline

Uganda• Mass Campaign (Sep 2012)

• Baseline (Dec 2012)

• Midline Qualitative (Feb 2013)

• Endline (May/June 2014)

• n=870 households at endline

• Nets 1.75 years old at endline

Evaluation survey methods• Only households that received a net from the mass distribution were

eligible for interview

• Campaign nets in the household were assessed for damage using the

standard hole index guidelines for “too torn” or “serviceable” condition

• Household survey questionnaire was administered to head of

household, spouse, or other adult

– Background characteristics

– Exposure to BCC intervention

– Attitudes and behaviors around net care and repair

• No household roster (no net use)

Challenges

Nigeria• Local radio station, which

did not reach into the control LGA in 2012, boosted its signal strength during Phase 2 of the BCC intervention

• Significant exposure to radio messages resulted in the control LGA

• => Combined control and intervention for analysis by exposure

Uganda• A 95/5 mix of Permanet and

Olyset were distributed in the intervention district, but only Olyset were distributed in the control district.

• A-Z confirmed that these Olysets were produced with the suboptimal knitting pattern

• => Analyzed random Permanet sample only – e.g. intervention district only

Results – exposure to BCC intervention increased in both study sitesNigeria Uganda

Results – exposure dose was associated with attitude score

Nigeria Uganda

Results – attitudes were associated with net condition

Uganda - % of nets in serviceable condition (Permanet only)

p-=0.033

Results – attitudes were associated with net conditionNigeria attitude scores by:% of nets in serviceable condition and% of nets with observed repairs

Results - differences

Nigeria

• Increasing damage with more children under five

• Nets observed hanging up were in better condition

• Frequency of washing was not associated with damage

Uganda (Permanet only)

• No association (yet) of damage with presence of children under five

• Nets observed hanging up were not in significantly better condition

• Nets washed more than 3 times in the past 3 months were in worse condition

Results – common to both studies• Exposure to the BCC intervention remained a

significant predictor of net condition in the multivariate regression models (Nigeria combined; Uganda intervention district only)

• Net survival was worse among the poorest households

• Signs of repair are correlated with more damaged nets…– repairs are being done very late, and do not change the

net’s pHI category

Results – contributors to median lifespan

Attitudes

(Nigeria)

Net quality(Uganda)

Implementation lessons learned• OR comes with significant challenges and considerations• Phased campaigns have many benefits• Formative research allowed us to use materials/concepts

that validated audiences’ experiences• Involving technical experts was helpful in refining the

design• CHWs are stretched. Working with schools and music

groups increased our capacity to implement• EE platforms can inject helpful enthusiasm

Implications for programming• Care and repair messages should become standard

part of LLIN SBCC strategies, following formative research and pretesting

• Primary focus on the preventive behaviors– Tying nets up during the day– Keeping small children away from the net– Not storing net where rats/kids can get at it

• Similar to net use messaging, C&R messaging:– Should start with net distribution– Can be most effective when net ownership is high – Needs to reminders to support everyday behaviors

Implications for programming (cont.)

• Net care and repair messages are well-accepted.• The poorest households need the most assistance. • Attitudes are important• BCC and improved behaviors cannot overcome sub-

optimally manufactured nets

Further research

• Impact on net condition of comprehensive malaria SBCC including care and repair messages

• Relationship between overall net use culture and net care and repair behaviors

• Relationship between continuous availability of nets, and cost to acquire a new net vs. net care and repair

• Which prevention behaviors are the most effective– Attitudinal factors for those prevention behaviors

• Relationship between net integrity and risk of malaria

Toolkit

http://www.k4health.org/toolkits/care-repair-LLIN

AcknowledgementsTropical Health LLP•Albert Kilian

Stop Malaria Project, Uganda •Ruth Enyimu, Pearl Kobusingye, Meital Tzobotaro, Daniel Eninu, Kenneth Mulondo, and Lillian Nakato

Omnicom Ltd, Uganda•William Bakkabulindi, Maggie Lukowe, Geoffrey

Malaria Consortium, Nigeria & Uganda•Geoffrey Namara, Michelle Helinski, Emmanuel Obi

Center for Communication Programs Nigeria•Babafunke Fagbemi, Seyi Akintola

Rachel Weber

Thank you!

Formative Research

• Topics: Behaviors, knowledge and attitudes, household roles, and exposure to messages about care and repair

• Culture of Net Use qualitative study: 12 households, 4 focus groups

• Baseline survey: 881 households, 1460 campaign nets. ½ in Serere ½ in Kaliro.

Net condition is a determinant of net use

When there are many holes, you can no longer use it. The mosquitoes would be inside the net just like you would not be using it, so you would just throw it.

Male, 35 yoWomen responsible, men approve

“I am responsible for net care & repair. I tell my wife to do it.”

Care and Repair• Recall: Low recall of C&R messages from the 2012 distribution

(30%); complained did not get C&R information.• Causes of damage: mainly rats (65%) and children. • Repair: Few repairs (5%) but high familiarity with the concept

(mainly stitching). Barriers: No time (24%), net too damaged (44%). Motivators: Preventing malaria, stopping mosquitoes. NOT a barrier: Lack of repair supplies.

• Care: Most associate care with washing and less with deliberately keeping nets away from causes of damage.

• Washing: Confused about proper washing behaviours and whether retreatment is needed. Most did not seem aware that overwashing damages nets.