Caregiver exposure to malaria social and behaviour change messages can improve bed net use among children in an endemic country: secondary analysis of the 2015 Nigeria Malaria Indicator Survey

Malaria is a major health issue in Nigeria. In 2016, there were an estimated 57.3 million malaria cases and 100,700 malaria deaths [1]. In 2015, approximately 21% of deaths, 60% of outpatient visits, and 30% of hospitalizations of children under five were caused by malaria [2]. To address the malaria burden, Nigeria is expanding key malaria interventions. The country’s National Malaria Strategic Plan (NMSP) 2014‒2020 aims to transition the focus from malaria control to malaria elimination, with the goal of achieving pre-elimination status and reducing malaria-related deaths to zero by 2020 [3]. To reach this goal, the strategic plan calls for the scale-up of prevention strategies, including universal long-lasting insecticide-treated net (LLIN) coverage.

Although coverage of key malaria interventions is improving, large gaps remain, especially among children under five, and further effort is needed to reach the country’s 2020 targets [4]. According to the 2015 Nigeria Malaria Indicator Survey (NMIS), approximately two-thirds of households in Nigeria own at least one insecticide-treated net (ITN), but only 44% of children under five used an ITN the night before the survey (2015 NMSP target: 50%) [4]. Notably, more than 90% of ITNs are obtained free-of-charge through campaigns or through regular distribution during antenatal care or child immunization visits or at government health facilities in Nigeria [4].

Social and behaviour change (SBC) interventions are also an important component of Nigeria’s NMSP and are seen as integral to achieving its intervention coverage targets by creating awareness and improving demand for and the uptake of prevention and treatment interventions. Malaria SBC interventions are widely employed in the country. For example, mass ITN distributions are accompanied by SBC messaging [5, 6]. Programme implementers have used SBC interventions that involve national mass media messaging, interpersonal communication at the community level, and multi-channel approaches in their programme areas [7‐9].

Despite widespread implementation of SBC interventions in malaria programming, there is limited evidence of their effectiveness for improving ITN use specifically among children under five and specifically in Nigeria [5, 6, 10‐19]. Nevertheless, several studies call for the implementation of SBC interventions to improve the uptake of malaria interventions or behaviours among children under five [20‐29]. Given this context and Nigeria’s emphasis on SBC interventions in its NMSP, this study assessed the relationship between caregiver exposure to malaria SBC messages and the use of ITNs among children under five.

This study assessed the relationship between caregiver exposure to malaria SBC messages and ITN use among children under five. The results suggest that caregiver exposure to ITN-related messages in the preceding 6 months has a positive effect on ITN use among children under five. Approximately two-thirds of households in Nigeria own at least one ITN, of which the majority are obtained through distribution campaigns [4] that usually include an SBC intervention to encourage regular, consistent, and proper use of the nets [5, 6]. ITNs are also obtained during antenatal care or child immunization visits, which offer opportunities for healthcare providers to share SBC messages specifically with caregivers of young children to ensure that they understand the benefits of their children sleeping under an ITN. The two most common sources of malaria messages are the radio and television [4], which can supplement messages provided during distribution campaigns and healthcare visits.

Other studies assessing the relationship between exposure to a malaria SBC intervention or message and ITN use among children have shown mixed results [11, 13, 16, 19]. For example, studies in Cameroon and Ghana found significant positive associations between caregiver exposure to malaria messages and ITN use in children [13, 19], but two studies in Zambia did not find a significant association between caregiver exposure to SBC interventions and ITN use among children [11, 16]. Although a limited number of studies explore ITN use among children in relation to caregiver exposure to relevant SBC messages, more studies look at ITN use among other household members in relation to exposure to SBC messages. In other parts of sub-Saharan Africa, studies show that SBC exposure has positive effects on ITN use in a variety of populations, including women of reproductive age [10], mothers of children under five [15], and all household members [14, 18]. Moreover, two studies conducted in Nigeria show that SBC exposure had positive effects on ITN use among household heads and their spouses [6] and all household members [5].

Our results suggest that SBC interventions can play an important role in improving ITN use among children under five. Given these findings and the low coverage of malaria SBC message exposure in the country, Nigeria should strive to scale up SBC interventions as the country seeks to achieve universal LLIN coverage. Meeting this intervention coverage target by 2020 requires improved ITN use among children. Although the country has made progress in improving malaria intervention coverage over the past decade, current coverage is behind 2015 targets, and large gaps remain to achieve the 2020 targets. Among women of reproductive age, only 36% recalled exposure to messages about malaria in the 6 months preceding the survey [4], even though SBC efforts to support key malaria prevention and management interventions have been ongoing [3, 7, 8]. Furthermore, of those women who recalled hearing any messages, fewer than half recalled messages related to ITNs. The most commonly recalled message was that sleeping inside a mosquito net is important (39%), but only 9% recalled messages about who should sleep inside a mosquito net [4].

The Federal Ministry of Health has an advocacy, communication, and social mobilization (ACSM) guide, which was updated in 2014 [33, 34], to help standardize ACSM programming, of which SBC messaging is an integral component, and to ensure that ACSM activities align with the NMSP. The NMSP notes that more evidence-based, culturally sensitive, and suitable SBC materials are needed, but it also states that the most effective SBC strategies (e.g., music, drama, sports, competitions) for improving the uptake of malaria interventions must still be determined [3]. In assessing possible SBC interventions, it will be important to consider the context in which they will be implemented. For example, mass ITN distributions are obvious opportunities on which to capitalize for promoting ITN use, but how is ITN messaging best conveyed if there are not mass ITN distributions? More evidence is needed to better understand and inform scaling up such interventions concurrently with prevention and treatment interventions in the country, especially in light of the substantial investments being made in SBC interventions and the country’s important push toward malaria elimination.

This study suggests that caregiver exposure to ITN-related malaria messages improves the use of ITNs among children under five. These positive effects can be leveraged to advocate for malaria SBC interventions as an integral part of Nigeria’s strategy to scale up prevention and treatment intervention coverage to meet its 2020 targets. However, more evidence is needed on the impact of specific SBC interventions to determine which are the most effective and scalable in Nigeria.