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June 28, 2017

How Do We Assess Behavioral Impact? BIMCP Adds School-Based Distribution of Bed Nets as a Novel Malaria Control Intervention in Equatorial Guinea


In June 2017, the Bioko Island Malaria Control Project (BIMCP) completed its first school-based distribution of mosquito bed nets to 36,000 primary school children to complement its long-standing keep-up distribution of nets to pregnant women through antenatal care clinics. This school-based distribution was one of the first of its kind in sub-Saharan Africa, thus the results were anxiously awaited to assess the effectiveness of this delivery channel in maintaining sustainable bed net coverage and use.

Long-lasting insecticidal nets (LLINs) are a proven, cost-effective malaria prevention measure expected to last two to three years. Every three years, the BIMCP carries out a mass top-up distribution and hang-up campaign of mosquito bed nets with the aim of achieving universal coverage of all households on the Island (target of 100%). The WHO recommends at least 80% coverage of the population, and the BIMCP has surpassed that rate with its hang-up campaigns including the last one in 2015. Unfortunately, for a variety of reasons, including the fact that bed nets are not available elsewhere in Equatorial Guinea (e.g. the mainland and other islands), bed nets have been found to disappear from homes on Bioko at a very high rate. For example, within one year of the 2015 mass distribution on Bioko, the number of LLINs that households reported owning during a follow-up survey had already declined by 55-72% relative to the post-distribution levels!

In light of the high rate of bed net loss, and knowing that the age group with the highest prevalence of malaria infection on Bioko Island is 10-14 year-olds and that 30% of the households on Bioko Island have at least 1 primary school aged child, it was evident that a primary school-based LLIN distribution could be an effective way of replenishing net supply in a targeted manner. In addition, teachers were considered influential communicators who could reach children in this age group with credible messages about malaria and how to prevent it by "keeping up" the use of bed nets. Finally, the children themselves were envisaged as agents of change within their households, who could be taught to make LLIN use a part of their bedtime routines, similar to the way they brush their teeth every night.

In order to inform the communication strategy for the primary school-based distribution, formative research was carried out with children, parents and teachers to formulate the main messages and barriers to LLIN use to be included in teaching materials. The BIMCP and the National Malaria Control Program (NMCP) enlisted the support of the Ministry of Education and the Ministry of Information in order to develop an illustrated teaching guide and other resources about malaria for primary school teachers, which also enhanced Spanish reading and writing skills. Master trainers were then prepared to train other teachers on the teaching guide. The teachers' understanding of the material was assessed with pre- and post-tests, and teachers were notified that their students' knowledge on the subject of malaria would be tested before and after teaching the new material. Pre-testing of selected students occurred prior to the distribution, using a set of pictorial questions for low-literacy students.

Following extensive preparations, the BIMCP/NMCP then successfully executed this first-ever school-based LLIN distribution on Bioko from March to June 2017. All primary schools were mapped, the needs were calculated, a distribution plan was devised, all 1,255 primary school teachers were trained, and a monitoring schedule was set. Students and teachers were followed up with by BIMCP staff with post-tests to assess any change in their knowledge and practices.

Testing revealed that teachers who were trained increased their malaria knowledge scores from 60.6% to 88.9%. By the time of the post-test, over 95% of students in a sample of 530 could identify that malaria was spread through the bite of the Anopheles mosquito and that LLINs had special "super powers" to protect people against malaria while they slept at night.

Overall, the impact on students' malaria knowledge and their ability to remember specific messages or themes from the curriculum was positive. The "super powers" of the bed net to protect against "killer mosquitos" was particularly memorable for the students. In spite of the evident improved knowledge, bed net utilization did not increase as a result of the primary school-based distribution. Based on pre- and post-distribution questionnaires administered to the 530 students who were asked whether they had slept under a bed net the previous night, only 43% of students reported having slept under a bed net the previous night, both before and after the nets were received. The results were discouraging in that improved household net supply and knowledge appeared not to translate into increased LLIN use.

As is often seen in behavior change efforts, enhanced knowledge and supply availability are simply not enough. A complex set of factors contributes to behavioral outcomes: individual knowledge and self-efficacy must be adequate, barriers to sustaining good health practices or adopting new behaviors must be well understood and then removed, and social support for the new behaviors must remain strong. The BIMCP will continue to calibrate its approach to encouraging LLIN use with behavior change communication by leveraging monitoring data that inform adjustments to the teaching materials, training and teaching methodologies, and execution of bed net distribution in schools. One conclusion may be that more needs to be done to bring parents into the conversation about LLIN use, as they are the ones responsible for lowering the bed nets for their children and tucking them in at night.

In addition to seeking ways of improving the impact of behavior change communication on bed net use by primary school aged children on Bioko, while seeking to maintain universal bed net supply coverage throughout the Island via mass top-up LLIN distributions supplemented by regular keep-up through ANC clinics and primary schools, the BIMCP will also continue to conduct targeted indoor residual spraying in areas with the highest prevalence of malaria infection, and to ensure timely access to effective diagnosis and treatment. Together, it is anticipated that these interventions will continue the progress towards elimination of malaria from the Island.

First picture: Children receiving bednets during the school-based distribution.

Second picture: Students being tested on their knowledge of malaria and bed nets.

Third picture: BIMCP staff training master trainer teachers on malaria messaging in schools.





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