Mosquito swarm at night

Behavior Change Can Prevent Malaria—and Keep Preventing It

Lessons Learned From Experiences in Western Kenya

Malaria infection, which causes suffering and even death, has plagued populations for decades, particularly in sub-Saharan Africa and especially among children. Global efforts and investments to control it have led to a substantial decline in the number of malaria infections and related deaths across the region. Long-lasting insecticidal nets (LLINs) are the cornerstone of malaria prevention efforts that have led to the notable reduction in infections. Ownership of LLINs has increased to almost 100% in most households in areas where malaria is widespread. But reductions in the prevalence of malaria-related infection and death are reversing, with most of the increase in malaria cases noted in areas that had achieved significant reduction. Worldwide, malaria infections increased from an estimated 224 million cases in 2019 to an estimated 241 million in 2020, mainly occurring in sub-Saharan Africa. Why? 

It’s Hard to Make New Habits, Even When They Can Prevent Malaria

In trying to identify the explanation for this reversal, several studies—including some that my colleagues and I conducted—looked to western Kenya, where malaria infections are increasing in areas that had been reporting declines. The studies found that human behavior may play a role in the breakdown of the infection-prevention chain alongside other factors—and innovative behavior change communication strategies are needed to ensure people create new habits and achieve maximum protection from infection-treated nets.

Malaria prevention and control efforts have often concentrated on ensuring that LLINs are successfully distributed to households. The success of malaria campaigns is measured by indicators such as the proportion of households with LLINs and the proportion of individuals sleeping under them the previous night. These data can give a false picture because they do not capture the actual behavior of insecticide-treated net (ITN) use every day throughout the year.

LLINs may wear out and get tears or holes that reduce the net’s integrity (breaking the barrier effect), therefore providing an opening for mosquitoes to get to the host. Many families live with nets of reduced physical integrity without knowing they can do something about it, such as stitch up the torn parts. Some families wash these LLINs frequently (as often as every month), which interferes with the effectiveness of the insecticide the nets are treated with. This information is important and needs to be reflected in the behavior change communication shared with people when they receive the bed nets.

We also noted that the distribution of ITNs commonly occurs during mass distribution campaigns, which take place every three to five years; when mothers attend antenatal care; and when they take their children to child welfare clinics. Many households, especially those without pregnant or nursing mothers, cannot afford to purchase the nets and must wait until the mass distribution campaigns to replace torn or worn-out nets. During this same period, the National Malaria Control Program team that distributes the nets often provides no follow-up communication on how to maintain and use them. People soon settle back into old habits and comfort zones, and the adoption of this simple and effective prevention method begins to breakdown.

All LLIN campaigns need to incorporate behavior change communication during distribution to remind people how to use and care for the nets. Communication should include the need to consistently use the bed nets for maximum protection and how to care for them properly (do not wash them frequently, stitch torn parts, etc.). But is it enough to share this information just once during distribution of the nets? 

How Information Is Communicated Is a Key Factor in Knowledge Retention and Behavior Change

A second key lesson learned from one of the studies we conducted in western Kenya is the need to package information in a manner that people can refer to again later. For example, in this same study we found that information packaged in the form of a poster, with pictures and explanations, is an effective way to encourage behavior change. People can check the poster, which is frequently posted on walls, as often as they need to for reminders on how to use and care for their bed nets. This repeated exposure to information is in contrast with communication shared through other channels, which is often provided just once. In the study we conducted, the group that received behavior change information in a poster changed their habits, while groups that did not receive the poster did not have a significant change in their behavior.

Another effective communication channel, especially in rural areas, is community health workers. These health workers interact with community members on an almost daily basis and can regularly relay information to them about effective practices.

People Need Reinforcement to Maintain New Behaviors

Behavior often changes depending on circumstances. People may adopt the right behavior at the beginning of a malaria prevention campaign but then quickly forget to continue with their new practices and return instead to their usual routines—old habits are hard to break.

Positive behaviors need to be repeatedly emphasized if people are to make new habits of them. Again, from the study we conducted, after one year, there was no difference in behavior among the various intervention groups and the control group. After some time, without reminders and positive reinforcement, people forget. Scheduling communication campaigns within a six-month interval could effectively remind people to pick up behaviors they left behind.

If communication is integrated into all LLIN distribution campaigns, we may see people more fully adopt the new habits needed to use and care for the bed nets to protect themselves from malaria—and reverse the increases in infection and death. 

Judith Nekesa Mangeni is a researcher and lecturer at Moi University in Kenya. She recently participated in a PRB policy communication program that focuses on strengthening the capacity of young researchers working on population and health studies to engage policy influencers and decisionmakers effectively.

Wendy O’Meara is an associate professor at Duke University School of Medicine in the Division of Infectious Diseases, a visiting professor at Moi University, and the associate director for research of the Duke Global Health Institute.