An Improved Method to Distribute Insecticide Treated Nets for Malaria Prevention in Kenya – Chelsea

In 1998 the international non-profit organization PSI developed a public health intervention to improve the coverage rate of insecticide treated nets (ITNs) for the prevention of malaria in Kenya (1). This program was designed to use of social marketing in order to increase both ITN ownership and use, especially by key groups such as pregnant women and children under the age of 5 years (1). The introduction of the program began in 2000 and was evaluated and revised in 2003 (1). To achieve the goal of improved ITN coverage social marketing was used as a means to encourage the private sector to have ITNs available in traditional and nontraditional settings for purchase (1).
In order to make the ITN sales successful and encourage the private sector to participate in the distribution, ITNs were subsidized based on location. In urban areas the subsidy was low at only 7% of the normal retail price in order to prevent too large of an impact on the existing commercial sector (1). In rural areas the subsidy was much greater, at 40%, primarily due to the lower socioeconomic status common in rural locations and the lack of existing commercial distributors (1). In rural locations ITNs were sold directly to small retailers by PSI (1). Additionally local entrepreneurs were identified and 700 rural kiosks were set up for these entrepreneurs to increase the number of rural retailers (1).
In addition to making ITNs available and affordable, an educational awareness campaign was developed (1). The goal of this campaign was to increase the demand for the nets by making individuals aware of the effectiveness if ITNs, importance of treating nets and who is most at risk for malaria and therefore should have preferential access to ITNs (1). This was done using radio, television and newspaper advertising with family-oriented messages. Additionally, a cartoon super hero named after the insecticide used to treat and retreat ITNs who killed mosquitoes and protects families was developed in an effort to create a brand (1). Included in the media campaign was a shock component designed to get people to take immediate action (1).
The basis for this intervention was the use of the social sciences theory of marketing. The basis of marketing theory is to know the needs and wants of your audience and then design and package products to meet those wants and needs (2). When applied to public health this is usually done in terms of taking a product that we have and then trying to sell it to the public based on their desire for health (2). This method has become increasingly common in the field of public health and can be successful if performed well (3).
In order to develop a successful public health intervention using marketing theory there are eight components described by Lefebvre and Flora that must be considered (4). First, your consumers must understand the goals of the marketing campaign (4). Second, the exchange of goods between the providers, in this case private sector retailers, and the consumer must be voluntary (4). The third and fourth components surround research into the audience to understand who your audience is and what products, messages and strategies will be most effective to achieve the goals (4). Fifth, you must have adequate channels for distribution of the product and communication at all levels (4). The sixth component is to ensure the correct mix of price, place and strategies for the implementation phase of the intervention (4). Seventh, a process to monitor and evaluate the strategies used and make revisions as necessary must be incorporated (4). The final component is that of a well designed management process to make adjustments when needed (4). The PSI intervention in Kenya incorporates many of these but does have some flaws in design and implementation.

Marketing Theory or the Health Belief Model?

PSI’s ITN intervention in Kenya is designed around social marketing but when it comes to the educational campaign, this is based more on the Health Belief Model. The Health Belief Model is an individual level model that says behavior is both rational and planned (5). In the Health Belief Model the perceived benefits and perceived barriers are being balanced by individuals when making a decision to take action or not to change their behavior (6). It is important to consider that this model is an individual model and does not take into consideration other people that may be involved in the decision making process (6). When designing a program using the Health Belief Model, one must take into consideration the perceived susceptibility and severity of the health outcome and how this affects the perceived benefit of changing behavior against the perceived barriers (6).
The educational component of PSI’s intervention in Kenya is focused on the individual and changing individuals perceived susceptibility and severity of malaria, especially in regards to pregnant women and children under the age of 5 years. The educational campaign tries to make people aware that young children and pregnant women are more susceptible to malaria than others. The primary reason for this is that it was thought that individuals were unaware of this (1). Additionally, the education campaign focused on the negative outcomes malaria can have on pregnancy and young children. This was designed to increase the perceived severity of malaria. Then the campaign stressed the benefits of ITNs for reducing susceptibility and severity and thus increasing the perceived benefits individuals have of using an ITN.
The second component of the Health Belief Model is that of perceived barriers, which the intervention did little to address. The intervention did lower the cost and increase access to ITNs but did not address any other barriers individuals may have. Additionally, social and historical factors were not taken into consideration in the educational campaign of this intervention. This makes the designed intervention more like the Health Belief Model than Marketing Theory, as the Health Belief Model does not take into consideration outside factors such as culture.
A true educational campaign designed around Marketing Theory would take into consideration cultural factors such as men being the primary breadwinner. This means that although men may not be more susceptible to malaria the consequences to the family may be more severe, in terms of financial resources, if a man contracts malaria and is unable to work.

Cartoons and Documentaries may not be Effective Branding

Branding is an important component of any intervention designed using the Marketing Theory. Branding is creating a set of associations that a person makes when they think of a product (2). When creating a brand you must consider what you want people to think about when they think of your product (2). Usually you want these thoughts to be something that will make them want to purchase the product you are promoting (2). It is also important to consider the core values of the target population when creating a brand for marketing. If you can target core values you are more likely to elicit a response from people and make them feel more connected to the product and your branding of it (2). While core values may change or have some differences between cultures, there are also many universal core values such as love, freedom, support, family, ownership and respect (2).
The PSI Kenya intervention uses two types of branding, one for the ITNs and retreatment tablets and another for the educational campaign. As a way of branding the ITNs and retreatment tablets PSI created a cartoon character called Mr. Power Tab (the retreatment tablets are called Power Tabs) (1). This character goes around killing mosquitoes and protecting individuals from malaria. This character is not a good use of branding because it is not something that individuals can relate to or connect with. It does not create associations that would want to make an individual purchase ITNs or the Power Tab retreatment. This is especially true in rural, malaria endemic areas where many families do not have access to television and therefore are probably unfamiliar with cartoons. Cartoons also do not appeal to an individual’s core values in a way that makes them associate the product with these values.
The second type of branding used by the campaign is in the educational awareness campaign. This uses radio, television and print media to educate populations about ITNs, malaria risk and importance of prevention (1). The television promotions are done in two forms, documentaries and soap operas. Neither of these are especially good models for branding because they are not likely to create favorable associations. Even if people enjoy soap operas, they are often overly dramatic and the real life applications of them may be unclear for families. Documentaries do not address of the core values that you would want people to associate with the products because they are primarily fact based and used to give information rather than packing the product to what individuals desire.
More effective branding would create positive associations between the community and the product so that they want to purchase the ITNs and retreatment tablets. Additionally the use of real people, who others can relate to and who share similar core values to those you are targeting with your intervention would be most effective. Perhaps having parents talk about these products and the benefits for their children or pregnant women who talk about their ownership of ITNs and retreatment would be more effective methods of branding.

People may not Suddenly Decide to Take Action

The PSI intervention in Kenya focuses part of its educational campaign on shock messages designed to encourage people to jump into action and purchase an ITN to protect themselves and their family (1). These educational messages sought to present families with the worst-case scenarios using television, radio and print advertisements (1). This is not likely to be effective because people do not typically take large jumps unless something negative happens to them or their family personally (6). Rather individuals carefully weight the benefits and barriers, consider social norms and past experiences before deciding to take action (6). This is part of the Transtheoretical Model; an individual level model that suggests behavior is planned (6).
While individual level models are not perfect and do not predict the behavior of groups, they can provide some insight and are beneficial to consider. The Transtheoretical Model says that people go through the stages of pre-contemplation, contemplation, preparation, action and maintenance (6). While not every individual will go through every step and some individuals may skip all steps, going directly to the action, this model does allow interventions to meet individuals where they are in the process of making a behavior change (6). In the case of purchasing an ITN, many individuals are probably in the pre-contemplation or contemplation stage. They have either never thought about purchasing an ITN to protect themselves and their family or have thought about it but have not actually taken any action.
It is here where the intervention needs to be targeted to allow individuals to take the next steps to make preparations such as saving money to purchase an ITN or talking to friends and neighbors about where an ITN can be purchased. The PSI intervention tries to get people to jump directly to the action of purchasing a net by presenting the worst-case scenario.
Some individuals do skip all of these steps and jump right to the action but that is usually only after there is been some sort of major life altering event (6). In the case of malaria in Kenya this could be something like a pregnant woman losing a baby because she has malaria or a child nearly dying from a case of malaria. These individuals could then be used to share their stories to encourage others to go through the steps of the Transtheoretical Model to lead them to purchase an ITN.

An Improved Intervention to Increase ITN Ownership and Use

I propose a similar but improved intervention to increase ITN ownership and use in Kenya based on three major social science theories. These theories are Advertising Theory, the Theory of Psychological Reactance and Social Expectations Theory and will be described in detail later. For the improved intervention I would keep the initial design similar in that ITNs are provided through private sector at a reduced cost. People will have a greater sense of ownership if they purchase the ITN themselves rather than be given it. Instead of having the subsidy be based on urban vs. rural location, there should be a sliding scale subsidy based on family size and income, thus people with many family members and little income would pay the least for their ITN. While this would be more difficult to implement it would lower the cost barrier for families.
The second component that I would improve would be to change the educational campaign from having a basis in the Health Belief Model to utilizing advertising theory. This would allow a greater consideration for group level dynamics and incorporate social factors not included in the Health Belief Model. I would use this to motivate people to purchase an ITN with a promise using stories and images from people rather than focusing on the knowledge and statistics on the importance of using an ITN, who is at greatest risk for malaria and the importance of retreating an ITN.
The third component I would change is the way in which branding is done for both educational campaign and the products themselves. Rather than using a cartoon and documentaries I would use real people who share similar core values. This would include parents and pregnant women who share their positive thoughts of ITN use with others in their communities. This would prevent psychological reactance and encourage more households to purchase ITNs to protect themselves.
The fourth and final change I would make would be to incorporate a social norms campaign to address social and cultural norms. This would be an effective way of reaching a large number of people at the same time. This could be done in a way similar to campaigns that increased the use of designated drivers in the United States (2). By working with media outlets to incorporate the use of ITNs in any scenes where there are individuals sleeping, especially children under the age of 5 years or pregnant women, social norms would begin to change and the use of ITNs would be seen as normal.


Advertising Theory

Changing from the use of social marketing that is presented more like the Health Belief Model in PSI’s Kenya intervention the new intervention would utilize advertising theory. Advertising theory is a group level theory that motivates people to purchase your product using promises and support of these promises (6). The promise should be something large that individuals are interested in and something that they would be willing to spend the money to purchase an ITN to receive the promise. In this intervention to increase ITN ownership and use you could promise happiness or better financial resources because there would be less productivity loss. These promises go beyond what is included in the Health Belief Model of balancing perceived benefits with perceived barriers.
Although the promise that you offer does not necessarily have to be true, it is essential that you provide support to back up the promise. The best forms of support come from personal stories, images, relevant music and other individuals (6). Supporting the promise with data or statistics is not effective and will not persuade families to purchase an ITN because they do not relate to these types of support as they do to stories and images. Images and stories reach out to entire communities and can take social and cultural factors into consideration unlike the Health Belief Model, which focuses on individuals and has no consideration for social factors (5).
In this intervention stories and images from parents and pregnant women could be used to reach out to the community and encourage the purchase and use of ITNs by vulnerable groups such as pregnant women and children under the age of 5 years. It is important to ensure that unintentional messages are not sent out through the use of Advertising Theory, which could reduce the effectiveness of the intervention.
Theory of Psychological Reactance
A better method of branding is needed to encourage individuals and families to purchase and use ITNs in their homes. The method of branding used in PSI’s Kenya intervention is not very believable and therefore individuals may feel like their freedom is being threatened. This threat to freedom from being told to do something from a less than believable source creates psychological reactance (7). Psychological reactance occurs when individuals do the opposite of what they are being told because they feel there is a threat to their freedom (7).
There are many ways to reduce psychological reactance. One is to make the message believable. Using real images, especially images that tell a story, can help to make a message believable, thus reducing psychological reactance. In the intervention of increasing ITN ownership and use, using images of children sleeping under ITNs and of women retreating their ITN with insecticide rather than drawings or the unrealistic image of a cartoon Power Tab killing mosquitoes. Another way to reduce psychological reactance is by using real people to spread the messages you want everyone to know (7). The best people to use are those who are similar to your target audience so that they can relate to these people sharing the message (7).
Additionally, psychological reactance can be reduced by downplaying the source of the message (7). This means that that you do not want your target audience to feel like they are being told to do something by an identified individual or organization but rather to feel like it is a general good idea of something they should do (7). The final way to reduce psychological reactance is by having the message come from as many people as possible (7). These should all be people who are as similar to your target audience as possible because the more similar and the more times a person hears the message the more likely it is that they will have decreased psychological reactance and will do what your message is telling them (7).

Social Expectations Theory

The final component that I would introduce into an improved intervention involves the Social Expectation Theory. This group level theory allows you to change a large portion of the society at one time by changing social norms (2). This can be used in combination with Advertising Theory and Psychological Reactance Theory to produce the most effective intervention to increase ITN purchase and use in Kenya. At the time of the PSI intervention only 17% of Kenyans owned and used an ITN, suggesting that ITN usage was not a social norm (1). It is important to develop effective means of incorporating ITN usage into messages that people see regularly without people knowing it to change the social norm.
This has been successful in the United States to ban smoking in bars and restaurants and also to increase the use of designated drivers (2). For this intervention radio, television and print media would need to be incorporated and participation from those who produce already existing media programs is necessary. Popular television shows and radio shows could begin to incorporate ITN usage into relevant scenes and over time people would come to believe that it is the social norm to own and use an ITN. As the use of ITNs in popular media becomes common and it is seen as a social norm, people may perceive fewer barriers, especially in terms of social or cultural factors, thus making them more likely to purchase and use ITNs in their own homes.
No one social science model alone will be effective in designing a public health intervention that will increase ownership and use of ITNs in Kenya, or in any other location, but a combination of many theories and models may prove effective. This is especially true for the group level models, which all work well together and can be used to influence entire groups of people rather than just individuals. Some of the individual level models can be used together but they are usually not as complementary as the group level models.

REFERENCES

1. Tilson D. The Social Marketing of Insecticide-Treated Nets (ITNs) in Kenya. Cases in Public Health Communication & Marketing. 2007
2. Siegel, M. (2010, October). Advertising and marketing theory – II. Speech Presented at Boston University School of Public Health, Boston, MA.
3. Grier, S., & Bryant, C. A. Social marketing in public health. Annual Review of Public Health, 26, 319-339. 2005.
4. Lefebvre, R. C., & Flora, J. A. Social marketing and public health intervention. Health Education Quarterly, 15(3), 299-315. 1988.
5. Irwin M. Rosenstock, “Historical Origins of the Health Belief Model,” Health Education Monographs, 2(4), 328-335. 1974
6. Siegel, M. (2010, September). Traditional models of individual behavior change: Are they helping or constraining us? – I. Speech Presented at Boston University School of Public Health, Boston, MA.
7. Siegel, M. (2010, November). Social Expectations Theory and Psychological Reactance Theory. Speech Presented at Boston University School of Public Health, Boston, MA.