The role of ideation on the effect of an SBC intervention on consistent bed net use among caregivers of children under 5 years in Nigeria: a multilevel mediation analysis

Background Malaria remains a significant public health challenge in Nigeria. Consistent bed net use (sleeping under a treated net every night) has been identified as a key malaria prevention behavior. This paper explores the relationship between mass media social and behavior change interventions, psychosocial factors, and consistent bed net use. Methods Data is from the endline survey of a USAID-funded social and behavior change communication campaign conducted from 2012 to 2017 across five states in Nigeria. The outcome measure was consistent bed net use, and the mediator variable was a composite measure called ideation from a set of psychosocial factors believed to influence bed net use. The independent variable was recall of malaria specific media messages. Multilevel mediation analysis explored if recall of malaria specific media messages had any effect on bed net related ideation and if this ideation had any effect on consistent net use. Results Respondents included in this study were on average aged 31 years, mostly married or cohabiting (97.5%) and female 75%. Four in 10 (39.7%) respondents were able to recall malaria specific messages. Respondents with low, moderate and high recall were 23, 32 and 80% more likely to have a higher ideational score in the emotional domain compared to those not able to recall. Respondents were more likely to have higher ideational scores in the cognitive domain if they had low (AOR = 1.26, 95% CI 1.15-1.38), moderate (AOR = 1.16, 95% CI 1.00-1.34) or high recall (AOR = 1.55, 95% CI 1.16-2.06), respectively compared to those with no recall. Similarly, respondents with low (AOR = 1.03, 95% CI .99-1.08), moderate (AOR = 1.15, 95% CI 1.08-1.23) and high (AOR = 1.15, 95% CI 1.01-1.30) recall were more likely to have a higher ideational score in the social domain compared to those with no recall. After adjusting for recall of media messages and other potential covariates, all three ideational domains also had a significant positive effect on consistent bed net use. For every unit increase in ideational score, the likelihood of reporting consistent bed net use increased by 5 to 10%. There was a significant indirect effect of recalling malaria specific messages on consistent bed net use through each of the ideational domains. Conclusion Access to a bed net is a critical first step in the process of bed net utilization. However, psychosocial factors e.g., emotional, cognitive, and social domains of ideation also play a major