NetWorks End of Project Report 2009–2014

"NetWorks rapidly recognized that social and behavior change communication (SBCC) is under-utilized and under-appreciated in malaria control programs and ignored in policy. The reasons have been largely due to a perceived lack of credible evidence, due in part to a lack of professional standards to ensure quality SBCC programming and reporting of results."

This is the End of Project Report for the NetWorks Project, which ran from 2009 to 2014 in several malaria-endemic countries in Africa, as well as Thailand. The goal of the NetWorks Project was to build sustainable long-lasting insecticide-treated net (ITN) systems to prevent malaria. This was achieved by supporting the key technical areas of advocacy, policy, distribution, monitoring, and communications to increase net access and use. The NetWorks project was funded by the United States Agency for International Development (USAID) and the President’s Malaria Initiative (PMI) and was implemented by the following partners: Johns Hopkins University Center for Communication Programs, Malaria Consortium, Catholic Relief Services, Mennonite Economic Development Associates, Tropical Health LLP, Swiss Tropical and Public Health Institute, consultants from the London School of Hygiene and Tropical Medicine and International Procurement Agency, and a wide range of in-country collaborating partners.

While the overall objective of the project was to increase ownership and use of ITNs, the project had four key intermediate result areas, which the report lists as follows:

• Develop and promote appropriate policies at both the international and national levels to encourage sustained, high levels of ITN and related technologies ownership and use.
• Develop, promote, and support efficient and effective distribution approaches to ensure sustained high-level coverage of ITNs and related technologies in communities, particularly among the intended populations.
• Increase demand for and use of ITNs and related technologies to promote sustainable high levels of ITN ownership and use.
• Design, conduct, and analyse strategic operational research to pilot, document, and scale up innovative best practices that contribute toward achieving and maintaining high levels of ITN and related technologies ownership and use.

The report outlines the impact of the project in each of these result areas. The following are just a selection of results related to communication:

• 5 countries are using new behaviour change communication (BCC) indicators.
• 29 countries have updated strategic plans.
• 186 people were trained in BCC methods across 30 countries.
• 16 tools were developed for ITN BCC.

In addition, the project has:

• Consolidated, refined, and disseminated standard malaria BCC indicators, which BCC planners at National Malaria Control Programmes (NMCPs) and PMI implementing agencies now use.
• Established that significant predictors of net condition were primarily household-related; for example: whether people tied up the net during the day and attitudes toward care and repair.
• Demonstrated that different ecological and cultural zones influenced net longevity, from a 2.7-year median lifespan up to 5.2 year.
• Published seminal articles recalculating the net use gap, which showed the gap to be very small when measured correctly.

The report goes on to describe in detail the impact of the NetWorks Project in relation to: policy change, ITN distribution, BBC, and monitoring and evaluation. Each section shares specific country stories to illustrate the impact in each area.

In terms of policy change, the report outlines how the NetWorks Project impacted on policy in relation to: ITN integrity, continuous distribution, campaigns, stimulating global policy on the Vector Control Working Group (VCWG) and Technical Expert Group on Malaria Vector Control (VCTEG), and on SBCC for malaria control. Throughout, the project has worked to ensure that communication remains a key part of all areas of policy, but in particular regarding policy and SBCC for malaria control, the report stated the following: “NetWorks undertook a series of activities to establish professional standards for reporting results from malaria SBCC activities through a task force on monitoring and evaluation (M&E) of SBCC for malaria, which included key stakeholders such as PMI and key implementing partners. NetWorks also began collecting evidence on the impact of SBCC activities through surveys and analyses of activities in Senegal, Uganda, Zambia and Tanzania. Key outputs with policy implications for continued follow-up include protective behaviors to increase the effective lifespan of ITNs (care and repair behaviors and attitudes), an analysis of the impact of SBCC messaging on net use in Zambia and perceptions of the value of net use in the context of reduced malaria burden. These activities resulted in a policy-focused editorial in the Malaria Journal urging malaria control programs to recognize the value of effective SBCC.” [Related journal articles are listed in the appendix of the report.]

In relation to ITN distribution, NetWorks did not only contribute to ITN policy, but, amongst other activities, also implemented and provided support to ITN distributions in ten countries. The project designed and/or implemented pilot continuous distribution in six countries, delivered nearly seven million nets in Senegal, and provided campaign technical assistance in six PMI focus countries.

In terms of BCC, the report explains how the NetWorks Project narrowed the net use gap - defined as the difference between household ownership of at least one net and use of nets the previous night - by taking into account that households are failing to use nets consistently, not because of lack of BCC, but because there are not enough for the whole family. Narrowing the net use gap has consequently made it easier to pinpoint the behaviour gap itself, which in most cases is much smaller than previously thought. The project also focused on net care and repair behaviours as part of operations research into net longevity. As mentioned above in the discussion on policy impact, the project also focused on building capacity in the monitoring and evaluation of ITN BCC activities and developed a package of training tools and resources, including an online training module.

To improve monitoring and evaluation, the NetWorks project, during its five-year lifespan, produced 28 peer-reviewed articles, with many looking at issues related to behaviour change (a list is given in the Appendix of the report), 5 operational research studies, 26 separate research studies, and a wealth of ensuing data to inform evidence-based ITN programming. M&E activities took place in 15 countries, ranging from qualitative studies on the culture of net use to a stepped-wedge-design pilot to test the effectiveness of school-based distribution.

The report concludes that overall, “NetWorks produced a wealth of information and made groundbreaking progress during its five years. This work has shown that continuous distribution can be an effective mechanism for ensuring maintenance of universal coverage, that net care and repair attitudes are important in determining how long ITNs last, and that the universal coverage indicators provide clearer pictures of the realities of ITN distribution and use. At the same time, vector control with ITNs is threatened by a number of serious issues. At the policy level, there is currently low incentive for innovation, a lack of concrete next steps for mitigating insecticide resistance impact, and flat or decreasing resources from donors/governments. For distribution, there is an ever-increasing need for efficiency and cost-effectiveness. For behavior change, there remain significant portions of populations that are reluctant to use ITNs, particularly year round, and ITN use is not always an appropriate solution for outdoor malaria transmission.”

Based on this, the report recommends a series of next steps for research and implementation in relation to policy, ITN distribution, BCC, and M&E. The report mentions the following in relation to BCC:

• “As countries move toward malaria elimination, test BCC programs that focus on non-malaria benefits of ITN use to maintain high use rates.
• Investigate subnational rates of ITN access and use them to inform BCC programming, taking into account the survey season.”