Roll Back Malaria: Rolling out the Resources without Rolling out the Behavior – Ashley Dunkle

Introduction
Many international public health initiatives use innovative technologies developed in the West that need to be implemented in a developing context, often requiring behavior change of communities and individuals. One major international health problem that has been the target technological initiatives by many public health campaigns is that of malaria. Malaria is a leading global killer, particularly of children under 5 years of age (1). Over half of the world’s population is at risk of malaria while 350-500 million illnesses occur each year (1). A multitude of studies have shown the substantial economic, social, and health burden of areas of high endemic malaria (2,3).
Roll Back Malaria (RBM) is a partnership campaign that was formed in 1998 in order to align global health and development advocates in the fight against malaria (1). Recently RBM has developed a Global Malaria Action Plan (GMAP), which outlines techniques for partners to use in programming in prevention and treatment of malaria (4). One of the most important factors in preventing morbidity and mortality of malaria is vector control, reflected in the main intervention for prevention promoted by RBM: the scaling up of use of insecticide-treated bed nets (ITNs). ITNs are a technology developed to cover the beds of individuals in malaria endemic regions in order to prevent mosquito bites at night, when most malaria transmission occurs (5). This innovative technology is relatively cheap and has proven to be an effective prevention measure for the spread of malaria (6). Around 120 studies have shown the effectiveness of ITNs in reducing malaria transmission, and as a result, morbidity and mortality (6). In order to promote ITN use, RBM states they are working to a) organize public education campaigns in malaria-endemic areas, b) lobby for the reduction or waiver of taxes and tariffs on mosquito nets, netting, materials, and insecticides, c) stimulate local ITN industries and social marketing schemes so ITNs are available at a price affordable by everyone, and d) to capitalize on the potential of newly developed long-lasting treated mosquito nets (5). However, despite large donations and wide disbursement of ITNs and the implementation of RBM’s GMAP, malaria continues to be a major problem worldwide with little overall change in morbidity and mortality (7). This analysis will look at why RBM has largely failed in preventing malaria through its ITN initiative and offer ways in which the GMAP strategy could be improved to increase the use of ITNs worldwide.
CRITIQUE 1 – Assuming Induced-Demand Reflects Intended Use - Application to the Theory of Planned Behavior
RBM’s major indicator for use of ITNs among its beneficiaries is ownership of a net (1). Because ITNs are so effective at preventing transmission of malaria, many initiatives have targeted getting ITNs to the people in endemic, high-risk areas. In order to increase ownership, RBM’s methods involve inducing demand through social marketing (4). This first means inducing an increase in supply of ITNs by manufacturing organizations. After doing so, RBM focuses on getting ITNs to the people by giving ITNs away for free, subsidizing the cost, or delivering vouchers to exchange for ITNs, all of which is intended to induce demand (1). Recent reports by RBM has shown impressive scaling up in ITN ownership among individuals in endemic areas (1). However, despite widespread availability and possession of ITNs by people in malaria endemic areas, malaria is continuing to be a problem (7).
The major fallacy in RBM’s GMAP regarding ITNs is that they are only focusing on the possession of ITNs, not the actual behavior of use. In many of their reports, they provide accolade of the amount of nets disbursed throughout the world without measurement of the actual use of the nets (4). It is as though RBM is assuming that the “demand” they are seeing, which they induced, will lead to an intention to use the ITNs. We can apply this assumption to the Theory of Planned Behavior (TPB), an individual-based behavioral theory that focuses on rational, cognitive decision-making which presumes that people think about what they do before they do it (8). This theory states there are four factors leading to the intention to perform a behavior and that intention will lead to actual behavior. These factors are: 1) attitudes - the person’s belief about the outcome of the behavior and whether it is good or bad, 2) subjective norms - the person’s belief that other people in their social group approve of the behavior and there is motivation to conform, 3) perceived behavioral control – the person’s belief about the existence of factors that promote or prevent the behavior, and 4) perceived power – the person’s belief in the amount of power they have over the behavior. TBM assumes all of these factors influence behavioral intention and that behavioral intention then results in behavior (9).
What RBM seems to be assuming is that the demand they induced reflects attitudes that owners of ITNs believe there is a positive outcome from use (attitude) and that other people in the social group approve of its use, as ITNs are now widespread (social norms). They also appear to assume that by providing ITNs, RBM is reducing the difficulty of performing the behavior (perceived behavioral control) and the person believes they have power to perform the behavior now that they posses an ITN (perceived power). As ownership of ITNs is presupposed to reflect these aspects of the TBM, RBM believes these individuals will intend to use the ITNs regularly (behavioral intention) and that intention will lead to behavior. However, these factors that lead to behavioral intention are not necessarily existent among new ITN owners. For example, just owning something does not mean you have a positive attitude about its intended use. Many people will take free things because they are free and may not value them for their intended use (10). In fact, regarding bed nets, a study evaluating their use in a village in Kenya found 25% of individuals used the ITNs for alternative purposes, such as fishing netting and hanging fish to dry (11).
Likewise, rational decision-making does not always result in performing the intended behavior. Other factors beyond conscious cognition motivate behavior, such as environmental and social factors (8). Many reports have shown that barriers to use exist beyond obtaining ITNs. One study revealed a statistically significant reason for lack of adherence to ITN use, among participants who were given free nets, was temperature (12). One participant stated that it was “too hot” sleeping under the nets (12). Social reasons also influence use such as the disruption of normal sleeping arrangements for various reasons such as visitors or multiple beds (12). Additionally, technical factors can be a barrier such as people stated, “cannot hang the net properly, difficult to spread net over mat, returned home too late to put up the net,” and “net is too hard to put up and take down,” (12). RBM’s assumption that ownership will lead to intended use via the TPB and ultimately result in ITN use is false. Demand does not reflect behavioral intent and there are other factors, social, environmental, and technical, that can prevent ITN use by beneficiaries of ITN social marketing.
CRITIQUE 2 – Focusing on Education Campaigns - The Fallacy of the Health Belief Model
Another error in RBM methods for increasing ITN use is reliance on the Health Belief Model (HBM) through community-based education to encourage use of ITNs. HBM, like TPB, is a theory based on cognitive decision-making about what motivates health behavior. It assumes beliefs concerning perceived risk, costs, and benefits to participate in a healthy behavior, such as bed net use, are considered in a rational way, and will influence health behavior (13). There are six factors in the HBM which will be explained in relation to malaria and ITN use: 1) perceived susceptibility – the degree to which the person feels they are at risk of contracting malaria, 2) perceived severity – the degree to which a person believes the outcomes of contracting malaria are severe, 3) perceived benefits – perception of the positive outcome of using ITNs to prevent contracting malaria, 4) perceived barriers – the negative outcomes of using ITNs, 5) cues to action – an external event, such as someone in the community dying from malaria, that motivates use, and 6) self-efficacy – a person’s belief they are able to effectively use the ITN (8).
RBM’s GMAP proposes the use of community education programs in order to target these HBM factors assuming this will result in the behavior of ITN use. In fact, in the GMAP, Bill Gates, a major donor to RBM, is quoted as saying, “I believe that if you show people a problem, and then you show them the solution, they will be moved to act. The Global Malaria Action Plan lays out an achievable blueprint for fighting malaria – now it is time for the world to take action,” (1). RBM relies heavily on the HBM in that education of the susceptibility and severity of malaria, the benefits and limited barriers to ITN use, and promoting self-efficacy through educational cues to action will result in ITN use.
Like TPB, one of the major problems with HBM is its focus on individual decisions without addressing social and environmental factors (8). An individual’s cognitive and rational processes exist within a social and environmental context in which external influences affect behavior and can counteract rational thoughts and intentions (8). A randomized controlled trial performed in western Kenya evaluated adherence to ITN use with free ITNs and extensive educational activities focusing on many of the factors in HBM (12). These educational activities taught individuals about malaria, its prevalence in the area, the outcomes if adults and/or children contracted malaria, and ITN’s effectiveness in reducing transmission (4). Despite knowledge of malaria and ITN use, as well as free ITNs, “adherence” was still only around 70% (12). Teachers also emphasized to participants that malaria is a more serious ailment in children than older people and it was very important that children are a priority in sleeping under the nets. However, one of the statistically significant findings in this study was older people were more likely to sleep under the ITNs than children (p=0.0001) (12). Another important indication of ITN use by this study was that ITN use decreased over time, a factor that was observed in other efficacy trials surrounding ITN use (12). Allaii et al. states, “That this occurred in spite of our educational campaign illustrates how difficult it is to impact human behavior…” (12). This study shows the limitations of the HBM and RBM initiatives in education resulting in behavior change. This approach relies too much on the client and fails to take into account the wider social and environmental factors that influence behavior (14). Thus, knowledge alone does not always mean behavior change.
CRITIQUE 3 – Inducing Psychological Reactance Through Education
As shown in the second critique, education is intended to teach individuals about why it is important to their health to use ITNs, but health education campaigns have not proven to be very productive in changing behavior. Whitehead and Russell reiterate the difficulty found of changing behavior in the Kenya randomized controlled trial by stating, “‘Fully’ informing individuals about health and health risk does not necessarily lead to a change in behavior” (14). In fact, sometimes it induces the exact opposite of what is intended, which in this case would motivate individuals to not use ITNs (14). Evidence that health education can sometimes be counterproductive is explained by the Theory of Psychological Reactance. This theory was developed by Jack W. Brehm in the 1960s and has been supported by a number of empirical studies, particularly those related to health behavior (15). This theory suggests that when someone is told what to do, the individual perceives a threat or reduction in their freedom, and will act in a way to restore that freedom, often doing the opposite of what was told to them (15). To explain in more detail, Brehm (16) states there are four elements fundamental to reactance theory: 1) freedom, 2) threat to freedom, 3) reactance, and 4) restoration of freedom (15). Individuals first have a perceived sense of freedom. In response to a stimulus, such as an authoritative voice, individual’s feel this freedom is threatened. Individual’s then react to the threat and are motivated to act in order to restore the freedom (17). While reactance can take many effects, often the result is a boomerang effect, in which the individual will engage in the behavior related to the challenge of freedom (18). For example, if a child is told not to eat a piece of candy, they will feel their freedom threatened and will want to eat that piece of candy to restore their sense of freedom. Education campaigns and programs are a type of social influence that often induce reactance and prompt freedom-restoring responses leading to rejection of the message, resulting in ineffective persuasion to change behavior(17).
Psychological reactance theory may explain why some individuals do not use ITNs. When people are told to use ITNs, particularly when the source of the information are individuals from outside of the cultures of the individuals being taught, it is likely that a boomerang effect may occur. People value freedom and control and telling someone it is imperative that they sleep under ITNs violates these values by seemingly challenging their freedom to choose how they sleep and how they take care of their own families. By someone telling individuals to use ITNs at night, it is likely they feel these freedoms threatened, and in response, they may refuse to use the ITNs as a means of gaining back this challenged freedom, thus ignoring the rationale of the education campaign. RBM’s educational programs may therefore be causing individuals to not use the ITNs, by threatening their freedom through the intent of instruction – the opposite of RBM’s goals.
Proposal 1 – Market ITN Use, Not Just Ownership
As this analysis has delineated, RBM has focused on increasing uptake of ITNs through inducing demand and encouraging their use through education. But as has been shown, ownership of a net and education do not necessarily lead to the behavior of using ITNs. Instead on inducing demand of ownership of ITNs and focusing on individuals’ rational, cognitive-decision making through education about malaria and ITNs, RBM could include in their GMAP, direct marketing of ITN use. Rather than inducing demand of the product, RBM would be marketing a behavior – the use of ITNs. Using principles in marketing theory, RBM could greatly revamp their action plan to reach many more people in numbers and reach them at heart - a much greater motivator than knowledge.
Marketing is defined as “human activity directed at satisfying needs and wants through exchange processes” (19). RBM wants their beneficiaries to benefit from the use of the ITNs they provide. However, RBM needs to consider the wants and needs of these beneficiaries. Marketing theory starts by looking at the wants and needs of individuals’, and then packages and promotes products for exchange based on these values (20). Effective marketers do not try to make the target audience accept their values and beliefs, as RBM has done, but rather start from the standpoint of the audience’s wants and needs, values, and perceptions (21). While RBM claims methods of social marketing, it really is only focusing on the exchange part, ignoring the wants and needs of their consumer. Marketing theory suggests that rather than telling people to use ITNs because the educator thinks it is the right thing to do, coming at ITN use from the audience’s point of view can be much more effective.
As RBM’s focus is a global initiative, there are many beneficiaries from various cultures and subpopulations. While some values tend to be universal, such as independence, freedom, control, respect, etc., values tend to vary across subgroups and they can vary across cultures. Marketers do not rely on intuition to know what the consumer wants and needs, but rather they perform formative research in order to understand the values, wants, and needs of the target audience (20). Essentially this requires, “getting inside the heads” of consumers (21). Formative research needs to be included in RBM’s marketing approach in order to have an empirical basis for their marketing efforts and marketing campaigns.
Overall, marketing of a health behavior is different from traditional public health paradigms such as HBM and TPB, which tries to “sell” a behavior based on an individual’s desire for health and their rational cognitive processes. While health is generally valued, it is also generally misunderstood by those who possess it, and largely taken for granted. By using marketing theory and formative research in the GMAP, RBM could focus their efforts on the actual wants and needs of their beneficiaries and effectively redefine and packages the behavior of ITN use in a more effective way.
Proposal 2 – Expand on Marketing Theory - Branding ITN Use
By using marketing theory as proposed, RBM would be selling the behavior of ITN use based on the core values discovered through formative research. However, RBM needs to extend this marketing approach one step further. After performing formative research, marketers repackage, reposition, and reframe their product in a way that shows the target audience that they will benefit from its consumption in a way that reinforces their core values (20). One of the primary modes of presenting a product in this manner is through branding. Branding is a concept used by marketers that associates a product or service being sold with something the brand represents (22). In public health, generally it is a branded message to partake in a health behavior, rather than a symbol of a product (23). A branded message is a “strategic communication designed to elicit a particular set of beneficial associations in the mind of the consumer which become linked to the brand’s identity, providing…a sense of value (24). The best brands represent the core values, wants, and needs discovered through formative research (20).
Public health has co-opting branding as a means of marketing healthy behavior. Unlike commercial branding, public health does not intend to brand products or services. Alternatively a behavior is branded which leads to a benefit from engaging in or refraining from a behavior and its consequences. Whereas the HBM and TPB associate the outcome of “health”, branding a public health behavior will associate the outcome with a core value (22). These branded behaviors can then be “sold” as embodying a “lifestyle” of the healthy behavior, which will become part of the identity of those who partake in the branded behavior, such as the use of ITNs (23). Branding of a health behavior is often more effective than educating about a health behavior. This is because the purpose of healthy behavior is often abstract, complex, and it is difficult to appropriately convey the benefits to the target audience (23). In addition, healthy behaviors often do not have quick or noticeable results, thus branding a behavior with a value can be much more effective (23). In the case of ITNs, it may be difficult for people to use ITNs on a hot night, when comfort is their immediate concern, rather than use them for the purpose of preventing a disease of which they have never experienced and which they may not contract. The benefit of a net-free bed may be seen as much better in the immediate moment then preventing an abstract event such as malaria. However, by branding ITN-use, the owner of a net may partake in the use of the net because they associate the use with an “identity” and core value. Branding, therefore, can create a value-based association with the behavior that is more likely to induce “compliance” than an abstract “health” concept.
There are three basic concepts surrounding a brand: a) building a relationship b) adding value and c) beneficial exchange (22). First, the public health brand, in this case ITN use, must build a relationship with its beneficiaries to encourage the adoption of the health behavior. This is often through the development of positive associations offering a “brand promise”. The brand promise is something of value that the consumer of the health behavior will acquire if they respond to the proposed “call to action” (22). Building a relationship is essentially making the brand “promise” understood to the beneficiaries. In the case of ITNs, the call to action would be for people in malaria endemic areas to use ITNs each night for themselves and their family members. Thus, RBM would need to link this “call to action” with a “promise” that their brand represents. The promise must be something appealing to consumers, such as the values of the target audience discovered through formative research.
There are three persuasive mechanisms for making the brand appealing to consumers of the health behavior based on these values which include: a) aspiration to an appealing ideal, b) modeling of a socially desirable good, or c) association with idealized imagery (22). These mechanisms are related to the second aspect of branding: adding value. This is making explicit the relationship between the brand and the value it is associated with, linking the brand with the values, needs, and wants of the consumers. An association with an aspiration of an appealing ideal is that the brand may represent beauty, status, sex appeal, or power (22). Some examples would be “ITN use gives you control” or “ITN use is a sign of status”, thus linking the behavior with other “social goods”, though this “value” may not be directly related to the actual utility of the ITNs.
The third aspect of branding is providing a beneficial exchange. This is what the individuals actually receive from the adoption of the behavior and is generally based on the added value and the brand promise. An important factor in this aspect is the development of trust that the individual will gain the promise of status, beauty, or power, by performing the desired behavior (22). While education campaigns might use scare tactics such as teaching individuals about the biology of malaria and how it can cause morbidity and mortality, building a trusting branding relationship for promoting the use of ITNs would work much better, thus creating a positive approach. An example that RBM partners promoting ITNs could use may be, “Wrapping your family’s beds with ITNs each night makes you an excellent mother,” or “It’s sexy to use an ITN,” or “ITNs – only for high-society.” Positive associations help build trust and will induce the brand to be associated with positive social norms. As Dan Ariely suggests, “There are social rewards that strongly motivate behavior – and one of the least used…is the encouragement of social rewards and reputation,” (10). By building associations between the public health “brand” of ITN use and social values and rewards, individuals are much more likely to want to participate in the behavior in order to gain these social rewards if they understand the association of the promise and trust that the behavior will result in this reward.
Proposal 3 – Use Psychological Reactance To Roll Back Malaria– Mitigating Reactance and the Brand-Value of Freedom
While the third critique of RBM’s GMAP showed how psychological reactance could induce non-compliance with ITN use, it is possible for RBM campaigns through branding to a) mitigate psychological reactance, and b) use psychological reactance in their favor to promote ITN use in branding.
Although there is a compelling amount of empirical evidence to support psychological reactance, attempts at social influence does not always reduce compliance (16). Some studies have evaluated factors that do not decrease compliance, despite attempts at social influence that would likely induce psychological reactance. One fact that has been empirically shown to reduce psychological reactance is introducing similarity in the source of the influence. Paul J. Silvia performed a study evaluating how similarity may overcome the resistance to persuasion (25). He showed that having the message of persuasion coming from someone who is similar to the recipient in certain characteristics, such as age or gender, can increase the positive force by increasing liking and decrease the negative force by decreasing perceptions of threat, both contributing to decreased psychological reactance (24). Based on this factor, branded messages from RBM about the use of ITNs to its beneficiaries can decrease the amount of psychological reactance by delivering them from someone similar to the beneficiaries. This means that any educational campaign or advertisements involved in the branding of ITN use should come from people who are similar to the target audience. For example, if RBM partners were targeting increased use of ITNs to mothers, they would associate the brand with values of the mothers of this community, and could decrease psychological reactance by having the message come from a mother in the community and culture.
Rather than reducing psychological reactance, RBM could actually use psychological reactance to their benefit and even combine it with their brand. Because psychological reactance often induces a boomerang effect, it is possible to induce psychological reactance as a means of promoting a desired behavior by challenging individual’s freedoms in the opposite manner. As described, psychological reactance is induced as a reaction to an influence that results in a perceived threat to freedom, causing the individual to perform the opposite behavior from what was asked. One way that RBM could use this to their advantage is by focusing on the value of freedom in their brand. This would first mean the overall association between the brand and the behavior of using an ITN would be the value of freedom. The ITN brand would thus need to “promise” that using the ITN would lead to freedom. However, first the target audience would need to believe there is a threat to their freedom, which would require support from the brand. One way in which RBM could do this is to present support in the advertisements of the ITN brand that the mosquito and malaria are a threat to their freedom, and that following the “cue to action” to use ITN nets would restore this freedom. Thus, RBM could use techniques of marketing theory, branding, and psychological reactance all to promote an increase in ITN use.
Roll Out Behavior Change
Overall, RBM has done an incredible job at getting nets to those who need them. However, as was shown, owning a net does not necessarily lead to use of the net – what is ultimately necessary to prevent malaria. By changing their tactics from focusing on demand, using assumptions of TPB and the HBM, and potentially inducing psychological reactance through education programs, RBM could change minimal behavior influence into wide scale use of ITNs. Marketing theory and branding are impressive tools that have been greatly refined by the commercial sector. By co-opting these methods into public health behavior change, and utilizing psychological reactance in their favor, RBM could reach a lot more people on a much more influential level – by eliciting the core values of individuals, a much greater motivator of behavior.








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