Receptivity of Pregnant Women in Lagos State to Communication Campaign Messages on Adoption of Insecticide Treated Nets for Malaria Prevention

RECEPTIVITY OF PREGNANT WOMEN IN LAGOS STATE TO COMMUNICATION CAMPAIGN MESSAGES ON ADOPTION OF INSECTICIDE TREATED NETS FOR MALARIA PREVENTION

AMOBI THERESA IFEOMA

MATRIC NO: 839009031 B.A. (HONS) Mass Comm., (UNN); MPA (UNILAG); M. Sc. Mass Comm., (UNILAG)

Department of Mass Communication, School of Postgraduate Studies, University of Lagos, Lagos, Nigeria

March, 2012

RECEPTIVITY OF PREGNANT WOMEN IN LAGOS STATE TO COMMUNICATION CAMPAIGN MESSAGES ON ADOPTION OF INSECTICIDE TREATED NETS FOR MALARIA PREVENTION

AMOBI THERESA IFEOMA MATRIC NO: 839009031 B.A. (HONS) Mass Comm., (UNN); MPA (UNILAG); M. Sc. Mass Comm., (UNILAG)

Department of Mass Communication,

University of Lagos, Lagos, Nigeria

THESIS SUBMITTED TO THE SCHOOL OF POSTGRADUATE STUDIES, UNIVERSITY OF LAGOS, IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF THE DEGREE OF DOCTOR OF PHILOSOPHY (Ph.D.) IN MASS COMMUNICATION

MARCH, 2012

DECLARATION

I, Theresa Ifeoma Amobi, declare that this Ph.D. thesis was originally written by me, and that to the best of my knowledge, this research has not been submitted to any other school or university for any other degree. I also declare that both published and unpublished materials used in this study are appropriately acknowledged.

Name: Theresa Ifeoma Amobi

Signature......

Date:

CERTIFICATION

TABLE OF CONTENTS Content Page

First title page i Second title page ii Declaration iii Certification iv Table of contents v List of Acronyms vii List of tables/figures viii List of appendices x Dedication xi Acknowledgments xii Abstract xv

CHAPTER ONE: INTRODUCTION Background to the study 1 Statement of the problem 11 Aims and Objectives 14 Research questions 14 Significance of the study 15 Scope of the study 16 Operational definition of terms 17 References 20

CHAPTER TWO: LITERATURE REVIEW Introduction 25 Conceptual framework 25 Review of empirical studies 45 Theoretical framework 53

References 77

CHAPTER THREE: METHODOLOGY Introduction 92 Research design 92 Population of study 95 Sample selection and techniques 95 Research instruments 107 Validity of survey research instrument 108 Procedure for data collection 109 Limitations of the study 111 References 112

CHAPTER FOUR: DATA ANALYSIS AND RESULT PRESENTATION Introduction 114 References 133

CHAPTER FIVE: SUMMARY AND DISCUSSIONS OF FINDINGS Introduction 135 References 149

CHAPTER SIX: CONCLUSIONS, RECOMMENDATIONS CONTRIBUTIONS TO KNOWLEDGE AND SUGGESTIONS FOR FURTHER STUDIES Conclusion 151 Recommendations 152 Contributions to knowledge 153 Suggestions for future research 155 Bibliography 156 Appendices 173

LIST OF ACRONYMS

ITN------Insecticide Treated Net

RBM------Roll Back Malaria

FMOH------Federal Ministry of Health

WHO------World Health Organization

UNICEF------United Nation’s Children’s Education Fund

NDHS------Nigeria Demographic Health Survey

NMCP------National Malaria Control Programme

CFSC------Communication For Social Change Theory

NMIS------Nigeria Malaria Indicator Survey

CDC------U.S. Centres for Disease Control and Prevention

IMPAC------Massive Promotion and Awareness Campaign

FBOs------Faith based organizations

MDGs------Millennium Development Goals

UNDP------United Nations Development Programme

NGOs------Non Governmental Organizations

SES------Socioeconomic Status

IEC------Information, education and communication

LGAs------Local Government Areas

FGD------Focus Group Discussion

INEC------Independent National Electoral Commission

NPC------National Population Commission

LIST OF TABLES/FIGURES Table Title Page 1 Reported malaria in pregnancy cases in Lagos state 2 2 ITN coverage from household surveys, 2007-2009 7 3 The 16 Local Government Areas in Lagos Metropolis (Urban) 105 4 4 Local Government Areas in rural Lagos 105 5 Focus Group Participants 110 6 Distribution of respondents by education 115 7 Distribution of respondents by income 115 8 Respondents’ exposure to health/ITN messages in the mass media 117 9 Respondents’ first source of information on the adoption of ITNs 118 10 Most frequently used persons, institutions or places by respondents as 121 their source of information on ITNs 11 Basic Knowledge/Awareness of the deadly nature of Malaria and ITN 122 12 Respondents’ perceived attitudes to Malaria and ITN related issues 123 13 Household ownership and respondents who were sleeping under ITN 124 14 Respondents’ frequency of sleeping under the ITN 124 15 Percentage of respondents who slept under the ITN the night before 125 16 Persons, places, things, institutions that influenced respondents’ 126 responses to ITN messages 17 Persons, things, institutions or places that influenced respondents’ 126 decision most to sleep under ITNs 18 Respondents’ who use ITNs because their friends or relatives are using 126 them 19 Relationship between geographical location and sleeping under ITNs by 127

respondents 20 Relationship between geographical location and respondents’ frequency 127 of sleeping under ITNs 21 Relationship between respondents’ academic attainment and their 128 sleeping under ITNs 22 Relationship between respondents’ academic attainment and their 128 frequency of sleeping under ITNs

23 Relationship between respondents’ income and their sleeping under the 129 ITNs 24 Relationship between respondents’ income and their frequency of 129 sleeping under the ITNs 25 Barriers to pregnant women’s receptivity of communication messages 130 on the adoption of ITNs 26 Matrix of responses from FGD Sessions with respondents 131

LIST OF FIGURES S/N Figures Page 1 Lasswell’s Linear Model of Communication 27 2 Integrated Model of Communication for Social Change 69

3 Modified Integrated Model, 2011 73 4 Map of Lagos 106

5 Respondents’ major source of information on ITN 119

6 M ass media of information most frequently used by respondents as 120 major source of information on ITN

LIST OF APPENDICES

S/N Title Page

1a Sample Malaria/ITN Billboard Message 173

1b Sample Malaria/ITN Billboard message2 174

1c Sample RBM Television message 175

2a List of government hospitals in the five selected LGAs 176

2b List of private hospitals and maternity homes in the selected

five LGAs in Lagos State 177

3a Questionnaire for pregnant women in selected LGAs 192

3b Focus Group Interview Schedule for pregnant women 202

3c Interview Schedule for Communication/Health Officials 204

4a Full text of interview with UNICEF Communication officer 205

4b Full text of interview with Matron, NAF Hospital, Shasha 208

4c Full text of interview with Commander, NAF Hospital, Shasha 211

4d Full text of interview with Communications officer, RBM

Secretariat, FMOH, Abuja 213

DEDICATION

Who is like unto thee oh Lord? From generation, to generation, thou art God. To you Alpha and Omega, the author and finisher of my faith, the- I am that I am, I dedicate this study. But for you, this study would have remained a largely unfulfilled dream.

To my Lord and Saviour, Jesus Christ, the King of Kings and Lord of the universe may your name be praised, honoured and glorified for all eternity. Papa, I say thank you and to you the most holy Trinity, the three persons in one God, I dedicate this work.

I also dedicate this work to the most loving and unforgettable memory of my father, Chief, (Sir) S. M. Ebuzeme (Ichie Odumegwu 1 and Traditional Prime Minister of Oba, Anambra State). Papa, my greatest and indescribable pain and regret is your absence at this auspicious time to

12 share the fulfilment of the dream which you initiated. In heaven where I know that you are papa, with my most beloved son Eric Gerard and brother George, I am proud to say to you that I finally made it and to thank you both for being my father and my son. Papa, I would never have wished for another and if there is another life, may you still remain my father.

ACKNOWLEDGEMENTS

First and foremost, I acknowledge the Almighty God who has been my strength and shield over these years. He provided me with the knowledge, wisdom, good health and understanding as well as the resources to accomplish this task.

Words alone cannot describe the depth of my gratitude, respect and admiration for my supervisor, Prof. Ralph Akinfeleye, the foremost professor of Journalism in Nigeria, a communicator of international repute, who God in his infinite wisdom has crowned the Chair and Head of the Department of Mass communication, University of Lagos. I appreciate his intellectual and meticulous guidance, criticisms, and direction at every stage of this work. I thank him for his utmost confidence in my abilities, and his encouragement and reassurances in the face of trials.

I am also indebted to Dr. Victor Ayedun-Aluma my second reader, for his intellectual insights and erudite suggestions which enhanced the quality of the work.

I appreciate Dr. Oloruntola Sunday- a man of enormous academic sagacity for peer-reviewing this work and always being there for me when I need him. Tola, you are indeed a true colleague and friend.

I can never appreciate my wonderful colleagues enough, great minds of a great department for their invaluable encouragements- Dr. Abayomi Daramola, Dr. Abigail Ogwezzy-Ndisika, Dr. Soji Alabi, Dr. Olubunmi

Ajibade, Mr. Teslim Lawal, Mr. Tayo Popoola, Mr. Taiwo Akinyemi, Mr Charles Onwunali, Mrs Joy Rita Mogbogu, Mrs Adepate Mustapha Koiki, and Mrs Khadijat Aledeh. To all of you I say a very big thank you.

I must not fail to acknowledge Professors Ritchard M’Bayo, Innocent Okoye, Idowu Sobowale, and Onuorah Nwuneli who taught me that crossing your T-s and dotting your I-s is the mark of a good scholar and communicator. Professor M’Bayo taught me that sleeping for more than five hours a day is not a mark of a good scholar; Professor Okoye taught me that mechanical accuracy is the mark of a good communicator; Professor Sobowale taught me that I could communicate better without the use of adverbs and Professor Nwuneli taught me to work under pressure and still remain at the top of the game- together they made me the person I am today.

I also appreciate the non academic staff- Mr. Friday Ozabor, Adeniyi Tijani, Azeez Ademosun, Ufot Ubong Nelson, Mrs. Josephine Ehirim, Mama Yemisi and the others who demonstrated surprising interest in the success of this programme.

What could I have been able to achieve without the limitless love, prayers and support of my family- my mother Lady Virginia Ebuzeme (Evidence of good living), husband Group Captain Eric Amobi (rtd), children Lilian Udodi and Denzel Amobi, in-law Squadron Leader (Dr.) Johnson Udodi and his most wonderful mother (my name sake) and siblings Princess Regina Okojie, Dr. Ngozi Okoye, Nkechi Onwuka, Vivian Saviour, Prince Charles Ebuzeme, Ebele Anigbogu and Prince Ekene Ebuzeme (Ebubedike Oba).

My mother- did nothing but pray for me night and day My husband never complained even when I was unable to perform my domestic duties, he always reaffirmed his understanding and enduring love. My daughter and best friend Lilian, who has always given me wise counsel and showed immense love and support. I couldn’t have asked for a better daughter. My ever caring son Denzel, who was always worried about my health and often cautioned me to reduce my work load, I say a big thank you. I also acknowledge the love of my friends, Becky Moore, Nkesse Eduok, Magistrate Violet Ogbe, Patsy Odigbo, Dr. Arafat Ifemeje, Barrister Beatrice Odiri, Justice Rita Pemu, Edna Kpagi, my brothers Professor Ritchard M’Bayo and Professor Innocent Okoye and others too many to mention. For four years, I was not there for them and even sometimes avoided their calls, but they showed me nothing but love and understanding- the mark of true friendship. I thank you for being there for me even when I was an absentee friend. May Almighty God bless and reward you all in Jesus name.

Ifeoma Amobi

ABSTRACT

Malaria disease remains a major health burden to the world; infecting 350-500 million people and killing over 1 million each year. Federal Ministry of Health (FMOH) Report identifies African countries as the worst hit, accounting for about 90% of the global deaths, with Nigeria representing one quarter of the continent’s malaria burden. Pregnant women and Children under the age of five mostly in Africa are the most vulnerable group. Over the past few decades, global interest in malaria disease has increased significantly and one of such is the Roll Back Malaria (RBM) Initiative, a global alliance to fight the malaria scourge. The major goal of the RBM was to reduce the malaria scourge by half, by 2010 and now 2013 and one of its four major strategies to realize this goal is the use of the Insecticide Treated Net (ITN) for malaria prevention and a target to get 80% of pregnant women and children under the age of five to sleep under the ITN daily. While results of several studies indicate that other African countries have made significant gains, recording as much as 50% ownership and 35% usage, Nigeria is reported to be lagging behind with ITN ownership in the South West put at 20% and 17% of pregnant women sleeping under the ITN daily. This study therefore investigated the receptivity of pregnant women in rural and urban Lagos State to communication messages on the adoption of ITN for malaria prevention. To this end, it examined the exposure of pregnant women to ITN messages, their major sources of ITN information, response to the messages and the extent to which social contexts influenced the responses. It reviewed the Individual Differences, Health Promotion and Education, Participatory Model, Behaviour Change Communication (BCC) theories as well as the Communication for Social Change theory, which was evaluated to determine the extent to which it explains the responses of the respondents to the ITN messages. The Triangulation approach, comprising survey, focus group discussion and in-depth interview methods was used for the study. The multistage, proportionate stratified, simple random and systematic sampling techniques were used to select one rural and four urban Local Government Areas, ten hospitals and five maternity homes and a total of 599 pregnant women for the study. Contrary to the reports about Nigeria’s slow progress, results show 93% awareness, 76% ownership, with 47% of the respondents sleeping daily under ITN. Exposure to ITN messages on television was as high as 88% and 76% of respondents chose the mass media with 65% identifying television as their major source of ITN information. Seventy seven percent of respondents said their decision to use ITNs was influenced by interpersonal networks, while no relationship was established between demographic factors and the adoption of ITN messages. Barriers to adoption included discomfort caused by heat, fear of the chemical

17 contained in the ITNs harming respondents’ unborn babies, skills required to put up and maintain the nets, mixed messages from the various sources of information as well as ignorance of the benefits of using ITNs. Among the recommendations offered is the inclusion of the communication element at the outset of the campaign planning, the stepping up of community dialogue, particularly in elite communities and the training and retraining of programme officers involved in social change projects, on interpersonal communication skills.

CHAPTER ONE

INTRODUCTION

Background to the study

Malaria disease remains a major health burden to the world; infecting 350-500 million people and killing over 1 million each year (Federal Ministry of Health (FMOH) Report, 2008). The havoc caused by malaria is no more in doubt as we see many people succumb to the disease year in year out in many parts of the globe. The FMOH report identifies African countries as the worst hit, accounting for about 90% of the global deaths, with Nigeria representing one quarter of the continent‘s malaria burden. Pregnant women and Children under the age of five mostly in Africa are the most vulnerable group. Bremann (2001) observe that in Nigeria, one in five of all childhood deaths are caused by malaria every year and the disease is also a major cause of prenatal mortality (cited in RBM Concept paper, 2003).

Similarly, the World Health Organization (WHO) and United Nation‘s Children‘s Education Fund (UNICEF) in their 2010 Joint report, identify malaria as the cause of 11% of maternal deaths every year, and this represents one in ten deaths of pregnant women. With 50% of the population facing a minimum of one case of malaria, and children under five years having as many as three or four episodes every year, about 11 million people are clinically diagnosed with the disease yearly (WHO/UNICEF Joint report, 2010). The 2005 FMOH World Malaria Annual Report also states that malaria is responsible for 60% outpatient visit to health facilities, while the Lagos State Ministry of Health, (2011 Report) puts the state‘s outpatient visit to secondary health facilities in Lagos State at 70%. FMOH (2005) also reports that 30% of childhood deaths are attributable to malaria, with 25% of them occurring in children under one year. Furthermore, 4,500 deaths occurring within the entire population are as a result of malaria infection, while 70% of pregnant women suffer from the disease yearly in Nigeria.

Table 1: Reported Malaria in Pregnancy cases in Lagos State

S/N Year RMiP NoD 1 2006 13,826 1 2 2007 15,536 Nil 3 2008 17,793 0

Terms: RMip= Reported Malaria in Pregnancy NoD = Number of deaths (Source: Lagos State Ministry of Health, 2011)

Malaria is widespread in tropical and subtropical regions, including parts of the Americas (22 countries), Asia, and Africa. Malaria transmission can be reduced by preventing mosquito bites through sleeping under Insecticide Treated Nets (ITNs), spraying insecticides inside houses and draining standing water where mosquitoes lay their eggs (FMOH, 2005).

Nigeria, Africa‘s most populated country with a population of 146,255,312 (National Population Commission, 2008), bears one quarter of the continent‘s malaria incidences, thus carrying more burden than any other country in the world. This may be attributed to the climate and topography of this West African country which support a prolific mosquito presence that transmits malaria unrelentingly throughout the year, leading to arguably the most virulent malaria environment on the planet (Chambers, 2009). Rated by UNICEF as still the number one killer of children in Nigeria, malaria also causes a strain on socioeconomic growth as funds meant for development are lost in man hours caused by absenteeism in schools and the work places and treatment of the disease. It is causing a mammoth economic and social burden on the country, thus perpetuating the cycle of poverty. For Nigeria the monetary cost adds up to N132 billion ($900 million) annually. Malaria, together with HIV/AIDS and Tuberculosis, is one of the major public health challenges undermining development in the poorest countries in the world and posing a grave barrier to the achievement of the Millennium Development Goals (MDGs) (UNICEF Report, 2010).

The FMOH (2000) study which has been rated as the most comprehensive study of the malaria situation conducted across the six geographical zones in Nigeria, demonstrates the degree of public health importance of the disease in Nigeria having confirmed that malaria is a major cause of morbidity and mortality especially among vulnerable groups, including pregnant women and children aged less than 5 years (FMOH, 2001). Results of the study show that apart from the North- Central and Northeast zones with 58.8% and 55.3% respectively, the Southwest has the highest malaria incidence with 36.6%. Others are the South-South with 32.7%, Southeast with 30.7% and Northwest with 33.6%. Malaria also accounted for 63% of the diseases reported in healthcare facilities across the six geographical zones. The prevalence of malaria among pregnant women was 48% and accounted for 11% of maternal deaths in the study areas (FMOH 2000; FMOH 2001).

National Governments and several International Donor Agencies, Civil Society and Non Governmental Organizations, Research Institutions, Professional Bodies, UN and Development Agencies including UNICEF, WHO, the United Nations Development Programme (UNDP), Development Banks, the Private Sector, the World Bank and the Media have embarked on various intervention/control programs in an attempt to eradicate the malaria menace. One of the latest and on-going campaigns is the Roll Back Malaria (RBM) initiative established in 1998 to halve the world‘s malaria burden by 2010 (FMOH, 2010). This global partnership with more than 500 organizations, including 50 malaria afflicted African countries, was founded in response to a growing concern by governments, particularly in Africa, about the rising cases of malaria related deaths and the recent successful efforts in malaria-affected countries to scale up action against malaria. Initiated by UNDP, WHO, UNICEF and the World Bank, its major goal is to work with governments, other development agencies, NGOs and private sector companies to reduce the human and socio-economic costs of malaria. The RBM alliance which is part of a broad societal action for health and human development is considered by African leaders as the main instrument through which they can achieve these goals. In April 2000, the Alliance in a summit held in Abuja Nigeria came out with a Declaration in which it set itself the initial target of halving the world‘s malaria by the end of 2010 and having at least 60% of pregnant women and children under five sleep under insecticide-treated nets (ITNs) to keep mosquitoes at bay among other strategies (RBM Concept Paper, 2003; FMOH, 2010).

In 2006 another summit was held in Abuja and the Abuja targets for 2010 were reviewed upwards. The new targets stated that by the year 2010, 80% of pregnant women will use ITNs. Again in September 2008, the RBM Partnership launched the Global Malaria Action Plan, which defines the steps required to accelerate achievement of the 2010 and 2015 targets for malaria control and elimination. This includes reaching all persons at risk for malaria with an insecticide-treated mosquito net (ITN) or indoor residual spraying (IRS) and providing laboratory-based diagnosis for all suspected cases of malaria and effective treatment of all confirmed cases (World Malaria Report, 2010). Although RBM supports efforts to tackle malaria wherever it occurs, it particularly supports Africa South of the Sahara which has 90% of the malaria burden and has identified pregnant women and young children as its main focus (RBM Concept Paper, 2003). Some of the RBM Abuja targets include:

 To reduce malaria mortality and morbidity by 50%  At least 60% of the population will have prompt access to appropriate and affordable treatment within 24 hours of symptom onset  At least 60% of all pregnant women will have access to chemoprophylaxis or to intermittent presumptive treatment (IPT) (FMOH, 2008)

The RBM Concept Paper (2003) notes that malaria in pregnancy reduces a woman‘s immunity to malaria, making her more susceptible to malaria infection and increasing the risk of illness, severe anemia and death, while for the unborn child, maternal malaria increases the risk of spontaneous abortion, stillbirth, premature delivery and low birth weight. The paper shows evidence that an estimated 30 million women per year become pregnant and that these women are at risk of Plasmodium Falciparum, the most deadly form of malaria, which medical experts have implicated as the major cause of serious illness for pregnant women. She also observes that Plasmodium Falciparum infection causes as many as 10,000 maternal deaths each year, contributes to approximately 2 to 5 per cent of maternal anemia, 8 – 14 per cent of low birth weight in infants and 3 – 8 per cent of all infant deaths (RBM Concept

Paper, 2003.

Tackling malaria in pregnancy contributes to three of the Millennium Development Goals (MDGs), namely:  Goal 4: reduce child mortality;  Goal 5: improve maternal health; and

 Goal 6: combat HIV/AIDS, malaria and other diseases. RBM‘s major objectives and strategies include the distribution of ITNs through campaigns, public health facilities, faith based organizations (FBOs) and non- governmental organizations. This is mostly implemented through stand alone campaigns and through integration with other interventions such as measles vaccination. The ITNs are given at subsidized rates and sometimes free of charge. Under the modified ITN Massive Promotion and Awareness Campaign (IMPAC), pregnant women attending antenatal clinics receive free ITNs at first attendance and children receive an ITN on completion of their third dose of the diphtheria, pertusis and tetanus vaccine (DPT3). This programme is implemented nationwide using routine health services and employing communication campaign approaches to create awareness about the innovation and bring about behavior change (RBM Concept Paper, 2003, National Population Commission (NDHS Survey, 2009). In collaboration with several World Organizations, the Nigerian government is taking measures to reduce the malaria scourge. But how effective have the measures been?

In spite of the numerous calls for the inclusion of insecticide spraying to eradicate mosquitoes, which have been successfully implemented in various parts of the world including the USA, the RBM Campaign favors and depends mostly on ITNs and early treatment with combination therapy. Scholars argue that in areas of Sub Saharan Africa with high levels of malaria transmission, regular use of ITNs can reduce mortality by as much as 30%, with significant impact on anemia (RBM Concept Paper, 2003). In agreement, Adebiyi (2011) notes that ITNs are the major tools for malaria control and in addition to other methods ITNs treated with IRS have been responsible for the elimination of malaria from many countries.

Adebiyi defines ITNs as mosquito nets treated with an insecticide that repels and kills mosquitoes, and doubles the efficacy of the untreated net in preventing malaria, from about 25% to 50%. ITNs were developed in the 1980s for malaria prevention and offer more than 70% protection compared with no net. They are dip- treated using a synthetic pyrethroid insecticide such as deltamethrin or permethrin which will double the protection over a non-treated net by killing and repelling mosquitoes (2011). ITNs protect people sleeping under the net and simultaneously kill mosquitoes that contact the net (FMOH, 2008).

Sleeping under ITNs has been shown to be an extremely effective method of malaria prevention, and also one of the most cost-effective methods. These nets can often be obtained for around N600 from the market and are often times distributed free by donor agencies such as UNICEF, the World Health Organization (WHO), governments and others using hospitals, health centers and other forums (WHO Report, 2010).

The WHO 2010 report observes that studies conducted throughout Africa have also provided evidence about the potency of Insecticide-treated nets (ITNs) in the prevention of malaria. They note that use of ITNs can reduce malaria cases by up to 50%. A notable example is the Kenya ITN efficacy trial conducted by the U.S. Centres for Disease Control and Prevention (CDC) which showed a 33% reduction in child mortality. The results were equally dramatic in pregnant women, with a 21% reduction in anaemia and 28% decrease in low birth weight in infants. The WHO 2010 report, also states that a total of 11 African countries have shown a greater than 50 per cent reduction in either confirmed malaria cases or malaria admissions and deaths over the past decade. The report also showed a decrease of more than 50 per cent in the number of confirmed cases of malaria found in 32 of the 56 malaria-endemic countries outside Africa between 2008 and 2010, while downward trends of 25 per cent – 50 per cent were seen in eight additional countries. Similarly, the report also notes that in 2010, more African households (42%) owned at least one ITN, and more children under five years of age were using an ITN (35%) compared to previous years. Household ITN ownership reached more than 50% in 19 African countries. In 2009, the WHO European Region reported no cases of plasmodium falciparum malaria for the first time and Morocco and Turkmenistan were also certified by the Director-General of WHO in the same year as having eliminated malaria (WHO, 2010).

In spite of these efforts and the gains recorded by several African countries, findings of the 2008 demographic and health surveys conducted by the National Population Commission and the Federal Ministry of Health report, reveal that the malaria situation is not recording the expected improvement in Nigeria. They show that only 8% of households in the country own at least one insecticide treated nets, 5% of the owners sleep under the nets, and the South West records the lowest usage rate (NDHS, 2009; FMOH, 2008). Similarly, results of the

NDHS study show that only 5% of pregnant women slept under an ITN and that pregnant women in rural areas are more likely to sleep under an ITN than their urban counterparts. Even the results of the latest Nigeria Malaria Indicator 2010 Survey (NMIS) put ITN ownership in the South Western states of Nigeria at 20%, while 17% of pregnant women nationwide slept under the ITN the night before the survey (NMCP, 2011).

Other results also show that the percentage of pregnant women who slept under any nets generally decreased with increasing level of education and income, while the opposite is seen with the use of ITN. Reasons for these are however not stated.

TABLE 2: ITN COVERAGE FROM NATIONALLY REPRESENTATIVE HOUSEHOLD SURVEYS, 2007-2009 % households % of % of % < 5 % of pregnant Type of with at least population population sleeping women sleeping survey one ITN potentially sleeping under under an under an ITN covered by an ITN ITN REGION/COUNTRY available ITNs AFRICAN REGION Angola, 2006-2007 28 15 12 17 22 MIS DR Congo, 2007 9 4 5 6 7 DHS Equatorial Guinea, 2008 64 National Ghana, 2008 33 24 17 28 20 DHS Gabon, 2008 70 National Kenya, 2008-2009 56 50 36 46 48 DHS Liberia, 2009 47 26 22 26 32 MIS Madagascar, 2008-2009 57 36 37 45 46 DHS Mali, 2008 82 79 National Mozambique, 2007 16 7 MIS Namibia, 2006-2007 22 15 6 10 9 DHS Nigeria, 2008 8 5 4 5 5 DHS Rwanda, 2007-2008 57 41 41 56 60 DHS Sao Tome and Principe, 2007 78 54 National Senegal, 2008-2009 66 40 28 29 29 MIS Sierra Leone, 2008 59 56 DHS Swaziland, 2007 4 2 0 1 1 DHS Togo, 2008 55 35 MOH- CDC Uganda, 2009 47 32 33 77 MIS UR Tanzania, 2008 39 25 AIS/MIS Zambia, 2008 62 41 43 MIS Weighted average 28 13 9 19 12 SOUTH-EAST ASIAN REGION Indonesia, 2007 3 2 2 4 3 DHS

Source: WHO Malaria World Report, 2010

Concerned health watchers, health experts and scholars have warned that if the situation is not remedied speedily, the targets to reduce the incidence of malaria in pregnancy will not be met and the complications caused by this old ailment will continue to wreak

25 havoc on our women and their unborn babies. For example, Choi, (1995) asserts that the prevalence of malaria in Nigeria is due to behavioral and non – behavioral factors, identifying the psychographic or behavioral factors that pose obstacles to the success of these interventions as socio – cultural, economic and political. This argument appears to be supported by the practice in Nigeria, where in spite of the free distribution of ITNs by several member bodies of the Roll Back Malaria Alliance, including Society for Family Health, Nothing But Nets, WHO, UNICEF, British Airways and the on-going distribution of 63 million ITNs by Nigerian government and other RBM partners majority of Nigerians demonstrate poor perception and prevention seeking behaviour as they prefer to buy and burn mosquito coils, than to sleep under free ITNs (RBM, 2010) thus rendering the RBM efforts unsuccessful with target communities. Heggenhougen, Hackenthal & Vivek (2003) however tie some of the behaviours to limited knowledge about causes and prevention of malaria as well as misperceptions of the disease which can inhibit prevention and treatment actions.

Chester, (2010), examining the environmental factors contributory to malaria infection, notes that the unhygienic conditions in which many citizens live, e.g. the pervasiveness of wreckage and wild grass, poor drainage systems which collect stagnant rain water all create breeding grounds for the mosquito vector to thrive near homes, and the more mosquitoes are allowed to breed, the easier it is for people to acquire the malaria parasite. He contends that the poor are often more afflicted with this disease as they live in malaria-prone rural areas and poorly constructed dwellings that offer few, if any barriers against malaria. He notes that even the higher Socioeconomic Status (SES) families who live in better constructed houses with barriers such as window nets and better drainages, still resort to spraying their homes with insecticides regularly, but the mosquitoes defy this strategy as the malaria scourge continues to be on the increase.

Some of these behaviours promote mosquito breeding and mosquitoes‘ access to particularly the at risk populations who fail to use innovations such as ITNs, residual spraying and artemisinin based drugs proven to be effective for the treatment, control and prevention of malaria promptly and appropriately. Apart from the lack of interest, tales of those who had bad experiences with the nets are enough to discourage others from using ITNs.

Nwenesi (2008), notes that although children and pregnant women are at the highest risk of malaria, men may use nets instead of the most vulnerable groups. He also points out the seasonal use of ITNs (i.e. use of ITN only when mosquito density is perceived to be high) as a barrier to achieving the RBM goals. Furthermore, Choi (1995) notes that the relatively wealthy urban households are more likely to own bed nets than rural and poor households, where people are at a higher risk of malaria as most people struggle to buy even subsidized bed nets.

In spite of the foregoing arguments, Oaks et al., observe that while human behaviour and social organization are vital determinants of the success of malaria control programs, enough is not known about how humans respond to malaria messages to be able to build strong multidisciplinary control programmes (cited in Nwenesi, 2008).

The questions therefore are: Are pregnant women exposed to the messages on the adoption of ITNs? If they are, are they adopting or rejecting these messages and what are the factors responsible for their responses? In spite of all the submissions by various stakeholders, answers to these questions are not readily known as very few empirical studies if any have focused on them. And although, the RBM Concept Paper (2003) states that health behavior change can best be achieved through communication, the RBM Partnership has only focused attention on resource mobilization, policy change, research and health system strengthening. It argues that using communication strategies, awareness can be increased and the right attitudes and behaviors created, thus propelling countries closer to the Abuja targets.

The use of communications strategies would be to create awareness about ITNs and their efficacy, and increase demand and consumer willingness to pay for ITNs and retreatment kits by: 1) increasing awareness among pregnant women that ITNs are the most effective protection from malaria, 2) increasing knowledge about the importance of treating nets with insecticide and 3) increasing consumer awareness about which household members are most vulnerable to malaria (pregnant women and children under five years) so that they are given preferential access to nets.

Gramiccia (1981), argues that the past failures of health education in malaria control is still applicable today as the method of education is not well adapted to local conditions.

In support, Mwenesi (2008) while noting the importance of communication in health intervention programmes argues that communication for behaviour has not received enough attention. She observes that while most intervention programmes include an information, education and communication component, the approach is not systematic and usually reduced to the production of posters and brochures or specific instructions regarding how to hang a net.

Report after report continues to place the solution to this problem at the doorstep of effective communication, insisting that the disease is best managed in the context of awareness. The most important factor regarding the prevention of the transmission of any disease is awareness, (WHO, 2003) and this is of paramount importance, especially in the case of malaria which is claiming lives by the millions across the globe (FMOH, 2001). In order to combat the constant threat of malaria, people will have to develop and sustain the right attitude and this can only be achieved through information and education.

Awareness however does not necessarily translate to behaviour change or the adoption of an innovation as getting pregnant women to sleep under ITNs appears to be posing a major challenge in Nigeria. As Klein posits ―There is an accumulation of knowledge now that says you have to go beyond awareness in order to make real change.‖ On their part, Heggehougen, et al (2003) view the ―micro-climate that influences decision making as being more important and should consequently be considered at programming and operational stages. Supporting this notion, Espino (1997) asserts that any communication around malaria needs to engage sensitivity with the entirety of local culture and beliefs.

The Communication For Social Change (CFSC) theory assumes that in developing societies such as Nigeria, health behaviour change is an outcome of dialogue and community action and must therefore take into account the social contexts of the people. It also recognizes these social factors as influencing the decisions to adopt or reject the recommended behaviour in a communication message. These assumptions have been supported by other scholars who have also noted that social contextual factors such as socioeconomic class, educational levels, social ties, social norms, beliefs, as are identified by the CFSC are important for the success of health campaigns (Ribera et al; RBM Concept paper, 2003).

Among the key issues that spurred the researcher’s interest to embark on this study are the following: 1. In spite of the fact that Nigeria records the highest incidence of malaria in the world, Nigerians have poor perception and prevention seeking behaviour to the disease. 2. The Southwest is one of the three zones in Nigeria with the highest malaria cases with Lagos State recording the highest number of hospital outpatient visits 3. In addition to the fact that pregnant women make up one of the two most susceptible groups to this disease, they also double as the major caregivers of under-5 children who constitute the second most vulnerable group. 4. In spite of the reported successes recorded in other African countries by the Roll Back Malaria (RBM) Campaign to control the malaria scourge in Africa, Nigeria has been unable to make tangible advancements towards the targets

Statement of the problem Of the 350- 500 million annual malaria cases worldwide, 90% of them are in Africa. Nigeria, with over 110 million clinically diagnosed cases yearly, bears one quarter of the Africa burden, making it the country with the highest malaria incidence in the world (RBM Concept paper, 2003; FMOH, 2008; NMCP, 2010). Results of several studies on the malaria situation in Nigeria confirm that it is a major cause of morbidity and mortality especially among vulnerable groups which comprise pregnant women and children under the age five. It is also said to be responsible for 11% of maternal deaths in the country (FMOH, 2010; WHO, 2010; UNICEF, 2010, NDHS, 2009). Results of the last study conducted in 2008, indicate that in Lagos State, malaria is responsible for 70% of outpatient visits to secondary hospitals (Lagos State Ministry of Health, 2011). The disease is also known to cost Nigeria about 132 billion Naira annually through loss of man hours from absenteeism in schools and places of work, and cost of treatment of the disease (FMOH & NDHS, 2009). Several Development Agencies and National Governments have developed an alliance and embarked on a campaign tagged ―The Roll Back Malaria Initiative‖ with the sole aim of halving malaria occurrence by the year 2010. The RBM considers prevention to be the best option and among its four major strategies is the promotion of the use of ITNs as a preventive method against the malaria scourge. One of its major targets is getting 80% of pregnant women to sleep under ITNs by the year 2010 and now 2013 (RBM Concept paper, 2003).

In spite of the RBM efforts, only 5- 17% of pregnant women in Nigeria were reported to be sleeping under ITNs (NMCP, 2011; FMOH, 2010; WHO, 2010; UNICEF, 2010, NDHS, 2009), whereas, several African countries have recorded gains towards realizing the set 2010 targets with usage of ITNs increasing to as much as 50% in 19 African countries, and Morocco and Turkmenistan recording total eradication,

Although reasons for this situation are unclear, scholars criticize the earlier behaviour change theories for their failures to bring about desired health behaviour change in the developing world. They argue that their individual based, linear and top-down communication approach can only result in individual and not social change (Figueroa and Kincaid, 2002; Obono, 2011) and that social change is needed for sustained behaviour change. Furthermore, Figueroa and Kincaid (2002), in their Communication for Social Change (CFSC) Theory argue that any health intervention programme which does not take into account the social contextual factors of the people, is bound to fail, particularly in developing nations like Nigeria where decision making about health issues is community driven. They identify community dialogue, collective action and social change as major determinants of positive behaviour change. These assumptions gain support in the allusions to socioeconomic class, social ties, norms, and beliefs, as important factors for the success of health campaigns (Ribera et al, 2007; RBM Concept paper, 2003).

Today, the RBM campaign in Nigeria has been designed with the CFSC as theoretical underpinnings. As part of a strategic campaign plan to promote sleeping under ITN, the RBM uses multipronged approaches which involve the use of media efforts such as news and public service announcements to increase awareness and support for the use of ITN and also gain the cooperation of media organizations for sustained coverage and solutions; creative formats such as entertainment education formats using dramas, puppet shows, community theatre, songs and dance, and other interpersonal outreach programmes which include community message boards and boxes. It also uses platforms such as antenatal clinics and health centers to reach pregnant women, distribute ITNs and educate them about the benefits of sleeping under the ITN (World Malaria Day, 2010; UNICEF workshop, Kaduna, May, 2011; Interview held on 5th August, 2011 with Deputy Director, Federal Ministry of Health; Interview held on 2nd May, 2011 with UNICEF Communications Officer, Lagos).

Similarly, the Lagos State Government has established technical working groups and other stakeholders to distribute ITNs to pregnant women and to strengthen effective communication, information, education and communication (IEC) materials are produced and disseminated, educative dramas and playlets have been presented in more than 770 communities in Nigeria; public service announcements (PSAs) are aired on radio and TV; Billboards are erected in strategic locations and World Malaria Day is celebrated annually (RBM Update, 2011). In addition it holds sensitization and advocacy seminars for heads of public health facilities on the current anti-malaria treatment guideline and policy as well as community mobilization and awareness programmes in communities in the State through the distribution of Information handbook and posters on malaria (Lagos State Ministry of Health, 2011)

Additionally, various scholars contend that social mobilization, advocacy, and changing individual and house hold behaviour, all rely on communication to achieve their goals (FMOH, 2010; Ribera et al, 2007; RBM Concept paper, 2003; Figueroa and Kincaid, 2002). However, extant literature search carried out by the researcher in this study reveals a gap in ITN communication research particularly in the area of communication for behaviour change. Most empirical studies reviewed were found largely to focus on assessing malaria incidences, distribution, ownership, knowledge, attitudes and usage and not on message exposure, sources of ITN information, responses to the messages and reasons for such responses. This agrees with the views of Ribera et al (2007), that although intervention studies mention use of health care services by vulnerable groups, there is a large absence of behavioural and social science research which goes beyond simplistic knowledge, attitudes and practices (KAP) studies.

In addition, contrary to the reports by WHO, UNICEF, FMOH, NDHS among others that ITN ownership and usage are low in Nigeria, in the course of this study, the researcher witnessed the free distribution of ITNs to pregnant women at the NAF Hospitals Ikeja and Shasha, as well as at 41 Road, G Close, House 26, Festac town in Lagos on the 1st of September, 2011, which was part of the ongoing house to house distribution in Lagos State. These realities further questioned the reports, thus underscoring the need for this study.

OBJECTIVES OF THE STUDY The general objective of this study was to investigate the responses of pregnant women in Lagos State to communication campaign messages on the adoption of ITNs and the extent to which Kincaid and Figueroa‘s Communication for Social Change (CFSC) theory explains those responses. In this regard, the study had the following specific objectives: 1. To ascertain the exposure of pregnant women in the study locations to communication campaign messages on the adoption of ITNs 2. To identify major sources of ITN information for the sampled pregnant respondents 3. To ascertain the knowledge and attitudinal dispositions of pregnant women in the study areas to malaria and the use of ITN 4. To establish the patterns of receptivity to messages on the adoption of ITNs among pregnant women in the study locations 5. To determine the extent to which social contexts influence the responses of sampled pregnant women to communication campaign messages on the adoption of ITNs 6. To identify the barriers responsible for the rejection of communication campaign messages on the adoption of ITNs

RESEARCH QUESTIONS In light of the stated objectives, the study sought to answer the following research questions: 1. To what extent are pregnant women in the study areas exposed to communication campaign messages on the adoption of ITNs? 2. What are the major sources (channels/media) of ITN information for pregnant women in the study locations? 3. What are the attitudinal dispositions of the sampled pregnant respondents to malaria and use of ITN? 4. What are the receptivity patterns of the sampled pregnant women to the communication campaign messages on the adoption of ITNs? 5. Do social contexts influence the receptivity of pregnant respondents to communication messages on the adoption of ITNs? 6. Are there barriers to the receptivity of pregnant respondents to communication messages on the adoption of ITNs?

Significance of the study The importance of this study lies in the several world reports, rating Nigeria as the country with the highest incidence of malaria in the world and constituting a major cause of morbidity and mortality in the country, accounting for 63% of the diseases reported in healthcare facilities across the country and 70% in Lagos State. With pregnant women and children aged less than 5 years as the most vulnerable group, the disease accounts for 11% of maternal deaths and 1 in 5 of childhood deaths. It also carries with it economic and social burden, costing Nigeria a whopping 132 billion naira yearly from cost of treatment and loss of man hours (UNICEF, 2010; FMOH. 2010), thus calling for investigation.

Considering the unique role of women in the domestic and economic sectors, as home makers and stabilizers, care givers, bread winners, vessels of procreation and, indeed, nation builders, a threat to this important group invariably constitutes a threat to children born and yet unborn and consequently generates grave concern for all stakeholders, of which solution can only be addressed through inquiries such as this.

Available literature also suggests that this may be one of the very few empirical studies to offer a comprehensive examination of the exposure, sources of information and responses of this group to communication campaign messages on the adoption of ITNs for the prevention of malaria. This study is aimed, therefore, at producing useful data on the exposure, the major sources of health and ITN information, and the responses of pregnant women in rural and urban Lagos. Similarly, it is aimed at throwing more light on the factors influencing their acceptance and barriers responsible for rejection of the communication campaign messages on the adoption of ITNs.

An understanding of these factors will aid the various Development and Donor Agencies and National Governments, particularly the Federal Government of Nigeria, in the RBM and other alliances by providing useful data and evidence for decision-making and programme planning, reinforcing or re-adjusting of on-going and future strong multidisciplinary control programmes/campaigns. Results will also help other health communication interventions and generally the growing scholarly research and literature field of Communication for development may benefit from its findings.

One of the key impacts of this study is the opportunity it offers the researcher to empirically test the assumptions of Figueroa and Kincaid‘s Communication for Social Change theory (CFSC) and its applicability to a largely metropolitan area in a developing nation. Since the birth of communication as an independent discipline, several scholars have conducted inquiries into the effects of communication at the individual, group and societal levels and have postulated several theories to explain the various kinds of effects or communication behaviour. The most recent of these theories known to the researcher is the CFSC Model. This Model which is still developing and appears not to have been empirically tested (at least not to the researcher‘s knowledge) offers a unique opportunity to the researcher to test its appropriateness and efficacy in explaining and predicting health behaviour change in the developing world.

Generally, it is the hope of the researcher that the study fills the apparent gap in the literature available in the area of malaria/ITN communication as its findings are expected to lead to a better appreciation of the importance of communication as an indispensible element in the planning and execution of development programmes and campaigns.

Research scope This study obtained data on the responses of 529 pregnant women drawn from five local government areas (four urban and one rural) in Lagos State to RBM communication messages on the adoption of ITNs. It examined their exposure to the communication messages and the effects of messages which are reflected in their responses or behaviours. Testing the applicability of the CFSC theory, it also examined their socio- demographic contexts. Furthermore, their social or interpersonal ties, socioeconomic status, educational levels and income levels, cultural beliefs and traditional practices as well as their values and orientations and to what extent these factors shaped their responses to the messages. Data were collected through the use of questionnaire administered to 549 pregnant women in five LGAs in Lagos State. Additional data were collected through Focus Group discussions held with 52 pregnant women in the same study locations and interviews conducted with communication representatives of four members of the RBM Alliance, and health practitioners at three of the health facilities in the study areas. These included the Communication Officer at UNICEF, Lagos, the Deputy Director of Communication at the RBM Secretariat, Federal Ministry of Health Abuja, all of who are members of the RBM Committee in Nigeria, the Chief Medical

Officer of the Air Force Hospital, Shasha and the Matron of the 445 NAF Hospital, Shasha.

OPERATIONAL DEFINITION OF TERMS A number of terms used in this study are operationally defined:

Communication - Communication in this study refers to the sending of information on the adoption and use of ITNs from the various campaign sponsors, healthcare workers/opinion leaders and or change agents to pregnant women through mediums such as the mass media and interpersonal channels.

Social change –is defined here as any significant alteration over time in social behaviour patterns and cultural values and norms, for example the adoption of ITN as a common method for malaria prevention in society.

Receptivity/Response- in this study, means the patterns of exposure and response (adoption or rejection) to ITN messages by pregnant respondents.

Adoption - Adoption refers to pregnant women‘s acceptance, approval, agreement to and implementation of the communication messages on the adoption of ITNs for malaria prevention. This is demonstrated by ownership, sleeping daily, occasionally, and rarely under ITNs.

Messages - Message means all the transmitted information between the mass media, interpersonal networks such as health care professionals/change agents, peers, family and friends, and the pregnant women in the study locations, intentionally or unintentionally meant to create awareness and bring about the adoption of ITNs.

Receiver -The receiver is the audience and is the individual or group to whom the message is targeted. It is also the destination or decoder without which there is no communication. Here, the receiver refers to pregnant women in Urban and Rural Lagos.

Health Communication Campaign- Health communication campaigns are those campaigns that use a coordinated set of media, interpersonal and/or community-based

35 communication based activities such as RBM, to influence pregnant women to change behavior towards desirable health outcomes and which in this study are usage of ITNs.

Psychographic variables - In this study psychographic variables refer to any attribute relating to attitudes, values, culture, opinions and beliefs that may or may not influence the decision of pregnant women in the study location to adopt ITNs.

Social contextual factors- in this study, refer to interpersonal variables such as social networks, roles/responsibilities, social norms, organizational factors e.g., health care, and neighborhood/community factors. It also includes socio-demographic variables such as age, sex, socioeconomic status, ethnicity and educational attainment.

Belief - Belief in this study refers to the psychological state in which an individual holds a proposition or premise to be true. This proposition may have been formed through the internalizing of the beliefs of the people around them during childhood or adopting the beliefs of a friend, charismatic leader or repetition of strong positive emotions.

Social network - here refers to a social structure made up of individuals, who are tied or connected by one or more specific types of interdependency such as friendship, kinship, common interest, financial exchange, dislike, or relationships of beliefs, knowledge or prestige.

Interpersonal networks- When the sources of the communication messages, and members of one‘s social networks speaks to or engages in dialogue with members of the target audience, then interpersonal communication has taken place.

Socioeconomic Status - Socioeconomic status (SES) in this study denotes a combination of factors including income, level of education, and occupation. It is a way of looking at how individuals or families fit into society using economic and social measures that have been shown to impact their health and well being.

Cultural Factors - Cultural factors in this study refer to ethnic, customs, religion, health and dietary factors which may influence the responses of pregnant women towards the communication campaign messages on the adoption of ITNs for malaria prevention.

Knowledge - In this study, knowledge refers to the awareness or familiarity of pregnant women, acquired through the mass media or interpersonal sources about malaria and the communication campaign messages on the adoption of ITNs for malaria prevention. ITN and Malaria knowledge here is based on a composite index comprising the causes, symptoms, and prevention of malaria and the benefits of ITN.

Attitudinal disposition - In this study, attitude refers to the outlook, perception and degree of agreement or disagreement with the messages on the adoption of ITNs by pregnant respondents.

Behaviour- In this study, behavior refers to the adoption of the messages on the use of ITNs by pregnant women in urban and rural Lagos for the prevention of malaria. This includes ownership of and sleeping under ITNs.

Rural - In this study a rural community is referred to as a small community or town with low population, lots of farms and without the basic social infrastructure such as portable water, good feeder roads, equipped hospitals, electricity, sanitation facilities, communications networks such as GSM phones, Internet access, public transportation and street or traffic lights. Its dwellers have low quality of life, are mostly poor and illiterate with low purchasing power, without government security apparatuses. At best their health facilities are dispensaries and security local vigilante.

Urban - Urban communities in this study refer to those communities, with high population, functional primary, secondary and tertiary productive activities. They have basic physical infrastructure– such as roads, water, electrification, storage and processing facilities; social infrastructure –namely, health and educational facilities, community centres, fire and security services; institutional infrastructure which include credit and financial institutions, law and order, modern communications technologies such as Internet, GSM phones, larger Mass media penetration and agricultural research facilities. They are often congested and consequently suffer from traffic jams.

Exposure - This is the intensity and frequency of contact, experience or usage of mass media or interpersonal networks by pregnant women for sourcing information or messages on the adoption of ITN for the prevention of malaria.

REFERENCES

Adebiyi, E. (2011). Code malaria: Eradication developments for the decade, An Inaugural

lecture series, vol. 1(1), delivered at Covenant University, Ota, Nigeria in March,

2011.

Ajala, V. O. (2009). Scholarly writing guide for researchers. Ibadan: Maybest Publishers

Akinfeleye, R. A. (2008). Social marketing paradigm: Message design theory and diffusion

for social mobilization. In R. A. Akinfeleye (Ed.), Health and behavior change

communication for development, pp.124- 134. Lagos: Integrity Press Limited.

Federal Ministry of Health. (2010). National malaria control programme: Advocacy,

communication, and social mobilization strategic framework and implementation

plan. Abuja: Federal Ministry of Health

Federal Ministry of Health. (2010). National malaria and vector control programme.

Guidelines for the implementation of indoor residual spraying for malaria vector

control in Nigeria. Abuja: Federal Ministry of Health

Federal Ministry of Health. (2010). National policy on malaria diagnosis and treatment

Abuja: Federal Ministry of Health

Federal Ministry of Health. (2010). World malaria day: “Counting malaria out” “Count me in”. Abuja: Roll Back Malaria

Figueroa, M. E., Kincaid, D. L., Rani, M. & Lewis, G. (2002). Communication for social

change: An integrated model for measuring the process and its outcomes. In Brian

Bryd (Ed.). Communication for social change: Working paper series one. New York,

New York: The Rockefeller Foundation

Lagos State indicator (December, 2009). Unveiling the Lagos State public works

corporation: 1000 days. Lagos: Ministry of Information

Makemba, A. M., Winch, P. .J., Kamazima, S. R., Makame, V. R., Sengo, F., Lubega, P. B.,

Minjas. J. N. and Shiff C J (1995). Community-based sale, distribution and

insecticide impregnation of mosquito nets in Bagamoyo District, Tanzania. Health

Policy and Planning 10 (1), pp. 50-59

National Population Commission (2010). Nigeria malaria indicator survey 2010:

Preliminary report. Abuja: National Malaria Control Programme

National Population Commission (2009). Nigeria 2008 demographic and health survey: Key

findings. Calverton, Maryland, USA: NPC and ICF Macro. Obono, K. (2011). From transmission to transaction: Toward network models for effective

health communication in Nigeria. Communication review. Lagos: Department of

Mass Communication, University of Lagos (In Press)

UNICEF. (2007). Interpersonal communication skills in the prevention of mother-to-child

transmission of HIV: A training manual for health workers. Abuja, Federal Ministry

of Health and UNICEF

World Health Organization (WHO), (1998). AIDS prevention and control: World summit of

ministers of health on programs for AIDS prevention, Oxford: Pergamon.

UNICEF. (2010). World malaria day 2010: Africa update. Abuja, Federal Ministry of Health and UNICEF

UNICEF. (2009). Malaria and children: Progress in intervention coverage. Abuja, Federal

Ministry of Health and UNICEF

World Health Organization. (2010). Nigeria: Country profile

Internet Sources

Chambers, R. (2009). Nigerian mosquito net deliveries protect millions from malaria

Retrieved July 31, 2010, from http://www.millenniumpromise.org/index.php/

2009/07/07/nigerian-mosquito-net-deliveries-protect-millions-from-malaria/

Chester, P. (2010). Malaria kills: Distributing 63 million bed nets in Nigeria with rapid sms.

Retrieved July 31, 2010, from http://www.mobileactive.org.

Choi, H. W. et al (1995). The effectiveness of insecticide impregnated bed nets in reducing

cases of malaria infection: a meta-analysis of published results. American Journal of

Tropical Medicine and Hygiene, pp. 377-382 Retrieved July 31, 2010, from

http://www.healthcomms.org

Espino, F. et al (1997). Perceptions of malaria in a low endemic area in the Philippines:

Transmission and prevention of disease. Journal of Acta Tropica, Vol. 63, pp. 221-

239. Retrieved June 19, 2011, from http://www.healthcomms.org

Federal Ministry of Health Nigeria. (2005). National Malaria Control Programme in

Nigeria. Retrieved June 19 2011 from http://www.who.int/countries /nga/areas/

malaria/nmcp_annual_report_2005.pdf

Federal Ministry of Health Nigeria (2008). A strategy for behaviour change communication

in the Roll Back Malaria Programme, Nigeria, Retrieved June 19 2011 from

http://nmcpnigeria.org/f/acsm/BCC

Grammicia, M. (1982). Studies on insecticide treated nets for malaria prevention. Retrieved

June 19 2011 from http://www.linkinghub.elsevier.com/retrieve /pii/

S0035920300900567

Heggenhougen, K., Hackenthal, V. & Vivek, P. (2003). Participatory communication in

malaria control: Why does it matter? Retrieved June 19, 2011, from

http://www.healthcomms.org

Hwang, J., Graves, P., Jima, D., Reithinger, R. and Kachur, S. (2007). Knowledge of malaria

and its association with malaria-related behaviors: Results from the malaria

indicator survey, Ethiopia. Retrieved January 27, 2011, from http://www.dx.

crossref.org

Lagos State Ministry of Health. (2011). Malaria control program. Retrieved September 28,

2011, from http://www.lsmoh.com/programme_info.php?programme_id=6

Mwenesi, H. A. (2008). Sociocultural and behavioural issues in the treatment and prevention

of malaria: Paper for the WHO/TDR scientific working group on malaria, Geneva,

Switzerland, 24–27 March 2003. Retrieved September 4, 2010, from

http://www.tropika.net/svc/review/030324-Malaria_4

Ribera, J. M., Hausmann- Muella, S., D‘Alessandro, U. & Grietens, K. P. (2007). Malaria in

pregnancy: What can social sciences contribute? Retrieved June 18, 2011, from

www.plosmedicine.org/article/info:doi/10.../journal.pmed.0040092

Roll back malaria factsheet. (2010). What is the roll back malaria (RBM) partnership?

http://www.malariafreefuture.org/resources/factsheets/RBMFactSheet.pdf Roll back malaria factsheet. (2010). Malaria control in Nigeria, 2008- 2010: A strategy for

behaviour change communication in the Roll Back Malaria Programme, Nigeria,

Retrieved June 19 2011 from http://nmcpnigeria.org/f/acsm/BCC

Roll back malaria factsheet. (2010). What is the roll back malaria (RBM) partnership?

http://www.malariafreefuture.org/resources/factsheets/RBMFactSheet.pdf Roll back malaria information sheet (2002). What is roll back malaria? Retrieved September 28, 2011, from https://apps.who.int/inf-fs/en/InformationSheet02.pdf

Roll Back Malaria concept paper, (2003) Retrieved October 8, 2010, from

http://www.rbm.who.int

RBM update (2011). The vision, the mission, the goal. Retrieved September 28, 2011, from

http://nmcpnigeria.org/f/ROLL%20BACK%20MALARIA%20IN%20NIGERIA-

update%20for%20HMH.pdf

UNICEF (2010) World malaria day: Africa update. Impact series no. 2. Retrieved September

28, 2011, from http://www.unicef.org/media/files/rbm-reportII-en.pdf

World Health Organization. (2010). World malaria report 2010, retrieved January 27, 2011,

from http://www.who.int/malaria/world_malaria_report_2010/en/index.html

World Health Organization. (2010). World malaria report 2010, retrieved January 27, 2011,

from http://www.who.int/malaria/publications/atoz/9789241564106/.../index.html

CHAPTER TWO

LITERATURE REVIEW AND THEORETICAL FRAMEWORK

Introduction

This section reviewed existing literature relevant to the present study and was done under the following sub-headings: Conceptual Review- Concepts related to the study are reviewed in this section. To this end, the dependent and independent variables are discussed as they relate to the research problem and these include: Dependent variable Receptivity- This is the major dependent variable and in this study means the reaction or feedback of the respondents to the ITN messages. Independent variables These include communication and communication messages, barriers to communication, health communication campaigns and the Roll Back Malaria Campaign.

Empirical studies; studies which focused on ITN use in developing countries as well as those with specific relevance to ITN use in Nigeria were reviewed in this section.

Theoretical framework - The Communication for Social Change formed the framework of analysis for this study and other supporting theories include the Individual Differences theory, Health promotion and education theory, Participatory Model and Behaviour Change Communication theories.

Conceptual Review The concept of Communication Communication is as old as society itself and is one of those everyday activities that are intertwined with all of human life so completely that we sometimes overlook its pervasiveness, importance and complexity. According to Wilson & Wilson (2001), ―Communication is mankind‘s most important single act. When improperly performed it turns friends into enemies and plunges nations into wars‖. Littlejohn and Foss (2008), note that scholars have made several attempts to define communication, but establishing

43 a single definition has proved impossible and may not be fruitful. Definitions of communication are as varied as the concept is complex.

Ogundowole (2007), observes that one of the early efforts of defining communication was made by I. A. Richards, an English literary critic, in 1928, who in his view sees communication as taking place when one mind so acts upon his environment that another mind is influenced, and in that other mind an experience occurs which is like the experience in the first mind and is caused in part by that experience. Similarly, Akinfeleye (2008), views communication as the process or the art of making things of common knowledge and this process must include a sender, code, a channel, a receiver and, of course, a feedback or a reaction.

Daramola (2001) sees communication as not only the exchange of news and messages, but also including all individual and collective activities embracing all transmission and sharing of ideas, facts and data. It is at the heart of all social intercourse, functioning as the motor and expression of social activity and civilization and maintains and animates life. He observes that communication creates a common pool of ideas, strengthens the feeling of togetherness through exchange of messages and translates thoughts into action, reflecting every emotion and need from the humblest task of human survival to supreme manifestations of creativity or destruction. Communication integrates knowledge, organization and power and runs as a thread linking the earliest memory of man to his noblest aspirations through constant striving for a better life.

In human culture and in the conduct of man‘s life and society, communication plays its most complex and distinctive role. At home, family members communicate with each other by talking, by gesture and by other means. In school students use many communication devices including instructions from teachers, and in hospitals, during antenatal visits doctors and nurses also communicate to pregnant women about the benefits of using the ITN. Communication is the life blood of society, from the Stone Age to the digital era; communication has proven to be indispensable. Lasswell‘s Model of Communication appears appropriate in explaining what happens when from the time the Roll Back Malaria campaign messages are disseminated to pregnant women to the feedback stage, which is demonstrated in their adoption or rejection of the messages.

Lasswell‘s Model of Communication Harold Lasswell, in his 1948 publication, ―The communication of ideas‖ created questions to explain the process of communication. The model simply comprises five key questions: Who Says what? In which channel To whom With what effect?

Figure 1: Lasswell's Linear Model of Communication

Watson, as cited in Uwakwe, (2010) posits that this is perhaps the best known model and arguably one of the most useful. It offers a very simple structure of analysis. Who are the communicators, what is the content or message of the communication. The channel comprises the means of communication, the technology and the mode or medium into which the message is encoded and transmitted. Whom is the audience, while one aim of the analysis is to gauge the nature of reception or response or feedback. He observes that communication occurs when a source sends a message, through a medium to a receiver, producing effect

(Buckalew and Wulfemeyer, 2005). His model is a narrative one that poses five questions and his channel component was that of technology; a technology defined mass communication with radio, television, film, newspapers, books, etc as channels.

Targeted at individual behaviour change, Lasswell‘s model can easily be used to explain the various stages of the RBM campaign. At the first stage it demonstrates what happens when the implementers of the RBM campaign (the Who) pass a persuasive message on ITN use (says what) to pregnant women (to whom) using platforms such as mass media and interpersonal networks (in which channel) and the pregnant women adopt or reject the message (with what effect) by either sleeping under ITN daily, occasionally, rarely or not at all. Encoded messages are carried by a medium or means of sending information. While sound waves are the medium that carries our voice in interpersonal communication, in mass communication, the medium is technology such as radio, television, film, newspaper, magazine, books, and now the internet.

Adapted to this study, Who stands for RBM partners, comprising the media, international development agencies, government and healthcare workers; says what stands for the communication campaign messages on the adoption of ITNs for malaria prevention; the channel stands for the mass media and other forms of interpersonal communication channels; whom stands for pregnant women in rural and urban Lagos and; with what effect stands for pregnant women‘s response to the messages. This model however assumes that pregnant women are passive and would respond to the messages in the manner expected by the encoder/sender.

It was however De Fleur who first depicted his conceptualization of communication as a cyclical process, underscoring the interchangeability of the source, encoder and receiver or decoder roles. He also recognized that noise can emanate from any of the elements and interfere with the communication process (Folarin, 2002).

Baran (2010), in defining communication builds on Lasswell‘s model, arguing that since the receiver/audience is active, a response is required and the act of feedback transforms the receiver to a sender and the sender to a receiver. He thus defines communication as the process of creating shared meaning. Osgood and Schramm developed a graphic way to represent the reciprocal nature of communication, depicting interpersonal communication, between two or a few people, with no clearly identifiable source or receiver or feedback. Thus, although pregnant women are the target audience of the

46 persuasive messages, they in turn become message senders themselves when they pass on the messages to others or when they initiate a dialogue with friends, neighbours and colleagues or the original senders of the messages such as during call-in programmes on radio and television, or response during the interactive health education sessions held during antenatal visits or community dialogues.

UNICEF (2007) describes communication as vital to human existence, relationships and interactions and an invaluable tool to health workers in gaining compliance from clients. It argues that when combined with strategies for the development of appropriate skills and capacities, and the provision of an enabling environment, communication plays a central role in positive behaviour development, behaviour change and the empowerment of individuals and groups.

Elements in the communication process

The Source This is the initiator in the communication process and can be individuals, groups or organizations. According to Nwuneli (1983), the source in indigenous media of communication can be any of the following; Emirs, Chiefs, Obas, Igwes, Elders and other authorities. As shown in this study, they can be the media, governments, donor agencies, and health care providers as in the case of the initiators of the Roll Back Malaria program and even the target audience when pregnant women become the initiators of the messages.

Channels

Uwakwe (2010) refer to channels as the medium through which messages travel to the receiver. For instance light waves carry visual images; sound waves carry spoken words; touch carries Braille messages; electromagnetic radiation carry radio signals until they are transformed by receiving sets into sound waves that travel through air; the newspaper, books, magazines, posters and billboards are channels and so are audio-visual media such as television, cable and satellite radio, sound recording and video recording. The CD-ROMs and the Internet are also channels of communication. The nature of the channel determines the

47 nature of the message. All the channels listed above are used to communicate messages on the adoption of ITNs to pregnant women in rural and urban Lagos.

Message

Watson views message as what an act of communication is about, or that which is deliberately conveyed by the encoder to the decoder. Messages might be information, entertainment, or persuasion; they might be verbal or visual, intentional or unintentional. In fact they might have a different meaning to the people sending them than to those receiving them. Bittner (2003) notes that a message originates with an idea, which then must be encoded into symbols that will be used to express that idea.

He observes that the source uses symbols in form of words, pictures or objects to elicit meaning in the mind of the receiver of the message (Bittner, 2003). Words and pictures are the most common symbols used in communication. Words attempt to describe an object or a concept, while pictures actually show a representation of the object or idea. Selecting symbols for an idea or an object is a very important step in the communication process because poorly selected symbols will result in a confusing or misunderstood message. Care must be taken therefore to choose symbols that will elicit the response or reaction from the receiver that is similar to that intended by the source or sender.

When communicators select symbols for their messages, they must keep in mind that each person has a different frame of reference or field of experience and as a result certain symbols may mean different things to different people. Each experience in people‘s lives leaves some sort of impression on them and they draw on these experiences to give meaning and interpretation to symbols. For example, a person who is a frequent sufferer of malaria is more likely to respond to messages on the use of ITNs than an infrequent sufferer.

In agreement with the CFSC theory (2002), Akinfeleye (2008) argues that for modification of attitude and behaviour, an effective communication mechanism called ―message design‖ which takes into account the environment in which one wants to mobilize for a course of action and which includes the cultural peculiarities and particularities of the target audience must be present and articulated before there can be any useful and balanced mobilization. The RBM messages have been designed to suit the various target audiences in Nigeria and examples of some of them are found in appendix 3 and 4 (Billboard and audio message).

The Receiver/Audience

The receiver is the audience and is the individual or group to whom the message is targeted. The receiver is sometimes referred to as the destination or decoder and without the receiver, there is no communication process. Decoding refers to the activities the individuals undergo in interpreting the messages into meaning. Sometimes, due to a number of reasons including the sophistication of the decoder, message empathy, attentiveness, and others, the receiver is unable to decode the message.

There is often concern about the effects of mass media on our lives, be it the impact of editorials on the election process, influence of televised violence on children or the influence of dramatized representation of sex on adolescents.

All of these have entered the discussions of legislators, parents – teachers associations, health care providers and academicians and the result is the realization that audiences are not passive receptors of media messages, but active participants in the construction of meaning (Croteau & Hoynes, 2000)

Audience Demographics

It is generally believed that the characteristics of the audience and the community or the socio-cultural system in which a medium operates are paramount in every communication process. With a mass audience it is often difficult to find segments of the population to which media messages are directed. For instance, a successful advertising campaign must first select the relevant target audience. As a result media buyers must rely on demographics to categorize the population. Demographic characteristics are the basic statistical data on such things as age, sex, education level, income, and ethnic background. Demographics are used more often than any other method to pinpoint a specialized audience (Bittner, 2003).

Audiences are both product of social contexts and a response to particular pattern of media provision. Often they both exist at the same time e.g. when a medium sets out to reach members of a social category or residents of a certain area. Media use also reflects broader patterns of time use, availability lifestyle and everyday routine.

Ansu-Kyeremeh (2005) argues that since cultures differ in the ways in which social relations are conducted (in terms of communication symbols and patterns), then one expects different outcomes from the impact of different media with different characteristics. In such

49 circumstances, audience characteristics, including their socio-economic and cultural milieu, may prove crucial in choosing the appropriate media for communication in especially the rural African environment. For these reasons, the attributes and characteristics of communication systems are examined in the context of the social interactive patterns, including their group and individual dimensions. In response to cultural and social differences, the RBM uses multi-method approach to reach different audiences.

Audience types can therefore be viewed in different and overlapping ways, by place – as in the case of local media; by people – as when a medium is characterized by an appeal to a certain age group, gender, political belief or income category; by the particular type of medium or channel involved – technology and organizations combined, by the content of its messages – genres, subject matter, styles; time – (McQuail, 2005). For example, pregnant women can be classified by people as audience type or category and messages designed to appeal and persuade taking cognizance of their peculiar and special needs. One such message is included in appendix 5 (Video message).

However, Ferguson, (1999) indicates that audience response to information or persuasion strategies depends on their beliefs, and opinions with studies of perception indicating that audiences are more likely to attend to and recall information that fits well with their existing belief systems.

Proof of how and to what extent audience makes use of media is hard to pin down, but basically researchers are in the business of analyzing audience use and response with a view to measuring the power of media. They want to find out if the media have the power to shape, modify, or alter people‘s attitudes, and behaviours, if they think people‘s ways of thinking; create consensus among audiences; stir in them alarm; make them more anxious and more security minded. And to what extent are they agents of change?

Feedback

This is an observable response or reaction from the receiver or audience to the sender of the message. Feedback reverses the flow of communication and creates a kind of new source. Feedback reveals the status of the communication, depicting whether the process was successful or not, continuing or terminated and whether to modify it. Feedback can take many forms. It can consist of words, gestures, facial expressions, or any other observable element such as sleeping under ITNs. It could be immediate as in the case of applause after a

50 presidential speech to a home crowd or long term as in the case of changing behaviour. Feedback in face-to-face communication is also immediate. The feedback allows the source to evaluate the success of the communication process and its effectiveness in reaching the target; it is a democratic process which allows receiver to also become the source; it allows both source and receiver to change some elements in the communication process. In this study, the feedback is meant to be the reaction of the target audience, which in this case includes pregnant women‘s receptivity to the messages on the adoption of ITNs. Failure on the part of the audience to develop the desired attitude or behaviour toward the messages would be an indication of the presence of some barriers which often impede effective communication, and these include noise, cultural barriers, social and psychological barriers.

Role of communication in behaviour change

Strategically designed communication can play a key role in behaviour change. In a 2003 concept paper for the first RBM communication working group meeting, Lettenmaier (RBM report, 2008- 2010), observes that communication strategies are generally called for whenever there is a need to change awareness, knowledge, attitudes, social norms, skills or expectations and thus should be designed from an audience perspective, to address the social and contextual environment, as well as individual behaviours and knowledge. She notes that the coordinated use of interpersonal communication, community mobilization, advocacy and mass media have been effective in a variety of other public health agendas and highlights the effective role malaria communication will play when a multi- sectoral approach is adopted. Similarly scholars contend that communication is essential to advocacy, communicating policy changes, home based management, improving the quality of healthcare, creating demand for malaria services and products, changing household practices and mobilizing communities for malaria control (FMOH, 2010; RBM report, 2008- 2010)). Lettenmaier (RBM report (2008- 2010), again notes that communication, through a variety of channels is the best way to change individual and community attitudes and practices that act as barriers to effective malaria control. Through multi-channel communication, including interpersonal, community, electronic and print media, and malaria programmes, it can convince the public of the safety of ITNs for children and pregnant women. The mass media are capable of facilitating short-term, intermediate-term, and long-term effects on audiences. Short-term objectives include exposing audiences to health concepts; creating awareness and knowledge;

51 altering outdated or incorrect knowledge; and enhancing audience recall of particular advertisements or public service announcements, promotions, e.g. through malaria branding ( see appendix 6). Intermediate-term objectives include all of the above, as well as changes in attitudes, behaviours, and perceptions of social norms. Finally, long-term objectives incorporate all of the afore-mentioned tasks, in addition to focused restructuring of perceived social norms, and maintenance of behaviour change. Achieving these three tiers of objectives is useful in evaluating the effectiveness of mass media (FMOH, 2010).

Lerner (1958), in his book for UNESCO, identifies the important role the mass media can play in development and behaviour change. Similarly, Schramm (1962) as cited in Snyder, (2003) highlights how the media can act as ―magic multiplier‖ to rapidly spread information throughout a population. He notes that there are two broad categories of activities used for social and behaviour change and these include communication channel enhancement and information provision. Communication campaign is part of information provision.

Health Communication campaigns

Backer, Rogers, & Sopory (1992) observe that there is a great need for transmission of health-related information and for active promotion of health behaviour change; health communication campaigns can help in this. Weiss (2002) defines health communication campaigns as those that use a coordinated set of media, interpersonal and/or community- based communication activities to change behaviour towards desirable health outcomes. She notes that most of these campaigns, which are developmental in nature, are geared towards behaviour change such as getting more people involved in using methods of family planning, using condoms for HIV prevention and ITNs for malaria prevention. The campaigns ultimate goals may include healthier mothers and children, families and communities or specific policy results that lead to these goals.

Similarly, Snyder (2003) defines communication campaigns as an organized communication activity, directed at a particular audience, for a particular period of time, to achieve a particular goal. Citing Paisley (1981), Snyder asserts that communication campaigns are part of an old democratic tradition dating back to the ancient Athenians campaigning to end slavery. He notes that the first mass media printed texts, enabled people to conduct communication campaigns as a means of social change, including the distribution of radical religious texts, pamphleteering for political independence in the American colony and a smallpox inoculation campaign in the late 1700s (Snyder, 2003). He notes that development

52 campaigns also drew on the diffusion of innovations framework which had shown some success in spreading new agriculture techniques and technologies to farmers in Canada and the United States through media and outreach workers. Following international recognition of the AIDS pandemic, AIDS campaigns were conducted in several countries in the 1980s and 90s with funding by several world bodies.

Kreps and Bonaguro (2009), note that health communication campaigns are designed to educate target audiences about important health threats and risky behaviours that might harm them, thereby raising their consciousness about such issues. Health communication campaigns are also designed to move target audiences to action in support of public health.

Weiss (1995) further observes that health communication campaigns are growing more sophisticated every day and campaign designers are diversifying their strategies and abandoning the flawed notion that information alone changes behaviour.

Maternal and child health as well as family planning and environment continues to receive priority and support and communication campaigns continue to remain one strategy for promoting these. Among the approaches used in health communication campaigns are:

 Formative research – this is research conducted during the planning stages of a campaign with the goal of creating a better campaign. Formative research can be used to segment the audience into homogenous groups, select the focus of the campaign, decide the content and the tenor of the messages, choose appropriate channels and pretest messages and programs. This approach is employed by RBM partners before designing their campaign messages to suit the various audience segments.  Participatory campaigns - this came about as a result of objections from critics about the role of foreigners in development. Some people began advocating participatory approaches to development, which aim to involve the affected people in the development process. This includes representative participation approaches which involve contacting local leaders to gain their support for a program and creating advisory boards composed of local representatives. Local expert participation approaches include funding local organizations to conduct campaigns, creating partnerships with local organizations and creating campaigns together, or hiring locals to participate in campaigns design, implementation or evaluation. Audience research participation calls for conducting intensive research with members of the

target audience prior to designing a campaign, using the feedback to refine campaign goals, targets, messages, persuasion strategy and channels. Local outreach worker participation builds on diffusion theory advice to choose communicators who are similar to or homophilous with the target audience, by choosing members of the target group to be communicators (Rogers, 1995). Government agenda-setting participation links people to the decision makers in government, by establishing means of communication such as videos created by local people or town meetings. Kiwanuku-Tondo and Snyder‘s study of 99 organizations involved in AIDS communication campaigns in Uganda, found that the greater the participation of the audience, the greater the participation of outreach workers, which led in turn to better message quality (Snyder, 2003). The RBM campaigns involve and fund local leaders such as community, and village heads, experts such as health care providers and using communicators who are similar to the target audience such as pregnant nurses to conduct health education programmes in antenatal clinics.  Organizational improvements - this involves paying attention to factors that can enhance campaign success. These include staff development and training; campaign management such as management training, technical assistance on managerial issues from consultants, conducting process evaluations, and gaining a commitment to and capacity for research as a management tool; coordination with service delivery and; coordinating multiple organizations. RBM partners organize training workshops to build expertise among the campaign managers at various levels.  Advocacy - the main targets for advocacy campaigns are decision makers in governments and corporations as well as the public. Health advocacy campaigns have targeted national and workplace breastfeeding policies, national immunization policies, and birth control policies. Today RBM campaigns targets decision makers in governments at various levels as well as NGOs and the private sector so as to influence malaria prevention and control policies. This advocacy campaigns draw on community organizing, lobbying, and public relations. Specific activities include attending meetings, providing tours of a facility to educate policy makers and the media, circulating posters, organizing letter writing campaigns, creating media events, and sponsoring original research by experts in the field to provide evidence of the need for change or efficacy of the proposal to get 80% of pregnant women sleep under ITNs by 2013.

 Creative formats for campaign messages - this is the use of creative formats such as news and public relations format in which some campaigns use the news media to increase community awareness and support for an issue by gaining the cooperation of media organizations for sustained coverage of a problem and solutions. The RBM uses entertainment education formats in which dramas, puppet shows, dance, and songs are used to promote ideas. A typical example is the dance drama group of the Kabala community, Kaduna, which uses the edutainment format to persuade the public to sleep under ITNs.  Multipronged approaches - this involves the use of media efforts, interpersonal outreach, services, policies, trainings, and other activities as part of a strategic campaign plan. This has been the trend in the past three decades and has been used in several countries with remarkable success Snyder (2003). Messages persuading pregnant women to adopt ITN for malaria prevention are communicated through multiple media including Radio, Television, Newspapers, Magazines, Rapid SMS, Billboards, and interpersonal networks.  Persuasion and message design - this is the use of persuasion and behavior change theories in developing campaign messages. According to Snyder (2003), some of these theories include: McGuire‘s 1981 information processing model, Bandura‘s 1986 learning theory, Janz and Becker‘s 1984 Health belief model, Ajzen and Fishbein 1980 theory of reasoned action, Prochaska and Diclemente 1983 stages of behavior change model, and Rogers 1962 and 1995 diffusion of innovations theory. In Nigeria, the RBM uses the CFSC and the Behaviour Change Communication (BCC) theories as theoretical base for designing ITN messages.  Social marketing - this is the application of commercial marketing technologies to the analysis, planning, execution and evaluation of programs designed to influence the voluntary behaviour of target audiences in order to improve their personal welfare and that of their society. In practice, social marketing activities include setting specific measurable goals and objectives for the campaign, targeting specific segments of the audience with communications designed for them, conducting formative research with the target audience and other important people, making sure that the target behaviour is one that could be acceptable and appropriate for the audience, planning the mix of appropriate channels to use, pretesting messages with the target audiences to improve them before using them, monitoring the

implementation of the campaign and evaluating the results. This approach integrates the earlier seven approaches and forms part of the CFSC paradigm which forms the theoretical underpinning for the RBM campaign.

In social marketing philosophy, products are envisioned at three different levels; core product, actual product and augmented product. In this case, the core product would be the decrease in the burden of disease and mortality due to malaria among the vulnerable segments of population. The actual product would be accepting a new behaviour such as using ITNs, rejecting a competitive behaviour such as sleeping in an open and unprotected environment, modifying the current behaviour such as spilling oil on wastewater logged in the closed vicinity to kill the larvae of mosquitoes and abandoning an old behaviour such as indoor burning of wood to generate smoke for repelling mosquitoes. The augmented product to be promoted is the ITN itself.

Roll Back Malaria (RBM) Campaign

Oso, (2008) posits that the ultimate goal of any communication intervention in the process of social change is to induce enduring and sustained behavioural, attitudinal and normative changes, which is only possible when the process of development is owned by the participant group through dialogue, debate, negotiation and exchange.

The Roll Back Malaria (RBM) is a global partnership which was launched in 1998 by the World Health Organization (WHO), the United Nations Children‘s Fund (UNICEF), the United Nations Development Programme (UNDP) and the World Bank, with the goal of halving the malaria burden by 2010. It emerged as a response to concerns by governments and other stakeholders particularly in Africa, about the increasing incidence and deaths from the disease and although it supports efforts to tackle malaria wherever it occurs, its focus is fighting malaria among the two most vulnerable groups in Africa with 90% of the disease burden (RBM Information sheet, 2002).

In pursuance of its goals, the RBM promotes four main strategies (RBM Report, 2003: 2):

1. Case Management using Artemisinin-based combination therapies 2. Insecticide-Treated Nets (ITN) and other vector control measures 3. Providing Malaria Treatment and Intermittent Preventative Therapy (IPT) for pregnant women 4. Improving Malaria epidemic preparedness and response

The goal of the RBM is to halve the malaria burden through interventions that are adapted to local needs. The African summit on Roll Back Malaria was held on the 25th of April in year 2000; Forty-four of the fifty malaria-affected countries in Africa were represented at the summit in Abuja. Nineteen heads of state were present, as well as prime ministers, vice- presidents, ministers of health and several other partners (RBM Report, 2003; FMOH, 2010).

In commitment to achieving the set goals of halving malaria mortality in Africa by 2010 through implementation of strategies and activities agreed upon at the summit African leaders promised to ensure that by 2013, at least 80% of the most vulnerable group use ITNs to limit human-mosquito contact

Amongst other things, they pledged to promote community participation in rolling back malaria, make diagnosis and treatment available and accessible for the poorest groups, prevent re-emergence of malaria, provide reliable information on malaria to decision makers at all levels (from household to national level), and reduce or waive tariffs for mosquito nets, insecticides, anti-malarial drugs and more (RBM Report, 2003).

To scale up prevention of malaria in pregnancy, technical working groups and other stakeholders have been established to distribute ITNs to pregnant women. Furthermore, to strengthen effective communication, information, education and communication (IEC) materials are produced and disseminated, educative dramas and playlets have been presented in more than 770 communities in Nigeria; jingles are aired on radio and TV; Billboards are erected in strategic locations and World Malaria Day is celebrated annually (RBM Update, 2011). For example, the Federal Radio Corporation of Nigeria FRCN, LTV, make several public service announcements to enlighten the public; the Nigerian Television Authority NTA, which is also an RBM partner, airs programmes such as Weekend File viewed by over 50 million people worldwide, Health Reports; Channels television airs ITN enlightenment programme; WAZOBIA FM airs a drama programme titled Marble Town; as well as the print media, which publish articles on malaria and ITN issues (FMOH, 2010) and Billboards by Society for Family Health among several others.

As part of Lagos State Government‘s contributions to the RBM initiative and fight against malaria several communication strategies have been put in place among which are the following (Lagos State Ministry of Health, 2011):

1. Sensitization and advocacy seminar for heads of public health facilities on the current anti-malaria treatment guideline and policy 2. Community mobilization and awareness programmes conducted in 15 Communities in the State. 3. Distribution of 20,000 copies of Information handbook on malaria. 4. Distribution of posters on Malaria in Pregnancy and Malaria/vector Control.

Though Nigeria failed to meet the set targets, another window of opportunity presents itself as the date for achieving the set goals is currently tied to the 2009- 2013 National Malaria Control Strategic Plan and 2015 Malaria related Millennium Development Goal (MDG), which states that by 2015, malaria will no longer be a major cause of mortality, nor a barrier to social and economic development and growth, anywhere in the world. Added to this is the renewed political commitment demonstrated through improved funding by governments, funding agencies and partners and integration of new programmes (RBM Factsheet, 2011; RBM Update, 2011).

Barriers to effective communication

Uwakwe (2010) sees communication as the interactive transmission of a message from an encoder (sender/source) to the decoder (receiver/target) operating in the midst of intervening variables such as culture and noise.

McCombs and Becker (1989) opine that successful communication involves an understanding of the actual phenomenon on which the message is based. They suggest that there are factors which by their very nature work against effective communication and may consequently hinder the effectiveness of communication campaigns. Since reception of a message is essential to communication, the communicator must overcome the barriers to and strive to optimize the reception of the message. Uwakwe (2010) identifies the following as barriers to effective communication:

Noise- This is anything that interferes with successful dissemination of messages in a communication process. Three examples of this are channel noise, semantic noise and psychological noise.

Channel noise refers to external interference in the communication process such as a large blast of static blocks interrupting a radio broadcast or tiny prints in a newspaper or a voice that is too soft or a blurred picture. For example, when there is a break in transmission during

58 the broadcast of a public service announcement on ITN, the truncated message may lead to misunderstanding on the part of the audience.

Semantic noise occurs when one clearly hears the message but cannot understand it. For instance when an unexplained technical word is used in a message meant to persuade pregnant women to adopt the use of ITNs it will most likely be confusing to them, especially those whose discipline is unrelated.

Psychological noise refers to internal factors that lead to misunderstandings in the communication process. The concept of psychological noise emanates from the consistency theory research that found that people usually prefer to seek out information and ideas that are consistent with their beliefs, attitudes and behaviour and tend to avoid information that is inconsistent.

Thus, broken messages, ambiguous messages or pregnant women‘s perceptions, beliefs and attitudes that are not consistent with the ITN messages, may very well constitute barriers to the adoption of the messages on ITN use.

Cultural barriers

These are hindering factors brought to the surface as a result of lack of correspondence or symmetry or relevance between the culture of the target social system and the demands of a message which in this study is advocated change. The perception of such incongruence could be individual or group based, and tends to be rooted in general in the prevailing socio-cultural and economic situation and in particular in cultural values and beliefs (Moemeka, 2000).

Harris (1983) in Baran (2010) defines culture as the learned, socially acquired traditions and lifestyles of the members of the society, including their patterned repetitive ways of thinking, feeling and acting. He also cites Geertz who was cited in Taylor (1991: 91) as defining culture as historically transmitted patterns of meaning, embodied in symbolic forms by means of which people communicate, perpetuate and develop their knowledge about and attitudes toward life.

Creation and maintenance of culture occurs through communication, including mass communication. For instance, when parents raise their children, when religious leaders instruct their followers, when friends converse, when teachers teach and grandparents pass on recipes or stories, when media professionals produce content for consumption, meaning is

59 being shared and culture is being constructed and maintained. Culture serves the purpose of helping people categorize and classify their experiences; it helps define the individual, his world and his place in it.

Additionally, Moemeka observes that socio-cultural and economic barriers find expression in numerous types of resistance, which invariably have solid justifications in the context of the target audience. Citing Okedeji (1974), he acknowledges a few examples of those resistances, which include resistance rooted in ideologies that run counter to health control and beliefs about the negative and positive aspects of specific methods. For instance in the case of malaria control and prevention, some believe that that the ITNs are poisonous and capable of harming them and their unborn children. Similarly, there are certain religious sects in the church whose members cannot take medicine, no matter how risky the health condition and still some others believe in the efficacy of herbs such as Agbo and Dogonyaro for malaria prevention and treatment. He argues that strong belief and trust in traditional ways of doing things may constitute constant barrier. Those who have high level of trust for traditional ways of doing things will stoutly oppose certain types of change behaviour. Kreps and Thorton (1992), in a study of health provision, confirmed that a person‘s beliefs influence his/her perceptions of health and illness. Healthcare providers who ignore these beliefs overlook a powerful source of information and a potent tool for healing, because evidence exists that knowing a patient‘s beliefs, values and attitudes can improve the outcome of the interaction (Cited in Moemeka, 2000)

Thus, target social system‘s values and beliefs can become behaviour instruments for resistance when the change advocated or the way it is advocated and the expected outcome are very different from what the people expect and are used to. However, such resistance usually fades away in the face of a well planned and executed development communication effort geared towards re-education and carried out within the target social system on a dialogical basis.

Social Barriers

Group norms, group solidarity and fear of isolation and group conflicts are some of the examples of social barriers that frequently cause resistance to change or development. These factors are however ordinarily positive elements of human interrelationships for any society but are capable of becoming impediments if new ideas and change efforts are perceived as threatening their existence or acceptance as sanctioned societal standards of behaviour and

60 community relationships. For instance, the use of condoms has met with strong opposition in some developing countries (Moemeka, 2000). Similarly, in the case of ITN use, some pregnant women view it as dangerous to their health and that of their unborn child. However, others see it as the best method of malaria prevention.

Knowledge

There is no single agreed definition of knowledge as there remain today, several competing theories, each attempting to give meaning to the concept. Sosale (2008) defines knowledge as (i) expertise and skills acquired by a person through experience or education; the theoretical or practical understanding of a subject; (ii) what is known in a particular field or in total; facts and information; or (iii) awareness or familiarity gained by experience of a fact or situation; (iv) the confident understanding of a subject with the ability to use it for a specific purpose if appropriate.

Perhaps the most relevant to this study is the definition by Drucker, (Cited in Davenport and Prusak, 1998), which views knowledge as information that changes something or somebody- either by becoming grounds for actions, or by making an individual or an institution capable of different or more effective action.

Attitude

Akinfeleye, (2008) defines attitude as unexpressed behaviour. It is a hypothetical construct that represents an individual‘s degree of like or dislike for an item. Attitudes are generally positive or negative views of a person, place, thing or event, and this is often referred to as attitude object. People can also be conflicted or ambivalent toward an object- this means that they can simultaneously possess both positive and negative attitudes towards the item in question. Attitudes are judgments which develop on the affect, behavior and cognition factors called the ABC model. Ziglar, (2011) observes that the affective response is an emotional response that expresses an individual‘s degree of preference for an entity with emotion as a common component in persuasion, social influence and attitude change. He notes that emotional appeals are commonly found in health campaigns, advertising and political messages with recent examples including no-smoking health campaigns, and political campaign advertising emphasizing the fear of terrorism. A message can appeal to an individual‘s cognitive evaluation to help change an attitude. Curran and Rosen (2006) indicate that attitudes are formed through exposure to words, images that people form in their

61 minds, experiences that they have, materials that they read and programs that they watch. Whatever information people accept becomes part of them and their worldview and thus rules their lives and directs them accordingly and when strengthened by adequate experiences makes the primary acceptance stronger and attitude deeper.

Similarly, Ziglar (2011) contends that attitudes can be changed through persuasion, thus attitude can be understood as a response to communication and factors that can affect the persuasiveness of messages as have been revealed from various studies and include:

 Target or audience characteristics- these are characteristics that refer to the person who receives and processes the message and these include intelligence, self esteem and mind-frame and mood. Some scholars are of the view that more intelligent people and those with high self-esteem are more difficult to persuade by one-sided messages, while mind-frame and mood also plays a role in attitude formation.  Source characteristics- these include expertise, trustworthiness and interpersonal attraction or attractiveness. The credibility of a perceived message has it is been found to be a key variable in attitude formation. For instance, if one reads a health report and believes it came from a professional medical journal, one may be more easily persuaded than if one believes it is from a story a popular newspaper.  Message characteristics- the nature of a message also plays a major role in persuasion. For instance, presenting both sides of a story is often useful in attitude formation.

Behaviour

Akinfeleye (2008) refers to behaviour as expressed attitude and the specific response of a certain organism to a specific stimulus or group of stimuli. Although behaviour has many causes, most scientists seek to isolate single causes. Many researchers use controlled experiments in which they can examine the effect of one factor at a time on a particular kind of behaviour. Weireich (1999) observes that some investigators design experiments to test the behavioural effects of several factors in various combinations, while others study behaviour in the ―real‖ world by observing people in their daily activities. Observing behaviour outside controlled experiments cannot prove that one thing causes another, but studying people in the real world often helps scientists see the ways in which causes identified in experiments actually operate in people‘s daily lives. Social scientists study individuals or small groups of people in controlled tasks to understand many aspects of behaviour, including the reasons for

62 people‘s feelings, thoughts and motives (Weireich, 1999). These studies help establish principles that can be used to explain, predict or modify behaviour.

UNICEF (2007) argues that the most difficult aspect of disease control is the human element since people can behave in different ways depending on various variables such as age, income, sex, environment, education, values, opinions, beliefs and culture. Effective communication is crucial to understanding how, where and when to engage with individuals and communities to successfully tackle malaria. It is an important process in convincing, through advocating, marketing, and mobilizing a broad range of individuals and organizations to take malaria seriously, to put away all kinds of barriers that may impede effective communication and to take preventive action such as the use of ITNs against malaria and for society to generate political will and resources to tackle the debilitating effects of the disease.

Oso (2008) indicates that changing any form of behaviour is a difficult task, which must involve a thorough social analysis to understand the various components of the behaviour factors that may inhibit or facilitate the adoption of a particular behaviour, and consequences for adopting it. It is important therefore, to recognize the existence and negative effects of these intervening variables so as to communicate the right message, in the right way, at the right time, to the right people in order to achieve the right effect.

Empirical Review of studies in developing countries

In the course of the literature search, the researcher found that although many studies looked at the knowledge, attitudes, practices and behaviours (KAPB) of people towards the use of ITNs for malaria prevention, very few if any focused on the role played by communication as a key and integral component of the RBM (ITN) campaign, pregnant women‘s exposure levels, their sources/channels of information, their responses and the factors influencing the responses to communication campaign messages on the adoption of ITNs for malaria prevention.

This finding supports Snyder who examined the effectiveness of communication campaigns in behaviour change and notes that despite the long history of communication campaigns, only a limited number of studies have examined their comparative effectiveness, using quantitative methods. He however shows evidence that in the United States, mediated health campaigns have small but real short-term effects, with an average increase of 7 to 10

63 percentage points in the desired behaviour, slightly larger for campaigns that promote commencement of a new behaviour (12%) and less for campaigns that promote cessation of a behaviour (5%) or prevention (4%) (Synder, 2003).

Snyder (2003) also highlights the similarity of results in the developing countries where a meta-analysis of 16 family planning programs from 1964 to 1987 revealed an average increase of 8 percent points in couples practicing family planning behaviour. He however reports a 19 percentage point increase for breastfeeding among those who gave birth at home or in a public hospital as opposed to those who gave birth in a private hospital.

Makekar, 1993; McAnany & Lapastina, 1994 and; Singhal & Rogers, 1999, opine that campaigns that use the entertainment-education approach are often more successful as the audiences often identify with the stories in the drama and talk about them with family, friends and neighbors. They further identify the importance of exposure to campaign messages stating that failure to reach people severely limits the possibility of the campaign changing behaviour. While observing that the average reach of development campaigns is not known, since it varies by type of channels used and the extent of media competition/monopoly, Snyder (2003) also notes that some development campaigns have shown very high rates of exposure as in a campaign in Kenya that reached 83%. Below are some of the studies that have proved to be useful in providing statistical data of the awareness, ownership and usage of ITNs among pregnant women in some of the malaria affected countries. Due to paucity of relevant literature, studies on other groups are also reviewed.

One of the studies which focused on the behaviour of pregnant women towards ITN use was the study of knowledge, attitude and practices regarding malaria prevention and treatment in Eastern India. Sabin et al (2010), explored views of 73 pregnant women in Jharkhand. They conducted 32 in-depth interviews and six focus group discussions with pregnant women in urban, semi-urban, and rural locations in a region with moderate intensity malaria transmission. Most respondents ranked malaria as an important health issue affecting pregnant women, had partially correct understanding of malaria transmission and prevention, and reported using potentially effective prevention methods, usually untreated bed nets. However, most conveyed misinformation and described using unproven prevention and/or treatment methods. Many described using different ineffective traditional malaria remedies. The majority also showed willingness to try new prevention methods and take medications if doctor-prescribed. The study does not indicate the role played by communication in creating

64 awareness/knowledge about the malaria prevention methods among these women and appears not to be empirical (1010-1016).

However, results of the Kenyan 2003 knowledge, attitudes and practices (KAP) study conducted by Tilson, of the School of Public Health and Health Services of the George Washington University in the United States of America, showed significant increases in two ITN brand awareness. While Supanet brand awareness increased from 27% to 79%, Power Tab awareness increased from 0% to 64% and the percentage of adults who had correct knowledge of malaria transmission and the effectiveness of ITNs also increased. Awareness of ITNs as an effective malaria prevention strategy increased from 3% in 2001 to 44% in 2003. A second KAP study also undertaken in Kenya in 2006 showed a national increase in awareness of the high risk groups about ITNs from an existing zero coverage to about 1.2 million people.

Similarly, a study carried out in 2008 by Habtai, Ghebremeskel, Mihreteab, Mufunda, & Ghebremichael (2008), on the Knowledge, attitudes, awareness, practices and beliefs among people visiting referral Hospitals in Eritrea showed a 100% awareness about at least one of the symptoms of malaria with nearly three quarters mentioning three or more of the classical symptoms including fever. More than 80% knew that mosquitoes were the vector for the disease with a similar proportion having participated in environmental preventive control measures. Awareness, ownership or use of ITNs was not examined in this study.

Some of the studies focused on distribution as was the case in two areas A and B in Burkina Faso, where a study by Beiersmann, De Allegri, Tiendrebéogo, Yé, Jahn, and Mueller, A. (2010), found that the ITN free distribution was well known to and highly appreciated in the malaria intervention area A. Awareness of the ITN social marketing distribution was however low in both intervention areas, except in the urban part (Nouna town) of intervention area B. Women were reported to be able to purchase ITNs independent of their husbands. However, poverty and frequent unavailability of ITNs for purchase were found to be the main barriers for ITN ownership. The same study was one of the few that assessed the sources/channels of communication as findings revealed that ITN information was mainly received through personal communication with health workers and through radio messages. The social marketing approach alone appeared not be sufficient to reach the goal of high ITN coverage, mainly due to prevailing poverty and the insufficient availability of ITN for purchase.

In a study on distributional coverage and assessment of the knowledge and utilization of ITNs conducted in 17 malarious districts in Ethiopia by Ethiopia Ministry of Health in 9 administrative regions from October 2005 to September 2006, about ninety one percent (91.1%) of the respondents were knowledgeable about the efficacy of ITNs for the control malaria either through prevention of mosquito bites sixty percent (60%) or prevention of the disease thirty nine percent (39%).

Knowledge, Ownership and usage of ITNs Some of the studies focused only on ownership and usage as was the Animuti et al 2005-2006 study which found that the majority of households in Ethiopia (53.2%) owned a single net per family, with the highest in Dire Dawa (93.7%) and lowest in Afar (17.6%). Thirty eight percent (38%) of the respondents owned two nets per household.

In Eritrea, behaviour patterns of pregnant women and children under the age of five were found to be tied to demographic factors, as the study on ownership and usage found an increase in household ownership of nets and coverage of pregnant women and children under five years was much higher in urban areas (ranging from 27% to 59%) than in rural areas (18% to 22%). The study also revealed that 44.6% of the respondents gave priority for usage of ITNs to children under 5 years and pregnant mothers (Habtai et al 2005).

In 2005, the Ministry of Health in Ethiopia launched a major effort to distribute over 20 million long-lasting insecticidal nets, provide universal access to artemisinin-based combination therapy (ACTs), and train 30,000 village-based health extension workers. A cross-sectional, nationally representative Malaria Indicator Survey was conducted by Hwang et al during the malaria transmission season in 2007. Analyses were performed to assess the effect of women's malaria knowledge on household ITN ownership and women's ITN use. In addition, the effect of mothers' malaria knowledge on their children under 5 years of age's (U5) ITN use and their access to fever treatment on behalf of their child U5 were investigated. Malaria knowledge was based on a composite index about the causes, symptoms, danger signs and prevention of malaria. Approximately 67% of women and mothers of children U5 reported some knowledge of malaria. Women's knowledge of malaria was significantly associated with household ITN ownership and with increased ITN use for themselves. Knowledge of malaria amongst mothers of children U5 was associated with ITN

66 use for their children U5, but not significantly associated with their children U5 seeking care for a fever (Animut et al, 2008).

A study by Kudom and Mensah in Ghana (2007), to get a better understanding of perceptions of malaria, knowledge on mosquitoes and the attitude towards the use of ITN in seven public high schools and four tertiary institutions in Cape Coast metropolis, Ghana. A total of 492 students took part in this study. About ninety percent (90%) of them had high knowledge of malaria transmission and ITN, but little knowledge of mosquito life history; only one percent (1%) in secondary and two percent (2.1%) in tertiary institutions had seen or knew about all the development stages of mosquitoes. In high school and tertiary institutions, twenty four (24.2%) and eleven percent (11%) of respondents, respectively, were able to mention other genera of mosquitoes, apart from Anopheles. Though ninety four percent (94%) in senior high school and eighty seven percent (87%) in the tertiary institutions knew that ITNs are either used to protect oneself from mosquito bites or to prevent malaria, thirty- three (33%) of the respondents in secondary and twenty-two percent (22%) in tertiary institutions who owned ITN did not use them. The study reveals that respondents did not have adequate knowledge on the biology and behavior of mosquitoes. This appears to be responsible for their low knowledge of the link between the use of ITN and malaria control and possibly accounts also for the non use of the ITNs by twenty- two percent (22%) of students who own ITNs.

The results of this study underscores the importance of the knowledge of biology and history of mosquitoes as only then will they be able to understand the methods of malaria prevention and control.

Effects of Communication channels/messages on ITN adoption Though results given were not quantitative, one of the few studies which focused on the effects of communication messages on the Knowledge, attitudes and behaviour toward ITN use was the Kenyan government study conducted through media research and KAP study by Tilson (2007). The brand communications strategy proved quite successful with large increases in awareness. The generic communications material which were two posters contained messages in Swahili saying, ―Malaria kills 36,000 children every year,‖ and, ―Make sure your child sleeps under an insecticide-treated net,‖ however, were not highly memorable as measured by media recall research, scoring significantly lower than the averages for this type of material. The KAP survey showed that awareness about the high risk

67 groups only increased slightly, and was well below target. The new communications strategy incorporated the generic messages under an umbrella ―brand‖ called ―Malaria Ishindwe!‖, (translated as ―Down with Malaria!‖). The branded slogan was developed through local research. ―Ishindwe‖ is a word often used by preachers in the churches to invoke campaigns against evil things or the devil. So the word had positive connotations among consumers and was readily understood and liked as a rallying cry to fight malaria. It was also easy to recall. There were three messages in this campaign under the umbrella slogan: 1) In order to beat malaria, you have to sleep under a treated net; 2) You must know the people most at risk (pregnant women and children under five); and 3) You must re-treat your net in order to keep your home a ―malaria free zone.‖ These messages were disseminated through mass media and interpersonal communications (clinic programs, community drama groups, road shows. etc), almost as a religious crusade. The messages were aired in three phases of three months each to insure that each message was understood and remembered by the target audience. The media research subsequently showed very high recall of the campaign and the campaign messages, much higher than the average recall for similar length ads (Tilson, 2007).

Most of the studies carried out in other malaria affected countries in Africa and Asia revealed significant increase in the awareness, ownership and use of ITNs with the lowest recording about 20% and the highest recording 100%. The situation appears to be different in Nigeria as is demonstrated in the following studies.

Nigeria ITN Studies

Findings of one of the early studies on malaria preventive health behaviours among pregnant women were found to be generally poor across the six geo-political zones in Nigeria (FMOH 2000). Salient findings from the national malaria situation survey relating to preventive health behaviour in malaria included the fact that bed-net use among pregnant women was found to be generally low across geo political zones as only 10% of the respondents claimed to use bed nets. The survey also revealed that the preventive measures reportedly adopted by some respondents included the use of the following: Window/door nets - 32.6%, Insecticides aerosol - 33.8%, Repellents -22.7% and Herbs - 23.0%

Onwujekwe, Uzochukwu, Ezumah, & Shu, in their 2005 study, found that willingness to pay for bed nets and insecticides for treating them were high in four communities in eastern

Nigeria. They also indicated that about 30% of their respondents were willing to pay for bed nets and actually redeemed their pledges. Brieger et al. (1996) also observed in a study conducted in Nsukka, Enugu State that altogether 22% of the survey respondents reported that bed nets had been used before by a member of their household. They note that in some isolated cases, people are willing to pay for bed nets.

A 2000-2004 and 2000-2006 trend study conducted by Baume and Marin, (2008) on the awareness, ownership and usage of ITNs among pregnant women in Nigeria, Senegal, Zambia and Uganda respectively, found that while there was an almost uniform increase in awareness in all countries, awareness in Nigeria increased from 7% to 60% over the four year period. Similarly in all the other countries, while none met the Abuja targets, the number of pregnant women sleeping under ITNs increased significantly. In Senegal the number of pregnant women sleeping under ITNs increased from 4% to 30%; Zambia 0% to 13%; Uganda 0% to 12%, while Nigeria recorded the least increase with 0% to 3%.

The Nigeria Demographic and Health Survey (NDHS, 2008- 2010) revealed that 12% of all households own at least a net (any type) while only 2% own at least one ITN. The result also showed that ownership of nets (any type) is significantly higher among the rural dwellers than those living in urban areas. There is also a wide variation of net ownership across the six geo-political zones with more nets being available among the households in the North (Except North East) than the South. A 2008 Nigerian Institute of Medical Research study evaluated awareness, accessibility and use of RBM malaria control interventions among the at-risk groups in Ogun State, Nigeria. 262 pregnant women attending antenatal clinics were surveyed and 233 mothers of under- five children and results showed poor awareness and low use of malaria interventions such as ITNs, in the study communities. ITNs were found to be grossly limited in supply in the government health facilities, while the private health facilities were not involved in the implementation of the RBM programme in the study area (NIMR 2009 Annual Report).

Another study to determine the degree of awareness and practice of malaria prevention strategies among antenatal attendees in Uyo, South-South Nigeria, was conducted by Abasiattai et al in 2009 at the maternity unit of the University of Uyo Teaching Hospital, Uyo. A total of two hundred and fifty pregnant women majority of who were 21-30 years (67.6%), married (98.8%) and 90.0% had at least secondary level education were surveyed.

About 71.2% of the respondents knew that malaria had adverse effects in pregnancy (p<.001) while 76.0% of them had received treatment for malaria during pregnancy (p<.001). 76.4% of the respondents had heard of Insecticide Treated Bed Nets (ITNs) (p<.001) while only 16.4% had used them (p<.001). The researchers also found that in addition to the low level of utilization of ITNs involvement of the mass media in community enlightenment programmes was also low.

Similarly, a 2010 study on the knowledge, attitudes and practices (KAP) of 192 households in Oyo town in relation to malaria showed that not much has changed in 10 years with only 16.7% of households using insecticide-treated nets (ITNs) for their children. Other results showed that about 93.2% (n=192) of respondents recognized mosquito bites as the cause of malaria. A small proportion of children (13.7%) and adults (5.3%) received prompt treatment; however, more adults (65.8%) got correct dosage of anti-malarial treatment than children (38.7%). About 90% of suspected malaria cases in children and adults were first treated at home with local herbs or drugs, purchased from medicine stores. Other reported malaria prevention methods include the use of insecticides (79.7%) and herbs (44.3%). In all, 17 (8.9%) of households did not have screening nets on their windows and 6.3% of 175 households with screening nets on their windows had rusty and torn nets. The level of education of heads of households was a strong predictor of positive malaria-related KAP. Window types and environmental hygiene were associated with prevalence of malaria in households. Furthermore, in 2010, Edelu et al carried out a study to determine the proportion of mothers using insecticide treated nets for their children and reasons for nonuse. Of the 230 mothers interviewed, results showed an ITN awareness level of 80% (184 mothers) while only 48 (26.1%) used ITNs for their children. There was statistically significant difference in terms of ITN awareness between the highly educated mothers and those with lower educational qualification (p=0.000) but, in terms of ITN usage, there was no significant difference between the two groups (p=0.40). Socio economic class did not influence the use of ITN (p=0.153). While reasons for non-use include use of windows and door nets 22 (16.2%) and limited knowledge about how to spread and use ITNs 18 (13.2%), a greater number; 56 (41.2%) had no reason for non-use (ITN usage report, 2010 Nigeria).

Results of the latest Nigeria Malaria Indicator 2010 Survey (NMIS) put nationwide ITN ownership at 42% and ITN ownership in the South Western states of Nigeria at 20%. It also

70 reports that 17% of pregnant women slept under the ITN the night before the survey (NMCP, 2011).

The concluded review of literature underscores researcher‘s earlier assertion that though the RBM Campaign on the adoption of ITNs has recorded huge gains in several African countries, Nigeria appears to be trailing with the highest ITN adoption rate put at less than 20% and the lowest at 2%. Besides, none of the Nigerian studies reviewed focused on communication as a vital component of the campaigns for the adoption of ITNs.

Against this background, this study attempted to give meaning to this situation by finding out the responses of pregnant women in rural and urban Lagos to communication campaign messages on the adoption of ITNs for malaria prevention. It did this by examining their exposure to communication messages on ITNs, sources of ITN/ health information and adoption levels of ITNs.

Theoretical Framework Observing that change is a very difficult phenomenon to sell, Akinfeleye (2008) asserts that attitude and behaviour change is a tough process and thus demands messages which must take into account the individual, peer groups, the mass media, the cultural particularities and peculiarities, religion, environment and other forces (evil or divine). He further notes that communication is at the center of the behaviour change process and identifies the major steps to include: Knowledge about the change; ability to recall major messages in the communication encounter; understanding the key issue in the message; personal network and/or peer influence and authority; recognition and appreciation of the benefits in the intended change; advocacy on other; and sustainability.

The Communication For Social Change theory (CFSC) by Figueroa & Kincaid (2002), was therefore considered most appropriate and served as the framework of analysis for this study. Some of its assumptions were tested to determine the appropriateness of the model in explaining the responses of the sampled pregnant women to the communication messages on the adoption of ITNs for malaria prevention. Other theories that found relevance in this study are the Individual Differences theory, the Health Promotion and Health Education theory, Freire‘s Participatory theory and the Behaviour Change Communication theory (BCC).

Many communication models have informed the field of behaviour change. The early models like Lasswell‘s communication theory of 1948 were linear in their understanding of communication, which was understood as a transfer of information, leading to foreseeable step-by-step change processes, as it is shown in its model illustrated below. These processes were usually identified with changes in behaviours much in line with the development thinking of the modernization paradigm. Persuasion theory, originating from the advertising industry, also became a strategy to achieve information transfer (Lasswell and Becker, 1989). Since the evolution of communication as an independent discipline, several scholars have conducted research into the effects of communication at the individual, group and societal levels and have postulated several theories to explain the various kinds of effects. The theory of mass communication effects propounded by Melvin De Fleur has undergone several paradigm shifts. In the mass society era, researchers believed in Lasswell‘s ―Hypodermic needle‖ theory of communication effects and individuals were believed to be passive consumers of media content which directly and heavily influence the audience to respond in the desired manner. The media were considered to be all powerful in changing people‘s perceptions and manipulating their actions in subtle but highly effective ways (Littlejohn, 2008: 298). The powerful effects of the media which appeared to have been underscored by the huge successes of propaganda during the first and second world wars as well as the continued funding and patronage of the media by advertising, appeared to have suffered a blow when, from the 1950s to 1990s, persuasion research provided a dominant strategy which represented a remarkable shift away from the focus on the role of propaganda in society to what happens when people are exposed to media messages (Baran & Davis, 1981; 2009).

The earlier theories were founded on the linear communication model of Lasswell which was an outgrowth of his work on the functions of the media as well as his work on propaganda which recorded success during the First and Second World Wars, using the media as its conveyor belts (Folarin, 2005). Lasswell had proposed a verbal model of the communication process through which communication functions are carried out. The model required answers to the questions of who, says what, in which channel, to whom and with what effect?

In these early models of strategic communication, there were no participatory elements. The assumption was that the power of communication to enhance development was in the correct crafting of the content and in the adequate targeting of audiences. The goal was individual behaviour change.

Scholars challenged the ―All Powerful Effects‖ theory for its lack of scientific basis, setting the stage for a shift to the ―Limited Effects Paradigm‖. Some of the theories in this era include the Individual Differences and Selectivity processes, the Two Step Flow of Communication, as well as many others. These theories have been considered useful in analyzing the behaviour of people towards communicated messages as they focus on the elements or factors that influence behaviour.

Individual Differences theory

Citing De Fleur, (1970), Baran and Davis (2009) note that Individual Differences theory argues that because people vary greatly in their psychological makeup and because they have different perceptions of things, media influence differs from person to person. Media messages contain particular stimulus attributes that have differential interaction with personality characteristics of members of the audience. Thus these personality attributes can act as effective barriers to the influence of media messages, but can also increase the likelihood of influence. In agreement, Jeffres (1997) posits that individual differences can alter media effects in several ways, for instance education is linked to a preference for print media that subsequently leads to a higher level of knowledge about public affairs. Individual differences may also operate as filters that affect how audiences process media messages. Citing Sherman et al, (1989), Jeffres also notes that differences in interpretation are due largely to differences in the structure, content and accessibility of prior knowledge.

The Individual Differences theory identifies the elements that may influence behaviour towards communicated messages as differences in intelligence and educational levels, psychological traits such as fatalism, phobic personality, emotional insecurity and lack of self confidence, while the selectivity processes are influenced by beliefs, prejudices or biases, past experiences, values, attitudes and other socio-psychological factors. The Two Step Flow however focuses on the influence of opinion leaders in both the diffusion of information and behaviour change. Invariably, what the Individual Differences theory in the context of this study suggests is that differences in intelligence and educational attainment, as well as the psychological traits of the pregnant women will influence their decision to adopt or reject the messages on the use of ITNs for malaria prevention.

Although communication was identified as vital in behaviour change, the Individual Differences as well as other theories of behaviour change such as the Modernization theory which were used as part of the development programmes in the developing world and which

73 were also based on the linear, top- down communication approach are reported to have failed due to their individual based perspective.

Cullen, (2009) notes that although these theories may have been effective in dealing with certain diseases in other societies, they have proved to be inadequate for health communication planning in Africa where decisions about preventing diseases are based on cultural norms that often override the individual‘s decision.

Health promotion and health education

The discipline of development communication, both as theory and as practice, emerged closely interconnected with the growing ―development industry.‖ From the outset ―development support communication,‖ ―program support communication,‖ ―communication for development,‖ or ―development communication,‖ has been seen as a strategic tool to persuade people to change and enhance development processes.

Waisbord, (2005), contends that the trajectory of health promotion was developed as a development communication tool, resembling the move of social marketing and diffusion of innovation, from originally gaining influence in the United States to being introduced in interventions in developing countries. The same approaches that were used to battle chronic diseases, high-fat diets, and smoking in the United States in the 1970s and 1980s, were adopted in development interventions such as child survival and other programs that aimed to remedy health problems in the Third World.

The Health promotion theory was based on the assumption that changes in personal behaviours were needed to have a healthier population. Although the idea that institutional changes were also necessary to achieve that goal made strides, health promotion remained focused on personal change at the expense of community actions and responsibility. A substantial number of studies were offered as conclusive evidence that personal choices determined changes in health behaviour, and were positively related with new developments that indicated the decrease of unhealthy practices Waisbord (2005). Obono 2011, WHO 2010, Kincaid and Figueroa 2002, Minkler 1999, Wallack and Montgomery 1992, criticized this model as a highly individualistic perspective especially in the context of developed countries for ―blaming the victim‖ and ignoring the social conditions that facilitated and encouraged unhealthy behaviours. They argue that it gave a

74 free ride to larger social and political processes that were responsible for disease and essentially depoliticized the question of health behaviour. To them, individual-centered health promotion ignores the surrounding social context of poverty and other factors in which individual health behaviours take place as well as the fact that certain unhealthy behaviors are more likely to be found among certain groups. They pointed out that the overall context needed to be considered both as responsible and as the possible target of change.

Glanz, Lewis & Rimer (1990) describe Health education as an important component of health promotion referring to learning experiences to facilitate individual adoption of healthy behaviours. The evolution of health education somewhat mirrored the evolution of the field of development communication. Steston & Davis (1999), explain that Health education includes different kinds of interventions such as conventional education, social marketing, health communication, and empowerment actions. Consequently, a vast range of activities such as peer education, training of health workers, community mobilization, and social marketing are considered examples of health education interventions. Health education was initially dominated by conventional educational approaches that, like modernization/diffusion models, were influenced by individual behaviourist models that emphasized knowledge transmission and acquisition as well as changes in knowledge, attitudes and beliefs (WHO, 2002).

Participatory Development Communication (PDC) Model After decades of interventions, the failure to address poverty, diseases and other structural problems in the Third World needed to be explained on the faulty theoretical premises of the programs. Any intervention that was focused on improving messages to better reach individuals or only change behaviour was, by definition, unable to implement social change (Mody, 2003). Development theorists also criticized traditional approaches for having been designed and executed in the capital cities by local elites with guidance and direction from foreign specialists. Local people were not involved in preparing and instrumenting development interventions. Interventions basically conceived of local residents as passive receivers of decisions made outside of their communities, and in many cases, instrumented ill- conceived plans to achieve development. Governments decided what was best for agricultural populations, for example, without giving them a sense of ownership in the systems that were introduced. The top-down approach of persuasion models implicitly assumed that the

75 knowledge of governments and agencies was correct, and that indigenous populations either did not know or had incorrect beliefs. Because programs came from outside villages, communities felt that innovations did not belong to them but to the government and thus expected the latter to fix things went they went wrong. The sense of disempowerment was also rooted in the fact that ―targeted‖ populations did not have the choice to reject recommendations or introduce modifications to interventions (Mody 2003, Servaes 1999).

It was against these criticisms that the participatory approach emerged. Paulo Freire, a Brazilian educator in 1970 developed the participatory model in which he argued that development communication required sensitivity to cultural diversity and specific context that were ignored by modernization theories. The lack of such sensitivity accounted for the problems and failures of many projects (Waisbord, 2005). The understanding of communication was central to the ideas developed by Freire whose writings and experiences became an influential strand in participatory communication. Freire‘s work in Northeastern Brazil in the 1960s and early 1970s challenged dominant conceptions of development communication, particularly as applied to literacy training. He argued that development programs had failed to educate audiences because they were interested in persuading them about the benefits of adopting certain innovations. Development programs tried to domesticate foreign concepts, to feed information, to force local populations to accept Western ideas and practices without asking how such practices fit existing cultures. The underlying premise of such programs was an authoritarian conception of communication that stood against the essence of communication understood as community interaction and education (Servaes, 1999). Freire‘s model and participatory models in general proposed a human-centered approach that valued the importance of interpersonal channels of communication in decision-making processes at the community level. Studies in a variety of Third World rural settings found that marginal and illiterate groups preferred to communicate face-to-face rather than through mass media or other one-way sources of communication (Okunna, 1995). The recommendation was that development workers should rely more on interpersonal methods of communication rather than national media and technologies, and that they should act as facilitators of dialogue.

The participatory model is a collaborative method employed to test new ideas and implement action for change. It involves direct participation in a dynamic research process, while

76 monitoring and evaluating the effects of the researcher's actions with the aim of improving practice. At its core, action research is a way to increase understanding of how change in one's actions or practices can mutually benefit a community of practitioners. Essentially the model describes all relevant parties actively examining together current action which they experience as problematic in order to change and improve it. They do this by critically reflecting on the historical, political, cultural, economic, geographic and other contexts which make sense of their collective action. It is action which is researched, changed and re- researched by participants (Tufte and Mefalopulos, 2009)

This theory also came under criticisms for lacking the methodological rigor and technical validity that is the standard of much academic research, similar to attacks on Action Research by mainly quantitative researchers that reject Interventionist epistemologies. For example, McKee (1992), criticized it for its elaboration at a theoretical level and not providing specific guidelines for interventions as well as its lack of clarity as regards the extent of involvement of communities in order for certain results to be achieved. He argues that in some cases such as epidemics and other public health crises, quick and top-down solutions could achieve positive results. Participation communication ignores that expediency may positively contribute to development and belaboring through grassroots decision-making process is slower than centralized decisions, and thus not advisable in cases that require prompt resolutions. Participation might be a good long-term strategy but has shortcomings when applied to short-term and urgent issues. Another problem was that participation in all stages does not have similar relevance and it was not clear what participation entailed. It was not true participation and, therefore, maintained power inequalities.

Mckee (1999), also explained that the focus on interpersonal relations underplayed the potential of the mass media in promoting development as participation and process with little attention paid to the uses of mass media in participatory settings, an issue that is particularly relevant considering that populations, even in remote areas, are constantly exposed to commercial media messages that stand in opposition to the goals set by programs. This lack was particularly evident in Freire‘s theory of dialogical communication that is based on group interactions and underplays the role of the mass media.

Behaviour Change Communication (BCC) Theory

Throughout the 1970s and 1980s, strategic communication approaches to enhance individual behaviour change evolved to be known as Behaviour Change Communication (BCC). Behaviour change communication is associated closely with social marketing and Social marketing strategies are a means to promote particular behaviours or social norms via communication interventions.

According to the AED Centre for global health communication and marketing, Behaviour Change Communication (BCC) is the strategic use of communication to promote positive health outcomes, based on proven theories and models of behaviour change. BCC employs a systematic process beginning with formative research and behaviour analysis, followed by communication planning, implementation, and monitoring and evaluation. Audiences are carefully segmented, messages and materials are pre-tested, and both mass media and interpersonal channels are used to achieve defined behavioural objectives.

It is an interactive process with communities (as integrated with an overall program) to develop tailored messages and approaches using a variety of communication channels to develop positive behaviours; promote and sustain individual, community and societal behaviour change; and maintain appropriate behaviours. BCC is often an essential part of a comprehensive program that includes both services (medical, social, psychological and spiritual) and commodities (e.g., ITNs, condoms).

Before individuals and communities can reduce their level of risk or change their behaviours, they must first understand basic facts about the disease, adopt key attitudes, learn a set of skills such as putting up an ITN, and be given access to appropriate products and services. They must also perceive their environment as supporting behaviour change and the maintenance of safe behaviours, as well as supportive of seeking appropriate treatment for prevention, care and support.

According to the Family Health International Instgitute for HIV and AIDS, FHI (2002), the BCC has its roots in behaviour change theories that have evolved over the past several decades. These theories are valuable foundations for developing comprehensive communication strategies and programs. These include the Diffusion of Innovations model

(Everett Rogers), the Stages of Change model (Prochaska, DiClemente and Norcross), the Self-Efficacy model (Bandura) and the Behaviour Change Continuum (World Bank).

BCC approach is based on sound practice and experience, focuses on building local, regional and national capacity to develop integrated approach that leads to positive action by stimulating society-wide discussions. BCC is considered both an essential component of each program area and the glue between the various areas. However, society-wide change is slow and changes achieved through BCC will not occur overnight (FHI, 2002).

This paradigm has also come under criticisms by scholars who have argued that the current theories and models may not provide an adequate foundation on which to develop interventions and may be particularly unsuitable in sub-Saharan Africa and the developing world. They contend that the shifting terminology, which characterizes this field, is a pointer to the fact that BCC is an evolving area, rather than a coherent topic. It is neither a discipline, nor a science or an art. It encompasses conflicting approaches, too little measurement of impact, a variety of theories, and approaches that some feel are too mechanistic. Theories emerging from the West reflect change ideologies rooted in rational choice, individual transformations, and the role of reason and knowledge. BCC practices emerging in developing countries illustrate the role of the community, social acceptance, emotion, and emulation in personal change (http://www.apin.harvard.edu/Chapter15.pdf). Another school of thought argues that BCC that focuses on "target" audiences and fixed externally determined behavioural outcomes can violate the very principles that underlie work in the community: dignity, participation, and choice (Wikipedia, 2011).

Communication For Social Change Theory Contemporary communication has been undergoing paradigm shifts from linear to transactional and cyclical processes that combine traditional and modern communication technologies to achieve effective health communication. Obono (2011) notes that the Linear models which traditionally dominated communication research are limited in certain respects, hence, the emergence of more holistic models that could capture the different sides of social reality.

Moemeka, (1994) cited in Waisbord (2005), observes that in spite of the revision of the top- down, sender-receiver model of communication, the idea of ―communication as process‖ has gained centrality in approaches informed by both behaviour change and participatory models.

He argues that ―Communication should be seen both as an independent and dependent variable which can and does affect situations, attitudes, and behaviour, and its content, context, direction, and flow are also affected by prevailing circumstances. More importantly, communication should be viewed as an integral part of development plans –a part whose major objective is to create systems, modes, and strategies that could provide opportunities for the people to have access to relevant channels, and to make use of these channels and the ensuing communication environment in improving the quality of their lives‖ (1994).

New integrated models are today designed to address the complexity of the communication processes involved in health information dissemination in developing countries like Nigeria. The CFSC which is one such theory was therefore considered most appropriate in predicting and explaining the behaviour of pregnant women in Lagos State to communication messages on the adoption of ITNs for malaria prevention.

The CFSC is a brilliant example of recent efforts to integrate different theories and approaches in development communication (Rockefeller Foundation 1999). Whereas traditional interventions were based on behaviour-change models, CFSC relies on participatory approaches in emphasizing the notion of dialogue as central to development. Development is conceived as involving work to ―improve the lives of the politically and economically marginalized‖ (1998, 15). In contrast to the sender-receiver, information-based premises of the dominant paradigm, it stresses the importance of horizontal communication, the role of people as agents of change, and the need for negotiating skills and partnership. Another important contribution of CFSC is to call attention to the larger communication environment surrounding populations. In contrast to behaviour change and participatory theories that, for different reasons, pay little if any attention to the wide organization of information and media resources, CFSC calls attention to the relevance of ongoing policy and structural changes in providing new opportunities for communication interventions.

The preceding behaviour change theories such as BCC, and Health Promotion Model used communication as a tool to persuade people to change their behaviours towards desired goals and although these theories had been rated as successful in the developed world, they failed in the developing countries because like the earlier communication theories, they are individual based and do not take into account the true contexts and challenges facing people in developing countries. They were for the most part fashioned after the linear, top- down

80 communication process characterized by the transmission of knowledge of experts to the millions of uneducated using the mass media, in a persuasive advertising campaign style with the assumption that it will lead to behaviour change. Campaigns were characterized by one- way flow of communication and prevention messages, where the target audiences are not involved in the decision- making, sharing or ownership of ideas. This strategy like others before it was aimed at individual change in attitudes and behaviour with the assumption that the media is all powerful. Cullen, 2009: 104; White, 2009 and Huesca, 2008, while acknowledging that the afore mentioned theories among other development theories may have been effective in dealing with certain health problems in other societies, note that these theories had proved to be inadequate for health communication planning in Africa and other developing nations, which are community- driven and where decisions about preventing diseases are based on cultural norms that often override the individual‘s decision. For example, the BCC which was commonly used by International and Development Agencies in relation to HIV Behaviour Change Communication was found to be less effective because it was limited mainly to promoting the knowledge and skills of individuals without taking into account the wider social and economic contexts. This theory consequently came under criticisms for its inadequacy to respond to the challenges of the pandemic, thus setting the stage for the emergence of the Communication For Social Change theory (CFSC).

Similarly, unlike the participatory theories, CFSC stresses the need to define precise indicators to measure the impact of interventions. It is particularly sensitive to the expectations of funding agencies to find results of interventions, and to the needs of communities to provide feedback and actively intervene in projects. Here accountability, a concept that is also fundamental in contemporary global democratic projects, is crucial to development efforts. Projects should be accountable to participants in order to improve and change interventions and involve those who are ultimately the intended protagonists and beneficiaries

Servaes, cited in White (2004), proposed the ―multiplicity model‖ in which all nations and cultures follow different paths of social development, arguing that the cultures, social conditions and histories around the world are so diverse that each context will generate its own process. Several other development scholars emphasize the attention to the local cultural values, including religious values as motivations for engaging in new health behaviours. They also submit that development is not just introducing technology from the west, but

81 encouraging a process of socio- political change in power structures that opens a space of freedom for people‘s initiatives, knowledge and technical capacities.

The CFSC theory is an integrated model which draws from the earlier behaviour change theories already discussed in this section as well as a broad literature on development communication developed in the early 1960s, particularly the work of Latin American theorists, communication activists, and the Convergence, Conflict and Network theories.

The CFSC describes how communication processes might be used at a community level to bring about both individual and social change. It defines communication in this respect as the act of people coming together to decide who they are, what they want, and how they will obtain what they want. The rationale behind CFSC is that social change will be more sustainable if the affected community owns not just the physical inputs and outputs, but also owns the process and content of the communication involved. In support, Deane (2002), as cited in Govender, (2010) argue that behaviour change alone is not sustainable unless it also involves different kinds of social change. The CFSC model says that if any external agents wish to contribute to the process of communication and social change, they should shift their approach away from persuasion and one-way transmission of information, and instead engage in dialogue and discussion with members of the community.

Inspired by the academic rigor of Maria Elena Figueroa, Larry Kincaid and Jose Rimon of Johns Hopkins Centre for Communication Programs in 1999, it was initiated in Bellagio, Italy in 1997 at a Rockefeller Foundation sponsored conference of communication professionals, community organizers, and social change activists from 12 countries. Their mandate was to examine the connections between communication and social change in the 21st century and to explore the possibilities of new communication strategies for social change. Gray- Felder and Dean (1999) as cited in Figueroa (2002), indicate that a follow- up meeting took place in Cape Town, South Africa in 1998 and 2000. These meetings clarified the most important questions and provided the appropriate perspective for an inclusive and participatory model of social change, but they did not produce any specific model.

Following their recommendations and at the instance of Rockefeller Foundation, Figueroa and Kincaid developed an integrated model of Social Change Communication which bridged the gap between the questions defined by the meetings in Bellagio and Cape Town, and a resource that can be used to advance some answers to these questions- a framework that was

82 expected to provide a far more refined idea of how the work of development communication might actually proceed in the field. Also drawing from the theories of group dynamics, conflict resolution, quality improvement, as well as network and convergence theory of communication, the CFSC model describes an iterative process where community dialogue and collective action work together to produce social change in a community that improves the health and welfare of all of its members (Figueroa et al, 2000: iii).

With the adoption of the Ottawa Charter in 1986, the social and cultural dimensions of health behaviour change began to form the basis of promoting more effective communication approaches to disease prevention and control. Social scientists observe that beyond an individual‘s own social network, aggregates or categories, there are larger structural and environmental determinants that affect health behaviour such as living conditions related to one‘s employment and family life (Cullen, 105: 2009; Figueroa et al, 2002). For example cost of ITNs, lack of access and availability of ITNs, adequate literacy to enable understanding and appreciation of the benefits of sleeping under ITNs, belief that eating oily foods or exposure to the sun causes malaria, or that the man as the head of the family will sleep under the ITN as against the pregnant woman or under five child, all work against people adopting safe health behaviours.

Faulting the earlier communication models, Figueroa et al, (2000: 2), argue that it is inappropriate to base a model of communication for social change on a linear model of communication that describes what happens when an individual source transmits a message to a receiver or group of receivers with some desired or predetermined individual effect. They note that for social change, a cyclical and relational model of communication is required that can lead to an outcome of mutual change rather than one- sided individual change. The model is thus based on the following assumptions:

 Individual behaviours and choices are often mediated and structured by social relationships, which are in turn are influenced by important differences of community, social status, educational levels, class, group affiliations and other structural differences such as gender and age. Thus, individual behaviour is always contextualized and socially embedded (i.e. social influence and peer pressure are major determinants of behaviour change).

 There is social influence for individual behaviour changes where individuals who adopt new health behaviour publicly advocate its adoption to other individuals so that the rate of change (decline) in the prevalence of the disease increases.  Social change can be achieved through individual behaviour change such as the adoption of ITNs and visits to local health clinics that when aggregated leads to reduction in the prevalence of disease within communities which experience sufficient individual change  That communication is dialogue rather than monologue and is a cyclical process of information sharing as participants take turns creating information to share with one another and interpreting and reinterpreting its meaning until a sufficient degree of mutual understanding and agreement has been reached for collective action to take place. Turn taking in dialogue constitutes a minimal form of collective action as none are passive receivers of the information.  Dialogue represents a horizontal, symmetrical relationship among two or more participants that is created by sharing information. The outcomes of information processing by the participants are social — mutual understanding, agreement and collective action as well as individual perceiving, interpreting, understanding and believing.  That when community dialogue and collective action take place, members of a community take action as a group to solve a common problem, and this leads not only to a reduction in the prevalence of disease within the community but also to social change that increases the collective capacity to solve new problems. This implies that behaviour change is dependent on social change  That information or message can be verbal or non verbal, intended or unintended and is shared or exchanged between two or more individuals rather that transmitted from one to the other. All participants act on the same information which can be created by the action of any participant or may originate from a third source such as media, person or institution not directly participating such as church, school or non governmental agency among others.  That community is a multilevel concept ranging from local, geographically defined entities, such as villages, cities and nations, to international entities widely dispersed in space and time. It is not a homogenous entity but is comprised of subgroups with social strata and divergent interests (individual differences) with disagreements and

conflicts because those who do not see an issue the same way nor agree with other participants may drop out of the group. And although this ensures greater uniformity among those who remain, dialogue is a primary means of overcoming such divisions and leaders should guide community members through this.  That emphasis should shift from audience members as individuals to audience members as social groups  That there are external factors which hinder or facilitate community dialogue or collective action  That over time, most groups will converge toward a state of greater internal uniformity also referred to as local culture  Externally generated change such as the construction of health clinics by outsiders leads to a reduction in the prevalence of disease within the communities affected.

The CFSC describes a dynamic model that follows five stages, starting with a catalyst or stimulus which can be internal such as an increase in malaria morbidity and mortality, mass media including messages designed to promote individual healthy behaviour or collective action such as messages on the adoption of ITNs for malaria prevention, a change agent such as the ones used in most NGO interventions, an innovation such as ITNs, policies that prompt the community to act, and availability of technology.

The catalyst represents the trigger that initiates the second stage- the community dialogue about a specific issue of concern to the community.

The community dialogue and action is a series of steps some of which can take place simultaneously, leading to the solution of a common problem. Where a particular step is not successfully completed, the group may ―loop back‖ to an earlier point in the process and consider earlier decisions. The 10 steps in community dialogue are: recognition of problem, identification and involvement of leaders and stakeholders, clarification of perceptions, expression of individual and shared needs, vision of the future, assessment of current status, setting objectives, options for action, consensus on action and action plan.

The collective action which is the third stage refers to the process of effectively executing the action plan and the evaluation of its outcomes and this comprises implementation, among four other action steps.

Individual change- This is the fourth stage where the individual adopts and sustains the recommended behavior.

Social change- At this stage, sufficient participation and individual change, when widespread and sustained, has societal impact. Stages four and five both feed into each other, since eother can lead to change in the other.

Developed by Figueroa and Kincaid, June 2001

Catalyst

Internal Change Mass Innovation Policies Technology Stimulus Agent Media

2. Community Dialogue

Recognition of a Identification and Clarification Expression Vision of problem involvement of of of Individual the Leaders and perceptions and Shared Future Stakeholders Interests

Conflict-Dissatisfaction Disagreement

Action Plan Consensus of Options of Setting Assessment of Action Action 3. CollectiveObjectives Action Current Status

3. Collective Action

Assignment of Mobilization of Implementation Outcomes Participatory Responsibilities Organization Evaluation

Y individuals Y Media Y Outcomes of Objectives Y Existing Community Y Health Groups Y Education Y View Community Task Forces Y Religious

Y Others Y Other

4. Individual Change 5. Social Change

SOCIETAL IMPACT

Figure 2: Integrated Model of Communication for Social Change

(Source: Figueroa and Kincaid, 2001)

There are seven possible outcomes of social change, with many of the individual and social outcomes being related and affecting one another. For example, individual knowledge about a health problem is aggregated at the community level to determine the average level or distribution of that type of knowledge in the community. The relationship between individual and social change is exemplified by the case of malaria prevention by sleeping under ITNs by pregnant women or removing stagnant water sources in the individual‘s surroundings. If pregnant women are given ITN education during antenatal visits, and a consensus is reached through dialogue and a critical mass of people take joint action at the same time, and then the strategy can lead to an effective long term solution to the problem of mosquito- borne disease.

When community dialogue and collective action are implemented in the stipulated ways, then in addition to an improvement in the health status of the community‘s members, there will be an increase in the community‘s sense of collective self efficacy (the confidence that together they will succeed in other projects), sense of ownership (the degree to which they perceive themselves as being responsible for the success), social cohesion (their degree of interconnectedness and cooperation), social norms (accepted rules of participation and sharing of benefits) and collective capacity (their overall ability to engage in effective dialogue and collective action often made possible by social capital). Thus the dialogue and collective action process is a learning process whereby individual members through their participation in community projects increase their capacity for cooperative action and form social structures such as networks, teams, leader- follower relationships, which increase the community overall capacity for future collective action.

Figueroa et al argue that individual and social change is both necessary for attaining sustained health improvement. They explain that individual change is often limited to a short duration in time while in a situation where only social change occurs, if it is not accompanied by the required changes in individual behavior for health and indeed other areas of development, the capacity or potential for improvement in health or other areas of development may increase but with little impact (2002).

Figueroa et al (2002), identify the catalyst in the CFSC model as the missing piece in most of the literature about development communication which implies that the community spontaneously initiates dialogue and action or that an external change agent visits the community to mobilize the community. They argue that communities rarely initiate a

88 dialogue about a problem spontaneously and that some do take action on their own without being visited by external change agents. What the model implies is that some type of catalyst is usually necessary to stimulate a community to consider and discuss a problem.

Thus, according to Social Scientist Kippax (2007), the contextual, rather than the individual factor which forms a key part of the CFSC theory where the focus is on seeing people and communities as agents of their own change appear to be more relevant in planning communication strategies in community driven societies such as Nigeria and is consequently appropriate in explaining health behaviour among pregnant women in Nigeria. In fact, several Development organizations such as UNESCO (2001: 20) and UNICEF have echoed this view and appear to be using this theory in planning health behaviour change communication programs. For example during a UNICEF Workshop held in Kaduna from 20- 26 March, 2011, in which this researcher was a participant, part of the program of activities was a visit to the Kabala Community Leader‘s palace where participants were treated to one of the community dance and drama pieces used by the community to influence its members to adopt safe health behaviors such as sleeping under ITNs and hand washing. This theory therefore becomes relevant in explaining how communities use culture based edutainment programs, through participatory approach to bring about social change in communities, while the communities will in turn bring about individual development and behaviour change through interactions between people, culture and environment.

Figueroa and Kincaid (2002) describe the CFSC as both a descriptive and prescriptive model as it could be used to describe and explain why previous community projects were successful or unsuccessful. It can also be used by local leaders and external change agents to increase the likelihood that community action will be successful. Thus the CFSC challenges the media to extend coverage of ITN adoption from primarily a health story to one that is linked to social, economic, cultural and political factors. CFSC cannot be adequately understood using traditional gauges that only isolate and analyze quantitative results but rather demands a more qualitative assessment.

Modified CFSC Integrated Model

Figueroa et al have identified three levels at which the CFSC Model can be assessed or evaluated (Kincaid et al, 2002: IV) and these include:

 Members of the community who want to know how well their effort has achieved the objectives they set for themselves and would like to share the results with the rest of the community  External change agents involved in the process who need to document how well a community has performed, to inform governments, funding agencies and the community  Researchers who want to conduct systematic analysis of the relationship between the process and its outcomes across a sample of communities to share with practitioners as well as other scholars.

It is, however, the third and last level that suits the purpose of this study, since researcher carried out a systematic analysis of the relationship between the social context factors and their outcomes across a sample of pregnant women in Lagos State. Furthermore, Figueroa and Kincaid called for contributions and modifications from scholars to suit the context of applications. In view of the foregoing, the researcher developed a modified model to suit the study at hand (Figueroa et al, 2002).

The Modified CFSC Integrated Model (figure 3) is an adaptation of Figueroa and Kincaid‘s CFSC Integrated Model, with the only differences being the specifity given to some of the elements in the change processes and the addition of a few other elements such as ―interpersonal or social networks‖ and ―learning‖ as some of the factors leading to individual and social change. These additions were informed by researcher‘s field experiences and in- depth literature search.

Figure 3: Modified CFSC Integrated Model, 2011 Source: Field work

The catalyst

In the first step of the change process, which Figueroa and Kincaid identify as the catalyst, the researcher, in a bid to relate the model to the study at hand includes specific elements and indicators as attributes of the variables in the CFSC Integrated Model. These include the following:

 The addition of Messages as an attribute deriving from the Mass Media,  ITNs as an attribute of Innovations  Health facilities and Antenatal Clinics‘ workers as attributes of Change Agents and  Free Distribution of ITNs, as examples of Government Policies.

The rationale behind this was to give the model practical application and life. It demonstrates the place of the mass media in the daily lives of the people and how media messages can be used as catalysts, by creating awareness about an innovation such as ITN. Similarly, the creation and emergence of a new product can stimulate dialogue. In the same vein, health care facilities such as Antenatal care units can also create awareness about ITN to pregnant women who hitherto were not exposed to media messages about ITN through health education talks during antenatal visits. These health talks may also have been stimulated by a new government policy such as the free distribution of ITNs using hospitals as conduits or government mouthpiece.

Community dialogue

In the second stage of the behavior change process, Social Networks have also been added to Interpersonal networks. These are considered important; particularly in our environment which is community driven and people depend on social context factors such as grapevine, neighbours, colleagues, healthcare practitioners, opinion leaders, friends and family for information about innovations and decisions on whether or not to use these innovations. This became necessary in the face of researcher‘s empirical testing of social context factors as determinants of pregnant women‘s responses to the communication messages on the adoption of ITN.

Collective action

No additions were made to the variables in stage three because they were found to be adequate in explaining the process of behavior change among pregnant women in Lagos State. This stage describes the implementation step as the outcome of dialogue. This means that all stakeholders recognize that malaria is a major problem in society and consciously or unconsciously get involved in actions to sensitize and create awareness about ITNs as a major solution to the identified problem. For example, government may enact a policy of distributing free ITNs to pregnant women using health care facilities as conduits. Hospitals, in turn may develop health education programmes to create awareness and inform pregnant women about the benefits and efficacy of ITNs in preventing malaria. An example of this is the recent ITN sensitization campaign carried out by the NAF Hospital, Shasha, in the Oguntade community of Alimosho LGA, during which the doctors, nurses and other healthcare workers gave health talks to the community members and ITNs were distributed free to all pregnant women. Another example of collective action is the decision making and

92 implementation after informal discussions between neighbours, colleagues in the work place, online and offline friends and family members. The mass media also play a key role in collective action through their agenda setting and social responsibility functions. The frequency and prominence accorded ITN messages determine the importance the public attaches to it.

Individual change

―Learning‖ was added to the elements in stage four of the change process and this decision was premised on the assumption that knowledge, which is an important element in behaviour change, is a learned process. The goal of the communication campaign messages on the adoption of ITNs for malaria prevention is to teach new information about health risks and the behaviour that minimizes those risks. This agrees with the assumption of the Health Belief Model, which posits that knowledge is brought to target audiences through an educational approach that primarily focuses on messages, channels and spokespeople (Andreason, 1995 as cited in Schiavo, 2007: 38). It argues that in order to engage in healthy behaviours, intended audiences need to be aware of their risk for severe or life threatening diseases and perceive that the benefits of behavior change outweigh potential barriers or other negative aspects of the recommended actions. Learning can also be achieved through an observational approach, with the person observing an action, understanding its consequences and as a result of personal and interpersonal influences, becomes motivated to repeat and adopt it (Schiavo, 2007: 38). For example the process of acquiring the knowledge and skill of putting up an ITN is a learned process and understanding its benefits will motivate pregnant women to not only sleep under ITNs occasionally but daily. Schiavo‘s assertions are drawn from Bandura‘s Social Learning theory (1977, 1986 & 1999) the National Cancer Institute and National Institute of Health Reports (2002) as well as the Health Communication Partnership (2005c), which identify attention, retention, reproduction, performance and self efficacy as the key components in the learning process and the factors that influence them and which include a combination of personal and outside factors and events.

The argument here is that learning plays a vital role in the decision of pregnant women to use ITNs, their knowledge about how to use and their decision to repeat and adopt it by sleeping under ITN daily. The individual change stage also identifies environmental constraints as some of the barriers hindering their decision to use ITNs, repeat usage and sustain the behaviour.

Social change

The process of behaviour change in the CFSC model is cyclical and transactional in nature, while the stages are in some instances simultaneous with their attributes in some instances overlapping and at other times complementing one another. Although there may be differences in the timing of individual change among pregnant women, if the change widespread and sustained, it may lead to the desired social change. Each of the two levels of change however feeds into the other as social change will in turn lead to more individual change.

Logic of study

This study was anchored on the assumption that majority of the pregnant women in rural and urban Lagos will positively respond to the communication messages on the adoption of ITNs for malaria prevention. The assumption was premised on the argument that due to the predominantly metropolitan nature of Lagos, its widespread technology diffusion and penetration, mass media plurality, and access, abundance of and access to healthcare facilities, majority of them will be exposed to the ITN messages. Similarly, this study further claims that while these responses are influenced by social context factors, including family and friends, opinion leaders, healthcare workers, colleagues, neighbours and the mass media, other social context factors such as income, geographical location and educational levels will have no significant relationship with their responses.

REFERENCES

Abasiattai, A. M., Etukumana, E. A. & Umoiyoho, A. J. (2009). Awareness and practice of

malaria prevention strategies among pregnant women in Uyo, South- South Nigeria,

The Internet Journal of Gynaecology and Obstetrics, vol. 11(1)

Airhihebunwa, C. & Obregon, R. (2006). A critical assessment of theories/models used in

health communication for HIV/AIDS: Theories and models of behavior change. In A.

Gumucio- Dagron & T. Tufte (Eds.), Communication for social change anthology:

Historical and contemporary readings, pp. 623- 628. South Orange, NJ:

Communication for Social Change Consortium

Ajibade, O. (2010). Perspectives in modernization and the role of the mass media in the

development of Third World Countries. Journal of Communication review, vol. 4(2),

pp.41- 59, Lagos: Department of Mass Communication, University of Lagos.

Akinfeleye, R. A. (2007). Essentials of journalism: An introductory text for the beginner. 3rd

edition, Lagos: Unimedia Publishers

Akinfeleye, R. A. (2008). Nature of communication, culture, environment and society. In

R. A. Akinfeleye (Ed.), Health and behavior change communication for development,

pp. 9- 25. Lagos: Integrity Press Limited.

Akinfeleye, R. A. (2008). Social marketing paradigm: Message design theory and diffusion

for social mobilization. In R. A. Akinfeleye (Ed.), Health and behavior change

communication for development, pp.124- 134. Lagos: Integrity Press Limited.

Akinfeleye, R. A. (2008). Attitude and behavior change communication theories and

methodologies at a glance. In R. A. Akinfeleye (Ed.), Health and behavior change

communication for development, pp.184- 188. Lagos: Integrity Press Limited.

Akinfeleye, R. A. (2010). Message and the messenger: Challenges for an envisioned

development. Journal of Communication review, vol. 4(2), pp.115- 129, Lagos:

Department of Mass Communication, University of Lagos.

Anaeto, S. G., Onabajo, O.S. & Osifeso, J. B. (2008). Models and theories of

communication. Bowie, MD: African Renaissance Books Incorporated

Ansu-Kyeremeh, K. (2005). Indigenous communication in Africa: A conceptual framework,

in K. Ansu-Kyeremeh (Ed.), Indigenous communication in Africa: Concept,

application and prospects, pp. 15- 25. Accra: Ghana University Press.

Ayedun- Aluma, V. I. (2008). An information paradigm for development communication

Journal of Communication review, vol. 4(2), pp.119- 137, Lagos: Department of Mass

Communication, University of Lagos.

Backer, T. E., Rogers, E. M. and Sopory, P. (1992). Designing health communication

campaigns: What works? Thousand Oaks, CA: Sage

Bame, K. N. (2005). The use of indigenous entertainment forms in development

communication in Ghana, In K. Ansu-Kyeremeh (Ed.), Indigenous communication in

Africa: Concept, application and prospects, pp. 65- 84. Accra: Ghana University

Press.

Baran, J. & Davis K. (2003). Mass communication theory: Foundations, ferment and future

(3rd ed.). Belmont, C A: Wadsworth.

Baran, J. & Davis K. (2009). Mass communication theory: Foundations, ferment and future

(5th ed.). Belmont, C A: Wadsworth.

Baran, S. J. (2010). Introduction to mass communication: Media, literacy and culture (6th

ed.). New York: McGraw Hill

Batta, H. E. (2011). Knowledge of traditional medicine among Nigerian journalists:

Implications for journalism education, the new media and national development. The

Nigerian journal of communication: The Journal of the African council for

communication education (ACCE), Nigeria chapter, vol. 9(1), pp. 204- 234. Uyo:

Bsm Resources

Bittner, J. R. (1989). Mass communication: An introduction (5th ed.). New Jersey: Prentice

Hall

Bittner, J. R. (2003). Mass communication: An introduction. Ibadan: Heinemann

Educational Books Nigeria, Plc.

Buckalew, J. K. and Wulfemeyer, K. T. (2005). Mass media in the new millennium:

Structures, functions, issues and ethics. Dubuque, I.O.: Kendall/Hunt Publishing

Company

Byrne, A. (2009). Evaluating social change communication: Expert group meeting.

Retrieved March 12, 2011 from http://www.communicationforsocialchange.org/

Chaffee, S. H. (1980). Mass media effects: New research perspectives. In Wilhoit, G. C.

(Ed.). Mass communication review yearbook, pp. 77- 108, Beverly Hills CA.: Sage

Publications

Croteau, D. & Hoynes, W. (2000). Media society: Industries, images and audiences

Thousand Oaks: Pine Forge Press.

Curran, J. M. and Rosen, D. E. (2006). Student attitudes toward college courses: An

examination of influences and intentions. Journal of Marketing Education, 28 (2), pp.

135-148

Daramola, I. (2001). Introduction to mass communication. Lagos: Rothan Press Limited

Davis K. and Baran, J. (1981). Mass communication and everyday life: A perspective on theory and effects. Belmont, C A: Wadsworth.

Disssayanake, W. (2000). Development communication: The interplay of knowledge, culture

and power. In A. Moemeka, (Ed.), Development communication in action. Maryland:

University Press of America.

Federal Ministry of Health. (2010). National malaria control programme: Advocacy,

communication, and social mobilization strategic framework and implementation

plan. Abuja: Federal Ministry of Health

Federal Ministry of Health. (2010). National malaria and vector control programme.

Guidelines for the implementation of indoor residual spraying for malaria vector

control in Nigeria. Abuja: Federal Ministry of Health

Federal Ministry of Health. (2010). National policy on malaria diagnosis and treatment

Abuja: Federal Ministry of Health

Federal Ministry of Health. (2010). World malaria day: “Counting malaria out” “Count me in”. Abuja: Roll Back Malaria

Ferguson, S. D. (1999). Communication planning: An integrated approach. Thousand Oaks:

Sage Publications

Figueroa, M. E., Kincaid, D. L., Rani, M. & Lewis, G. (2002). Communication for social

change: An integrated model for measuring the process and its outcomes. In Brian

Bryd (Ed.). Communication for social change: Working paper series one. New York,

New York: The Rockefeller Foundation

Folarin, B. (2005). Theories of mass communication: An introductory text. Abeokuta: Link

Publishers

Gitlin, T. (2003). Media unlimited: How the torrents of images and sounds overwhelm our

lives. New York, N.Y.: Henry Holt and Co.

Govender, E. M. (2010). How effective is HIV and AIDS communication in Africa? Journal

of African communication research, pp. 205- 234. Mwanza, Tanzania: Faculty of

Social Sciences and Communications at University of Tanzania

Herman, E. S. & Chomsky, N. (1999). A propaganda model. In J. Hansen & D. J. Maxcy

(Eds.), Sources: Notable selections in mass media pp. 180- 192, Connecticut: Dushkin

Publishing Group.

Huesca, R. (2008). Tracing the history of participatory communication approaches to

development: A critical appraisal. In J. Servaes (Ed.), Communication for

development and social change (pp.180- 198), London: Sage Publications

Jeffres, L. W. (1997). Mass media effects (2nd ed.). Illinois: Waveland Press.

Kreps, G. L. & Bonaguro, E. W. (2009). Health communication as applied communication

inquiry. In L, Frey. and K, Cissna (Eds.) Routledge handbook of applied

communication research, New York: Routledge

Lagos State indicator (December, 2009). Unveiling the Lagos State public works

corporation: 1000 days. Lagos: Ministry of Information

Littlejohn, S. W. and Foss, K. A. (2008). Theories of human communication, Belmont, CA.:

Thompson Wadsworth.

MacBride, S. (1981). Many voices, one world, Ibadan: University of Ibadan Press

Makemba, A. M., Winch, P. .J., Kamazima, S. R., Makame, V. R., Sengo, F., Lubega, P. B.,

Minjas. J. N. and Shiff C J (1995). Community-based sale, distribution and

insecticide impregnation of mosquito nets in Bagamoyo District, Tanzania. Health

Policy and Planning 10 (1), pp. 50-59

McNamara, J. (2005). Mass media effects: A review of 50 years of media effects research.

Australia: Carma international.

Nwuneli, O. E. (1983). Traditional channels of communication. Journal of language and

Communication, vol. 2(3)

100

McCombs, M. E. and Becker, L. (1979). Using mass communication theory. New Jersey;

Prentice Hall Inc.

McQuail, D. (2005). McQuail’s mass communication theory (5th Ed.). Los Angeles,

CA.: Sage Publications.

McQuail, D. (2010). McQuail’s mass communication theory (6th Ed.). Los Angeles,

CA.: Sage Publications.

Melkote, S. (2003). Theories of development communication. In B. Mody (Ed.).

International and development communication: A 21st century perspective, pp. 129-

146. London: Sage Publications

Mefalopulos, P. (2008). Development communication sourcebook: Broadening the

boundaries of communication. Washington, D. C.: The World Bank

Moemeka, A. A. (2000). Audience participation and messages effectiveness in radio

broadcasting for health education: A case study from Nigeria. In A. Moemeka (Ed.),

Development communication in action. Maryland: University Press of America.

Moemeka, A. A. (2000). Development communication: Strategies and methods. In A.

Moemeka, (Ed.), Development communication in action, pp. 115- 132. Maryland:

University Press of America.

Moemeka, A. A. (2000). Development and mass communication: Effective use of the mass

media in rural (or inner-city) development. In A. Moemeka, (Ed.), Development

communication in action, pp. 133- 160. Maryland: University Press of America

101

Ochonogor, C. and Iroham, B. (2011). Ensuring a safe driving habit in Nigeria through public

service announcements. In Des, Wilson, (Ed.), Communication for social change and

development, pp. 69- 90, Uyo: BSM Resources for Africa Council for Communication

Education

Ogwezzy, A. O. (2008). African communication systems: Concepts, channels & messages.

Bowie, Maryland: African Renaissance Books Incorporated.

Okunna, C. S. (1999). Introduction to mass communication, (2nd ed.). Enugu: New

Generation Books.

Oso, L. (2008). ACADA model for development: Meaning, elements and application. In

R. A. Akinfeleye (Ed.), Health and behaviour change communication for

development, pp. 151- 159. Lagos: Integrity Press Limited.

Paterson, B. L., & Thorne, S. (2003). Enhancing the evaluation of nursing care

effectiveness. Canadian Journal of Nursing Research, vol. 35(3), pp. 26-38.

Pyrczak, F. (2000). Completing your thesis or dissertation: Professors share their techniques

and strategy. Los Angeles, C.A.: Pyrczak Publishing

Reardon, C. (2003). Talking cure: A case study in communication for social change. In Brian

Bryd (Ed.). Communication for social change: Working paper series two. New York,

New York: The Rockefeller Foundation

Rodman, G. (2006). Mass media in a changing world: History, industry, controversy. New

York: McGraw Hill.

102

Rogers, E. M. (1995). Diffusion of innovations, 4th edition New York. NY: The Free Press

Schiavo, R. (2007). Health communication: From theory to practice, Biotechnology Journal

of Health Communication: doi.wiley.com/10.1002/biot.200790098 Retrieved March

12, 2011 from http://books.google.com/books/about/Health_communication.html?id=

Sosale, S. (2008). Communication, development and democracy: Mapping a discourse.

Cresskill, N.J.: Hampton Press Inc.

Steeves, H. L. (2003). Development communication as marketing, collective resistance and

spiritual awakening: A feminist critique. In B. Mody (Ed.), International and

development communication: A 21st century perspective. Thousand Oaks: Sage

Synder, L. B. (2003). Development communication campaigns, In B. Mody. (Ed.),

International and development communication: A 21st century perspective, pp. 167-

188. Thousand Oaks: Sage

Thornton, B. C. and Kreps, G. L. (1993). Perspectives on health communication. Prospects

Heights, I.L.: Waveland Press, Inc.

UNICEF. (2007). Interpersonal communication skills in the prevention of mother-to-child

transmission of HIV: A training manual for health workers. Abuja, Federal Ministry

of Health and UNICEF

Uwakwe, O. (2010). Introduction to mass communication in the digital age: Print-radio-TV-

film-internet-industry-effects. Onitsha: Base 5 Publishers Limited

103

Waisbord, S. (2001). Family tree of theories, methodologies, and strategies in development

communication. New York, New York: The Rockefeller Foundation.

Waisbord, S. (2005). Five key ideas coincidences and challenges in development

communication. In O. Hermer & T. Fufte (Eds.). Media and global change:

Rethinking communication for development, pp. 77-78. Buenos Aires: Nordicom

Watson, J. (2003). Media communication: An introduction to theory and process (2nd

Ed.). New York: Palgrave Macmillan

White, R. (2009). Research on communication for development in Africa: Current debates.

African communication research, 2(2) 203-252. Tanzania: Faculty of Social Sciences

and Communications at St. Augustine University.

Wilson, D. (2005). Taxonomy of traditional media in Africa. In K. Ansu-Kyeremeh (Ed.),

Indigenous communication in Africa: Concept, application and prospects, pp.39- 61

Accra: Ghana University Press.

Wimmer, R. D. & Dominick, J. R. (2011). Mass media research: An introduction ( 9th

Ed.). Belmont, C.A: Thomson Wadsworth.

Internet Sources

Adedotun, A.A., Morenikeji O.A & Odaibo. (2010). Knowledge, attitudes and practices

about malaria in an urban community in South-Western Nigeria. Retrieved January

27, 2011, from http://www.fags.org.

104

Animut, I., Gebre-Michael, T., Medhin, G., Balkew, M., Bashaye, S. & Seyoum, A. (2008).

Assessment of distribution, knowledge and utilization of insecticide treated nets in

selected malaria prone areas of Ethiopia. Ethiopian Journal on Health Development,

3 (issue), 268-274. Retrieved June 19, 2011, from http://ejhd.uib.no/ejhd-v22-n3/268

Baume C. A. & Celeste Marin, M. (2008). Gains in awareness, ownership and use of

insecticide treated nets in Nigeria, Senegal, Uganda and Zambia. Retrieved February

27, 2011, from http://preview.malariajournal.com/content/7/1/153/

Beiersmann, C., De Allegri, M., Tiendrebéogo, J., Yé, M., Jahn, A, and Mueller, A. (2010).

Community perceptions on different delivery mechanisms for insecticide- treated bed nets in rural Burkina Faso. The open public health journal. Vol. 9 (352), Retrieved June 19, 2011 from http://www.ncbi.nlm.nih.gov /pmc/articles /PMC3003674/

Chester, P. (2010). Malaria kills: Distributing 63 million bed nets in Nigeria with rapid sms.

Retrieved July 31, 2010, from http://www.mobileactive.org.

Choi, H. W. et al (1995). The effectiveness of insecticide impregnated bed nets in reducing

cases of malaria infection: a meta-analysis of published results. American Journal of

Tropical Medicine and Hygiene, pp. 377-382 Retrieved July 31, 2010, from

http://www.healthcomms.org

Cullen, T. (2009). Health communication theories: Implications for HIV reporting in Asia

and the Pacific. Asia Pacific media monitor, vol. 19(10), pp. 99-111. Retrieved March 20, 2011, from http://ro.uow.edu.au/apme/vol1/iss19/10

Davenport, J. Prusak, M. (1998). Of knowledge and probability: An essay concerning human

understanding. Retrieved March 20, 2011 from http://www.nwlink.com

De- Valenzuela, S. J. (2002). Sociocultural theory. Retrieved June 18, 2011, from

http://www.unm.edu/~devalenz/handouts/sociocult.html

105

Dunn, A. (2005). Participatory communication in malaria control: Why does it matter?

International perspectives on health communication, vol. 6(4). London: Exchange.

Retrieved December 20, 2010 from http://www.healthcomms.org

Edelu, B. O., Ikefuna, A. N., Emodi, J. I. and Adimora, G. N. (2010), Awareness and use of

insecticide-treated bed nets among children attending outpatient clinic at UNTH,

Enugu: The need for an effective mobilization process. Journal of African Health

Sciences, vol. 10(2), pp. 117–119. Retrieved June 19, 2011, from

http://www.ajol.info/journal

Espino, F. et al (1997). Perceptions of malaria in a low endemic area in the Philippines:

Transmission and prevention of disease. Journal of Acta Tropica, Vol. 63, pp. 221-

239. Retrieved June 19, 2011, from http://www.healthcomms.org

Federal Ministry of Health Nigeria. (2005). National Malaria Control Programme in

Nigeria. Retrieved June 19 2011 from http://www.who.int/countries /nga/areas/

malaria/nmcp_annual_report_2005.pdf

Federal Ministry of Health Nigeria (2008). A strategy for behaviour change communication

in the Roll Back Malaria Programme, Nigeria, Retrieved June 19 2011 from

http://nmcpnigeria.org/f/acsm/BCC

Gumucio-Dagron, A. (2010). Communication for social change: A key for participatory

development. Retrieved March 12, 2011 from http://knol.google.com/k/

communication-for-social-change#

106

Habtai, H., Ghebremeskel,T., Mihreteab, S., Mufunda, J. & Ghebremichael, A. (2008).

Knowledge, attitudes and practices about malaria among people visiting referral

hospitals of Eritrea. Journal of Eritrean medical association, vol. 4(1). Retrieved June

19, 2011, from http://www.ajol.info/index.php/jema/article/view/52117

Heggenhougen, K., Hackenthal, V. & Vivek, P. (2003). Participatory communication in

malaria control: Why does it matter? Retrieved June 19, 2011, from

http://www.healthcomms.org

Hwang, J., Graves, P., Jima, D., Reithinger, R. and Kachur, S. (2007). Knowledge of

malaria and its association with malaria-related behaviors: Results from the malaria

indicator survey, Ethiopia. Retrieved January 27, 2011, from http://www.dx.

crossref.org

Kudom, A. A. and Mensah, B.A. (2010). The potential role of the educational system:

Addressing the effect of inadequate knowledge of mosquitoes on use of insecticide-

treated nets in Ghana. Retrieved January 27, 2011, from http:// www .malariajournal

.com/ content/9/1/256

Lagos State Ministry of Health. (2011). Malaria control program. Retrieved September 28,

2011, from http://www.lsmoh.com/programme_info.php?programme_id=6

Mwenesi, H. A. (2008). Sociocultural and behavioural issues in the treatment and prevention

of malaria: Paper for the WHO/TDR scientific working group on malaria, Geneva,

Switzerland, 24–27 March 2003. Retrieved September 4, 2010, from

http://www.tropika.net/svc/review/030324-Malaria_4

107

Nigerian institute of medical research annual report (2009). Retrieved June 18, 2011 from

http://www.nimr.gov.ng/_areports/2008

Onwujekwe, O, Uzochukwu, B., Ezumah, N. and Shu, E. (2005). Increasing coverage of

insecticide-treated nets in rural Nigeria: Implications of consumer knowledge, preferences and expenditures for malaria prevention. Malaria Journal, vol. 4(29) doi:10.1186/1475-2875-4-29

Ribera, J. M., Hausmann- Muella, S., D‘Alessandro, U. & Grietens, K. P. (2007). Malaria in

pregnancy: What can social sciences contribute? Retrieved June 18, 2011, from www.plosmedicine.org/article/info:doi/10.../journal.pmed.0040092

Roll back malaria factsheet. (2011). What is the roll back malaria (RBM) partnership?

http://www.malariafreefuture.org/resources/factsheets/RBMFactSheet.pdf Roll back malaria information sheet (2002). What is roll back malaria? Retrieved September

28, 2011, from https://apps.who.int/inf-fs/en/InformationSheet02.pdf

Roll Back Malaria concept paper, (2003) Retrieved October 8, 2010, from

http://www.rbm.who.int

RBM update (2011). The vision, the mission, the goal. Retrieved September 28, 2011, from

http://nmcpnigeria.orf/ROLL%20BACK%20MALARIA%20IN%20NIGERIA-

update%20for%20HMH.pdf

Tavoosi, A., Zaferani, A., Enzevari, A., Tajik, P. & Ahmadinezhad, Z. (2004). Knowledge

and attitudes towards HIV/AIDS among Iranian students. Retrieved March 15, 2011, from http://www.pibmedcentral.nih.gov/articlerender.fcg.?article420470

Tilson, D. (2007). The social marketing of insecticide-treated nets (ITNS) in Kenya: Cases

in public health communication & marketing. Retrieved January 27, 2011, from

http://www.casesjournal.org

108

Sabin, L., Rizal, A., Brooks, M., Singh, M., Jordan, T., Wylie, B., Joyce, K., Yeboah- Antwi

K., Singh, N. and Hamer, D. (2010). Attitudes, knowledge, and practices regarding malaria prevention and treatment among pregnant women in Eastern India. The American journal of tropical medicine and hygiene 2010 vol. 82 (6), pp. 1010-1016, doi: 10.4269/ajtmh.2010.09-0339. Retrieved January 27, 2011, from http://www. http://www.ajtmh.org/content/82/6/1010.full

World Health Organization. (2010). World malaria report 2010, retrieved January 27, 2011,

from http://www.who.int/malaria/world_malaria_report_2010/en/index.html

World Health Organization. (2010). World malaria report 2010, retrieved January 27, 2011,

from http://www.who.int/malaria/publications/atoz/9789241564106/.../index.html

World Health Organization. (2003). Africa malaria report 2003, retrieved January 27, 2011,

from http://www.rollbackmalaria.org/amd2003/amr2003/amr_toc.htm

Ziglar, Z. (2008). Attitude makes all the difference. Retrieved, October 2, 2011, from

http://fibo777.hubpages.com/hub/attitude-in-life-some-notes-about-positive-and-

negative-attitude

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CHAPTER THREE

Methodology

Introduction

This study set out to determine the receptivity of pregnant women in rural and urban Lagos, to RBM Communication Campaign messages on the adoption of ITNs. To this end it examined their patterns and degree of exposure to communication messages on the adoption of ITNs, their major sources (channels/media) of communication/information such as mass media and/or interpersonal sources, their responses and reasons for the responses, and the extent to which their socio cultural and demographic contexts such as geographical location, educational and income levels, beliefs, norms, traditional practices and values as well as demographic factors influence their responses. It also set out to find out other barriers to the adoption of the messages.

In this chapter the methods of data collection and analyses for the study are presented and they provide the blueprint for inquiry into the research problem.

RESEARCH DESIGN AND METHOD

This study though exploratory is also descriptive and explanatory as it attempted to determine not only the exposure levels of the target audience to communication messages on the adoption of ITNs and the responses to the messages, it also examined the reasons for the responses. The multi-method or triangulation approach, achieved through the use of both quantitative and qualitative methods was used and this included the Survey, Focus Group Discussion and the Intensive or In-depth Interview methods.

Decision to use triangulation was premised on the logic that since the researcher sought to determine the knowledge levels, beliefs, attitudes and behaviors of pregnant women towards communication campaign messages on the use of ITNs and the reasons for their behaviors, a single method was not considered adequate in providing answers to the relevant questions required to address the many issues emanating from a study of this breadth and depth. This is in agreement with Wimmer and Dominick‘s view of triangulation as the use of both qualitative and quantitative methods to fully understand the nature of a research problem (Wimmer and Dominick, 2011).

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Wimmer and Dominick, (2011) also argue that neither the quantitative nor the qualitative method is better than the other as each approach has value and the decision to use one or the other depends on the goals of the research. However, each of the three methods has its shortcomings, and using more than one method makes up for these. For example, the Survey method which is quantitative in nature possesses breath, but lacks depth since it can only answer the question ―how much‖ or ―how many‖. This weakness can be made up by the use of focus group discussion method which has its own weakness of only being able to answer the questions ‗why‖ and ―how‖, consequently making up for the depth which the survey method lacks. Patton, (1990), & Glaser and Strauss, (1967), note that multiple sources help to overcome flaws inherent in the use of one method as different types of data provide cross- data validity checks. They observe that for instance in an interview the researcher cannot trust all statements made by the respondent, not merely because of his intention to mislead the researcher, but because of social rules about what can and cannot be told (Cited in Obijiofor, 2009).

Survey, which has been chosen as the major method of this study is defined by Sobowale (2008) as a method involving the use of questionnaire and/or statistical surveys to gather data about people and their thoughts and behaviors. It is considered quantitative in nature and ideal for measuring knowledge, attitudes and behaviors of a large number of people. Trochim (2006) notes that survey research is one of the most important tools of measurement in applied social research, encompassing any measurement procedures that involves asking questions of respondents. Wimmer and Dominick (2011) identify the ability to collect a large amount of data with relative ease from a variety of people as the advantage of this method over other research approaches, and its flexible nature, which allows researchers to examine many variables such as demographic and lifestyle information, attitudes, motives, intentions and behaviors and to use a variety of statistics to analyze the data. Since this study deals with a large sample it naturally lends itself to the survey method as its major research design.

Wimmer and Dominick (2006) observe that the survey method was pioneered in the 1930s and 1940s and was initially used by Paul Lazarsfeld to examine the effects of radio on political opinion formation in the United States. They note that it has since formed the basis for the setting up of the quantitative research in the Social Sciences and used widely as one of the most effective scientific research techniques.

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The second method chosen for this study is the Focus Group Discussion approach. This method has been described by Wimmer and Dominick (2006) as a qualitative research strategy for understanding audience attitude and behavior. They note that this method deals with a relatively low number of people (from 6 to 12) interviewed simultaneously with a moderator leading the respondents in a relatively unstructured discussion about the focal topic. According to them, the focus group technique has four defining characteristics and these include the following:

 Focus groups involve people  The people possess certain characteristics and are recruited to share a common quality or characteristic of interest to the researcher.  Qualitative data from focus groups are used to enhance understanding and to reveal a wide range of opinions, some of which the researcher might not expect.  Focus groups have a focused discussion and most of the questions asked are predetermined, the sequence of questions established and the questions designed to further the goal of the researcher. The moderator is however free to depart from the structure if relevant information is presented by the participants (Wimmer and Dominick, 2006).

This method was also considered ideal for this study because its characteristics adequately address the needs of this study, since it gathers qualitative data to answer the questions of ―why‖ and ―how‖. Although it rarely provides exact numbers and percentages except where enough groups are conducted, it is expected to make up for the lack of depth in the answers generated by the survey method. Furthermore, unlike in the survey method, where the respondents are restricted to answering a structured set of questions, the focus group discussion gives plenty of room for the participants to express their thoughts, therefore revealing a wide range of opinions some of which the researcher did not anticipate. Whereas the interviewer in Survey works from a rigid series of questions, the moderator in Focus Group though working from a list of broad questions is able to follow up on important points raised by participants in the group, and is able to clear up confusing responses from subjects during the discussion. Wimmer and Dominick identify another advantage of Focus Group Discussion as the ability of one respondent‘s remarks to stimulate new lines of thinking from other participants and with a competent moderator can have a snow ball effect as one respondent comments on the views of others while the moderator can also detect the thoughts

112 of the less articulate ones through their gestures and facial expressions when others are talking.

The third method considered appropriate for this study is the in-depth or intensive interview approach. This is also a qualitative technique for obtaining in-depth and comprehensive information that are not easily available to the researcher using the Survey method. It involves one person interviewing another for detailed information. The intensive interview design was used to gather data about the communication strategies used in the Roll Back Malaria Campaign on ITN adoption and the barriers encountered, from two members of the RBM Implementation Committee and three health care practitioners. These included the Communication officer of UNICEF, Lagos- Mrs. Caroline Akoshile, the Deputy Director, Federal Ministry of Information, Mrs. Adelaide Ojogu, the Commanding Officer of the NAF Hospital Shasha- Squadron Leader (Dr.) Johnson Udodi, the matron at the 445 NAF Hospital Ikeja, and the matron at the General Hospital, Ifako- Ijaye.

Using qualitative methods are vital to understanding not only audiences‘ communication behaviors but also the reasons for those behaviors, and this is critical to the success and sustainability of any community based health program.

POPULATION OF STUDY

The target population for this study comprised all pregnant women in urban and rural Lagos. Although the National Population Commission of Nigeria puts the population of women in

Lagos State at 4,394,480, the Lagos State Government puts it at 8,437,901. Due to the transitory nature of pregnancy, however the population of pregnant women is unknown. Decision to study only one state in Nigeria was informed by financial constraints; time that would not allow a study with national spread; and the fact that malaria is endemic in all Nigerian States. Lagos State was also purposively selected from the 36 states in the country, because it is one of the states with the highest malaria occurrence and outpatient visits to secondary hospitals.

SAMPLE AND SAMPLING TECHNIQUES

The sample for the survey consisted of 529 pregnant women selected from ten hospitals and five Maternity Homes in four urban and one rural local government areas in Lagos State. The

113 samples were selected from two Antenatal clinics (ANC) of two hospitals and one Maternity Home drawn from a list of health care facilities in each of the five selected Local government areas in rural and urban Lagos. Decision to use Antenatal clinics Maternity Homes was premised on the logic that these health care facilities are the crucial points of contact for malaria prevention during pregnancy (Ribera et al) and States in Nigeria, especially the South West, South East and South - South States have been rated to record high levels of ANC attendance (RBM Report, 2008- 2010).

The multistage cluster, the systematic as well as the simple random sampling technique were used to select the sample for this study. Specifically, the LGAs were stratified into rural and urban settings, while the selected hospitals were stratified by types such as public/government owned and private owned. This technique was chosen to ensure that the desired samples were drawn from the population of pregnant women from the two different geographical locations. This was to determine if geographical locations influence the responses of the sampled pregnant women in urban and rural Lagos.

Justification for the choice of the multistage cluster technique was premised on its appropriateness for national and state studies. Since it would have been impracticable for the researcher to have a complete list of the population of pregnant women in Lagos State, the sample was selected in groups and categories, thus the state was divided into Local governments and then Hospitals and the pregnant women were selected from each antenatal care clinic of the hospitals selected. The use of the multistage cluster technique for selection of respondents involved six stages.

At the first stage, Lagos State was purposively selected and this decision was premised on the fact that though malaria is endemic in all States in the country, Lagos State is one of the states with the highest malaria incidence.

At the second stage, five Local Government Areas were selected also using the simple random sampling technique. The 1999 Constitution of the Federal Republic of Nigeria and the 2011 Calendar of the Ministry of Local Government Affairs, Alausa, Lagos, as well as the Lagos Indicator, a publication of Lagos State government, were used as sampling frames for picking the five Local Government Areas in Lagos State. The five LGAs selected include: Four urban namely- Lagos Island, Alimosho, Ikeja and Ifako- Ijaye and one rural- Ibeju- Lekki. Alimosho and Ifako- Ijaye LGAs have been classified by Lagos State Government as urban and this is perhaps because the land use is in many ways dynamic, with extreme

114 population growth or movement, intense road infrastructure development and a high degree of commuting. For instance, the National Population Commission puts Alimosho as the LGA with the highest population in Lagos State with 1,277,714 people (National Census, 2006). Some may classify Alimosho and Ifako- Ijaye as semi urban since scholars have defined semi urban areas as being so classified when it can be proven, possibly by using a reference landscape, that the area of study is neither ―pure‖ urban core (village, city, town), nor ―pure‖ agricultural‖ land, nor ―pure‖ natural area (Meeus and Gulinck, 2008) and indeed there are areas of the two LGAs that cannot yet be classified as urban. However, the Lagos State Government classification is employed in this study.

Simple random sampling technique gives every unit of the population an equal opportunity of being represented in the sample of study, but is often used for drawing samples from smaller populations. In this study therefore, it was used to obtain the samples in the four stages.

At the third stage two hospitals and one Maternity Home were selected from each Local Government Area also using the simple random sampling technique. There are a total of 28 Public hospitals in Lagos State: three belonging to the Federal Government hospitals and 25 to Lagos State government (See Appendix 2a). There are also a total of 222 registered Private hospitals and Maternity Homes in the five selected LGAs in Lagos State (See Appendix 2b). Ten hospitals and five Maternity Homes were selected; one public and one private hospital and one Maternity Home from each of the four urban and one rural Local Government Areas and these include the following:

1. Lagos Island LGA (Urban)

There were one Federal government and four State government hospitals and 27 private hospitals and Maternity homes in Lagos Island LGA. Of these, one government and one private hospital were selected using the simple random sampling technique and these are:

I. Island Maternity, Lagos - Government owned II. St. Nicholas Hospital, Lagos- Private owned III. Obalende Maternity Home

2. Ikeja LGA- (Urban)

Technically, there were two government hospitals, one federal government and one Accident/Emergency hospital in Ikeja LGA. The other State general hospital was under

115 renovation at the time of this study. The federal government hospital therefore became the natural choice for government hospital since the Accident/Emergency hospital did not have an antenatal clinic. There were also 58 private hospitals and maternity homes, out of which one each was selected through the random sampling technique. The selected hospitals and Maternity Homes are as follows:

I. 445 Nigerian Air Force Hospital, Ikeja- Government owned II. Lagoon Hospital, Ikeja- Private owned III. Moye Maternity Home

3. Ifako- Ijaye LGA- (Urban)

The only State government hospital was also selected as well as one private hospital and one Maternity Home drawn from the 15 hospitals and maternity homes in Ifako- Ijaye LGA.

I. Ifako- Ijaye General Hospital- Government owned II. Gideon Salvation Specialist Hospital, Oke-Ira, Ogba - Private owned III. Blessed Divine Maternity Home

4. Alimosho LGA- (Urban)

Alimosho LGA recorded the highest number of hospitals with two government hospitals (one federal and one state), and 115 private hospitals and maternity homes. Of these, one government and one private as well as one Maternity Home were selected, using the simple random sampling technique and these are as follows:

I. Nigerian Air Force Hospital, Shasha- Government owned II. Crystal Hospital, Akonwojo- Private owned III. Remtina Maternity Home, Shasha

5. Ibeju- Lekki LGA (Rural)

Conversely, Ibeju- Lekki recorded the lowest number of hospitals with one state government and 7 private hospitals and Maternity homes. Again, the government hospital was selected, as well as one private hospital and one TBA using the simple random sampling technique. Health facilities selected include:

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I. General Hospital, Akodo- Government owned II. Royal Infirmary Hospital- Private owned III. Adebek Maternity Center, Obadore-

At the fourth stage, the Systematic sampling technique was used to select varying samples from the health facilities in the five LGAs. These samples were selected from a list of 1,370 registered pregnant women who attended antenatal clinics on the scheduled antenatal clinic days which varied from hospital to hospital. In each of the hospitals, 40% of the population of 1,370 pregnant women attending clinics on all the chosen antenatal days was selected. The systematic sampling technique was used to select the samples at the hospitals while the convenience sampling technique was used to select 10 pregnant women, two from each from the Maternity Homes. A total sample size to 548 pregnant women was drawn from the list of registered women which was obtained from the matrons in each of the antenatal care units. These lists constituted the sampling frame from which the samples were selected. This meant that the sample size obtained from each antenatal clinic depended on the population of the registered pregnant women attending antenatal care on the selected days. A total of ten pregnant women were also selected from the five selected Maternity Homes bringing the total sample size to 558. Of this number 529 correctly filled out their questionnaires, making it a 95% return rate. The selections were made as follows:

LAGOS ISLAND LGA

1. Island Maternity

At the Island Maternity, research assistants found that the antenatal clinic was open every week day except Wednesdays. Two days of the week- Tuesday and Thursday were selected using the simple random sampling technique. On the two selected days a total of 250 women attended antenatal clinic and using the systematic sampling technique, 100 constituting 40% of the population of pregnant women were drawn and surveyed. 89 out of the 100 selected filled out usable questionnaires, others were either too tired or simply complained that the questions were too many.

2. St Nicholas

Similarly, at St. Nicholas Hospital, antenatal days were scheduled for Tuesdays, Wednesdays and Fridays. Of the 75 registered pregnant women who attended antenatal clinic on the two selected days, 30 of them constituting 40% were chosen through the systematic sampling

117 technique. However 29 questionnaires were properly filled and considered usable at the end of the day.

3. Obalende Maternity Home- A sample of 2 pregnant women was selected from the Maternity Home, using the convenience sampling technique.

IKEJA LGA

1. 445 Nigerian Air Force Hospital Ikeja

The NAF hospital held antenatal clinic every Tuesday. Two consecutive Tuesdays were therefore chosen and out of the 150 registered pregnant women who attended antenatal care on both selected days, 60 representing 40% were chosen through a systematic sampling method. However, 59 of the administered questionnaires were recovered as one pregnant woman left the premises unnoticed with a copy. Efforts to reach her were unsuccessful as the hospital refused to give out her home address.

2. Lagoon Hospital Ikeja

Lagoon hospital held antenatal clinic every day except Sundays. Three days, Monday, Wednesday and Saturday were selected using the simple random sampling technique. A total of 155 registered pregnant women attended antenatal clinic in the three selected days and 62 of them representing 40% were selected through the systematic sampling method and surveyed. Of the 62 questionnaires 56 were found usable.

3. Moye Maternity Home- Two samples were selected also from the Maternity Home, using the convenience sampling technique.

IFAKO- IJAYE LGA

1. General Hospital, Ifako- Ijaye

Antenatal clinic at the Ifako- Ijaye General hospital held every Monday, Tuesday, Thursday and Friday. Monday and Tuesday were selected, using the simple random sampling method. A total of 180 registered pregnant women attended antenatal clinic on the two selected days and 72 of them representing 40% were picked, using the systematic sampling technique. The questionnaires were administered, filled out and returned and all 72 questionnaires were found to be usable.

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2. Gideon Specialist Hospital, Ifako- Ijaye

The Antenatal clinic at Gideon Specialist hospital is open only on Tuesdays and Thursdays every week. The two days were chosen and a total of 125 registered pregnant women attended the clinic on both days. Of these, 50 representing 40% of the population of pregnant women were selected and surveyed using the systematic sampling technique. 45 of the returned questionnaires were found usable.

3. Blessed Divine Maternity Home- A sample of two pregnant women was selected from the Clinic, using the convenience sampling technique.

ALIMOSHO LGA

1. Nigerian Air Force Hospital, Shasha

Antenatal clinic opened only on Tuesdays and Wednesdays at the NAF hospital, Shasha. The two days were therefore picked. A total of 99 registered pregnant women attended the clinic on both days and 39 of them representing 40% were selected using the systematic sampling technique. All the questionnaires administered were filled out and returned, thus a 100% return rate was recorded.

2. Crystal Hospital Shasha

Crystal hospital holds its antenatal clinic only on Thursdays of every week. Two consecutive Thursdays were consequently chosen and a total of 33 registered pregnant women attended antenatal clinic on the chosen days. 13 of them representing 40% were selected using the systematic sampling technique and questionnaires administered. The questionnaires were fully filled out and returned.

3. Remtina Maternity Home, Shasha- A sample of 2 pregnant women was then selected from the Maternity Home, using the convenience sampling technique.

IBEJU-LEKKI LGA

1. General Hospital Akodo

At the General hospital Akodo, research assistants found that the antenatal clinic was open only on Wednesdays. Two consecutive Wednesdays were selected. On the two selected days a total of 154 women attended antenatal clinic and 61 constituting 40% of the population of

119 pregnant women were drawn using the systematic sampling technique and surveyed. The questionnaires were administered to the selected respondents. All 61 questionnaires were properly filled out and returned.

2. Royal Infirmary Hospital

Royal Infirmary Hospital held its antenatal clinic only on Mondays of every week. Two consecutive Mondays were consequently chosen and a total of 153 registered pregnant women attended antenatal clinic on the chosen days. 61 of them representing 40% were selected using the systematic sampling technique and questionnaires administered. 56 of them fully filled out the questionnaires while the remaining 3 returned the instruments half or barely filled out, complaining of tiredness and that the questions were too many. The 3 were therefore not usable.

3. Adebek Maternity Center, Obadore- A sample of 2 pregnant women was also selected from the Adebek Clinic, using the convenience sampling technique.

FOCUS GROUP DISCUSSION

The participants for the focus group discussions were selected from respondents who had participated in the survey using the following techniques:

Alimosho

At Alimosho LGA, ten respondents were selected from the Antenatal clinic at the NAF Hospital, and six from Crystal Hospital, both in Shasha. These women were invited for the FGD, during the survey interview and they agreed to participate. However, on the appointed day, only five of them from the NAF Hospital, four from Crystal Hospital and one from the Maternity Home turned up, bringing the group total to ten.

The FGD took place at the Angelic Women Ministry premises. Angelic Women Ministry is an NGO that caters for widows and orphans within and outside Nigeria. The location was considered ideal because all the participants were familiar with it and agreed that it was accessible and convenient for them to reach.

Ikeja LGA

Recruiting participants from Ikeja was relatively easy as all the respondents were familiar with the NAF Base, Ikeja and greed that it was the most ideal place to hold the FGD. The

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Children‘s Park, belonging to the Nigerian Air Force Officers‘ Wives‘ Association NAFOWA was the venue of the FGD which recorded a 100% response rate as all the fifteen participants invited from the three Health care facilities where the survey had earlier been conducted, turned up for the discussion.

Lagos Island LGA

The researcher experienced some difficulty convincing respondents in Lagos Island to participate in the FGD. Most of them complained of the inconvenience of traffic jams characteristic of Lagos. The venue for the FGD posed another challenge, as most respondents complained about the initial venue chosen by the researcher. Consequent upon the intervention of one of the consultants, Dr. Mrs. Arafat Ifemeje, the matron offered a room which was used as the venue. The researcher overcame the challenge of traffic jam by inviting twenty five of the respondents, eight from St. Nicholas Hospital, fifteen from Island Maternity and two from the Obalande Maternity Home. Luckily, sixteen of them turned up for the FGD on the selected day.

Ifako-Ijaye

It was easy to get the respondents from the Antenatal clinics at Ifako-Ijaye LGA. Again they were all familiar with the venue which was suggested by one of the research assistants who also resides in the same LGA. A 100% response rate was recorded as the five respondents from Gideon private hospital, eight from Ifako-Ijaye General Hospital and one from Blessed Divine Maternity Home all participated in the FGD on the selected day.

Ibeju- Lekki

The most pleasant surprise came from Ibeju- Lekki LGA, which is considered rural. All the respondents selected showed enthusiasm and demonstrated their zeal by attending the FGD on the selected day. The researcher contacted the management of Atwool Schools, Awoyaya, which offered one of its classrooms for the FGD.

A total of fifteen pregnant women participated in the focus group discussions.

SAMPLING FRAME

The sampling frames for this study included a list of all the Local Government Areas in Lagos, a list of all the health care facilities in Lagos State, as well as a list of all the registered

121 pregnant women in the selected health care centers. The lists of hospitals are attached as appendices 2a and 2b. The list of registered women was not released by the hospitals due to client confidentiality.

STUDY AREA This study was carried out in Lagos. Lagos is a port and the most populous conurbation in Nigeria. UN-HABITAT, 2008 puts the population of Lagos at 7,937,932, making it currently the second most populous city in Africa after Cairo. It is also estimated to be the fastest growing city in Africa and the seventh fastest growing in the world. Lagos is the economic and financial capital of Nigeria and was once the capital of Nigeria. In the 1970s Nigeria experienced an oil boom, with Lagos witnessing a population explosion, economic growth and unmitigated rural migration. The Lagos State Government has put the population of Lagos State at 20.19 million and the population of metropolitan Lagos at 17.16 million. It has been estimated that by 2015, the population of Lagos would have risen to 24.6 million, making it the 3rd megacity and one of the most populous cities in the world. However the 2007 Voters Registration from INEC puts the Lagos State population at 9,013,354, while the 2006 census puts the population of Lagos State at 9,113, 605 (National Population Commission, 2011). Authorities of Lagos State have accused the Nigerian National Population Commission of having undercounted the inhabitants of the state (Lagos State Ministry of Information, 2011).

The indigenous people of Lagos State are the Yoruba subgroups of the Awori in Ikeja, the Egun in Badagry, the Ijebu in Ikorodu and Epe, while Lagos Island consists of an admixture of Benin and Eko Awori as well as repatriated Yoruba and other immigrants. In its modern form the state is a socio-cultural melting pot that has attracted Nigerians from all over the country as well as Non-Nigerians from other African countries and the rest of the world. Malaria is endemic in this area and occurs throughout the year with peaks during the rainy season (Lagos State Ministry of Information, 2011).

Lagos is a huge metropolis which originated on islands separated by creeks such as Lagos Island that fringe the southwest mouth of Lagos Lagoon protected from the Atlantic Ocean by long sand spits such as Bar Beach which stretch up to 100 km east and west of the mouth. From the beginning Lagos has spread on the mainland west of the lagoon and the conurbation, including Ikeja and Agege, now reaches more than 40 km north-west of Lagos Island. There are suburbs like Ikorodu, Epe and Badagry and recently more local councils

122 have been created to bring the total number of local governments in Lagos to 57. Lagos State is made up of three senatorial Districts: Lagos Central, Lagos East and Lagos West and 20 Local Government Areas (LGAs).

There is however 16 Local Government Areas in Lagos Metropolis and 4 in Rural Lagos and these are distributed as follows: Table 3: The 16 Local Government Areas in Lagos Metropolis (urban)

Local Government Area Land area Population (Census, Density 2006) Agege 11.2 459,939 41,071 Ajeromi- ifelodun 12.3 684,105 55,474 Alimosho 185.2 1,277,714 6,899 Amuwo- Odofin 134.6 318,166 2,364 Apapa 26.7 217,362 8,153

Eti- Osa 192.3 287,785 1,496 Ifako- Ijaye 26.6 427,878 16,078 Ikeja 46.2 313,196 6,785 Kosofe 81.4 665,393 8,174 Lagos Island 8.7 209,437 24,182

Lagos Mainland 19.5 317,720 16,322 Mushin 17,5 633,009 36,213 Ojo 158.2 598,071 3,781 Oshodi- Isolo 44.8 621,509 13,886 Shomolu 11.6 402,673 34,862 Surulere 23.0 503,975 21,912 Metropolitan Lagos 999.6 7,937,932 7,941

(Source: Lagos State Government, 2011)

Table 4: Local Government Areas in rural Lagos

Local Government Area Population

Ibeju- Lekki 99, 540 Epe 323,634 Ikorodu 689, 045 Badagry 380,420 (Source: Lagos Government, 2011)

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Figure 4: map of Lagos State (Source: Lagos State Ministry of Information, 2011

Study Locations

Summary of Sampling Procedure

These four sampling techniques are considered appropriate for this study and were used in the following ways:

 The Multistage Cluster sampling technique was used at four stages to select the study areas and subjects.  The 20 LGAs in Lagos State were stratified. Thus, the 16 urban and 4 rural Local government areas in Lagos state were classified in line with the Lagos State Government classification contained in the 2011 Diary/Calendar and National Population Commission.  Using the theory of proportion, a ratio of 1:4 was realized. The simple random sampling technique was then used to select four urban local government areas and one rural local government area from the 16 urban and four rural local government areas in Lagos State.

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 With the aid of the sampling frames containing the lists of all Hospitals and Maternity Centers in the five LGAs, the simple random sampling technique was used to select one public and one private health care facility and one Maternity Home from each of the five LGAs.  Using the health centers‘ registration records as sampling frames, the systematic sampling technique was then used to select 40% of the pregnant women attending antenatal care on the selected days.  10- 16 pregnant women who participated in the survey in each of the selected health care facilities in the five local government areas were selected to take part in 5 focus group discussions.  Two members of the Roll Back Malaria (RBM) Alliance as well as two health care experts were purposively selected and interviewed. Thus, the Communications Officer of UNICEF, Lagos, the Director of Communications at the Federal Ministry of Health, Abuja, the Commander of the NAF Hospital, Shasha and the Matron at the 445 NAF Hospital Ikeja were all interviewed.

DATA COLLECTION INSTRUMENT

Triangulation method comprising survey, focus group discussion and in-depth interview methods was used to collect data for this study and the tools or instruments chosen for data collection were the questionnaire for the survey, the interview schedule for the in-depth interviews and unstructured interview guide for the focus group discussions.

For the survey method, a 66- item questionnaire comprising three sections was used for quantitative data gathering. The first section contained questions on the exposure of respondents to the mass media and other sources of information on the adoption of ITNs. The second segment contained questions on cognitions and context of the respondents. This section also contained a 15- item likert scale questions on the knowledge, attitudes, opinions, beliefs, practices and behavioural patterns of the respondents. The likert scale approach was adopted because of its ability to measure opinions, attitudinal perceptions, and beliefs. The third section contained questions on demographic attributes such as age, sex, income, level of education, religion, marital status, and ethnicity.

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The interview schedule was used to collect data from two members of the RBM Alliance- the UNICEF Communication Officer in Lagos, and the Director of communications, Federal Ministry of Health, Abuja who represents the ministry at the RBM committee and two health care practitioners. These experts are directly involved in the planning and implementing of the health communication campaigns for the RBM Alliance. The instrument for data collection was a 12- item schedule containing questions on how communication is used to disseminate information on the adoption of ITNs, the major channels employed and the challenges encountered by the campaign.

The third instrument was the unstructured questionnaire for gathering data during the Focus Group Discussions. In each LGA, 10- 16 pregnant women representing the various sub- set of the respondents who participated in the survey were selected and brought together in participatory discussions. The major reason for this was to obtain information on the socio cultural practices, beliefs, opinions and values that constitute barriers to or promote the responses of the respondents to communication campaign messages on the adoption of ITNs. It was also expected to expose information that the questionnaire may have failed to reveal or which researcher never anticipated.

UNIT OF ANALYSIS

This is what is actually measured or studied to test hypotheses. It is the person, place or thing from which measurement is obtained. In this study, the unit of analysis was the individual pregnant woman, which constituted a unit of the 558 samples drawn from the population of 1,380 pregnant women in the five selected urban and rural Lagos.

VALIDITY AND RELIABILITY OF RESEARCH INSTRUMENT

Internal and external validity

The internal and external validity of this study was determined through analysis, but while the internal validity was assessed by determining if the study really investigated the proposed research questions, the external validity was assessed by the degree to which the findings could be generalized to the entire population.

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Instruments 1, 2, and 3 were developed by the researcher and were validated by giving copies to the supervisors and other experts in communication scholarship. They were asked to comment on the appropriateness and relevance of the items in the instruments to the research questions, clarity of the items and content validity. Their comments were taken into account in modifying the instruments.

Reliability of the instruments/Pilot study

In order to maximize consistency in coding and formally assess intercoder reliability, the coding sheet was pilot tested. To this end, a mini study with a small sample of 20 pregnant women who did not form part of the main study, was conducted. To determine whether the study approach was correct and to help refine the questions, the respondents were asked if they understood the questions and if the questions were easy to answer. Areas of misunderstanding and confusion which emerged were noted and corrected.

PROCEDURE FOR DATA COLLECTION

Twenty research assistants were recruited from the undergraduate programme one from the Masters programme of the Department of Mass Communication, given an insight into the nature of the study and then trained on how to administer the research instruments. While four of the research assistants were deployed to the two hospitals in each LGA- two to each hospital, the Masters student covered the Maternity Homes. All of them worked together with the researcher administering the instruments while the researcher physically supervised the activities.

METHOD OF DATA ANALYSIS AND PRESENTATION

The Statistical Package for Social Sciences (SPSS) was used to analyze the data collected, and with the aid of a computer it was used to generate frequency/contingency tables for the study. Results are presented in a clear and concise manner appropriate to the research questions formulated for the study.

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FOCUS GROUP DISCUSSION

The intention behind the focus groups was to get close to what the pregnant respondents thought about the use of ITNs for malaria prevention and their various reasons for adopting or rejecting the recommended behaviour. The central idea was to track attitudinal perceptions and behaviours towards the RBM communication messages on the adoption of ITNs which the survey method, due to its predominant close ended questions was unable to uncover. Thus, participants for the FGD were drawn from among the survey respondents and aspects of the results formed the basis for concentrated questioning.

Five focus group discussions were conducted between the 23rd of May and 3rd June, 2011 consisting of 10- 16 respondents. The groups all consisted of pregnant women drawn from the survey respondents. Each session lasted between two and three hours and the researcher provided refreshments for all the participants and transport fares for those of them who accepted since some turned down the offer, as well as remuneration for the five research assistants. The FGDs were carried out in five study locations and the structure and dates of the groups were as follows:

Table 5: Focus Group

Date LGA Location of FGD No of participants

23/5/2011 Alimosho Angelic Women Ministry, Shasha 10 participants

25/5/2011 Ikeja NAF Base, Ikeja 15 participants

29/5/2011 Ifako-Ijaye Blessed DivineMaternity 14 participants

1/6/2011 Lagos Island Lagos Island Maternity 16 participants

3/6/2011 1beju- Lekki Atwool, School premises 15 participants

Total number of participants = 70

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LIMITATIONS OF THE STUDY Since the study was limited to Lagos State, its major weakness may emanate from the environmental contexts of Lagos State which differ from those of other states in Nigeria, particularly in the areas of technology diffusion such as a wider reach and penetration of the mass media, telecommunication services through GSM phones, the internet and other modern means of communication, which facilitate rapid dissemination of information, as well as availability and easy access to health care facilities. Similarly, the differences in cultural beliefs, norms, values and practices of the various ethnic nationalities in Lagos, which Akinfeleye (2008) refers to as cultural peculiarities and particularities, may influence pregnant women‘s response to communication messages on the adoption of ITNs for malaria prevention. These contextual differences may consequently decrease the generalizablity of the results.

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REFERENCES

Akinfeleye, R. A. (2008). Social marketing paradigm: Message design theory and diffusion

for social mobilization. In R. A. Akinfeleye (Ed.), Health and behavior change

communication for development, pp.124- 134. Lagos: Integrity Press Limited.

Lagos State indicator (December, 2009). Unveiling the Lagos State public works

corporation: 1000 days. Lagos: Ministry of Information

Merrigan, B. & Huston, C. L. (2004). Communication research methods. Belmont, CA.:

Thomson Wadsworth

Morrison, D. E. (2000). The search for an understanding: Administrative communications

research and focus groups in practice. UK: University of Luton Press

Obijiofor, L. (2009). Issues in ethnographic research methods. Oko journal of communication

and information science, 1(2), pp. 1-20. Onitsha: Base 5 Press Limited.

Onabajo, O. (2010). Foundations of communication research. Lagos: Sibon Books Limited

Pyrczak, F. (2000). Completing your thesis or dissertation: Professors share their techniques

and strategy. Los Angeles, C.A.: Pyrczak Publishing

Sobowale, I. (2008). Scientific journalism: What tools for the precision journalist? Lagos:

Idosa Konsult.

Tejumaye, A. (2003). Mass communication research: An introduction. Lagos: Dapson

International Nigeria Limited.

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Watson, J. (2003). Media communication: An introduction to theory and process (2nd

Ed.). New York: Palgrave Macmillan

Wimmer, R. D. & Domonick, J. R. (2006). Mass media research: An introduction. Belmont,

C.A.: Thomson Wadsworth.

Wimmer, R. D. & Dominick, J. R. (2011). Mass media research: An introduction ( 9th

Ed.). Belmont, C.A: Thomson Wadsworth.

Internet Sources

Lagos State Ministry of Information. (2011). Lagos State. Retrieved September 28, 2011, from http://www.lsmoh.com/programme_info.php?programme_id=6

Meeus, S. J. and Gulinck, H. (2008) Semi-Urban Areas in Landscape Research: A Review.

Retrieved July 16, 2011 from http://landscaperesearch.livingreviews.org/open?pubNo =lrlr-2008 Roll Back Malaria report 2008- 2010 (2010) Retrieved October 8, 2010, from

http://www.rbm.who.int

Trochim, W. M. K. (2006). Survey research. Retrieved August 24, 2010 from

http://www.socialresearchmethods.net/kb/survaddi.php

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CHAPTER FOUR

DATA ANALYSIS AND RESULT PRESENTATION

Introduction

This chapter contains a detailed presentation of data gathered in the field, the analysis, interpretation and the discussion of findings from the data. A sample size of 558 pregnant women was used for this study. This represented 40% of the population of 1,370 pregnant women attending Antenatal clinics in the ten hospitals selected from the four urban and one rural local government areas in Lagos State as well as five Maternity Homes. The local government areas are Ikeja, Alimosho, Ibeju Lekki, Ifako Ijaye and Lagos Island, while the selected hospitals are Lagoon Hospital and 445 NAF Hospital in Ikeja LGA; Ifako Ijaye General Hospital and Gideon Specialist Hospital, Ifako- Ijaye LGA; St. Nicholas Hospital and Island Maternity in Lagos Island LGA; Crystal Hospital and NAF Hospital Shasha, in Alimosho LGA; Ibeju Lekki General Hospital Akodo and Grace‘s Specialist Hospital Awoyaya, in Ibeju- Lekki LGA. 558 copies of questionnaire were administered in the field, of these, 529 of them were properly filled which is about 95% of the administered questionnaires. Of the remaining twenty- nine, five were unreturned, while twenty- four were unusable.

The data analyzed and presented below are therefore based on information from 529 copies of the questionnaire that was successfully administered, collated and analyzed. The results are presented in two parts- Part One, which contains the demographic information of the respondents and part two, which comprises answers to the six research questions that drove the study.

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Part One

Demographic Data of respondents

Table 6: Distribution of respondents by education

Education Percentage

No formal education 3.7 Quaranic education 1.5 Primary school 6.8 Secondary 21.4 ND/NCE 12.5 HND/B.A/B.Sc 6.9 M.A/M.Sc 14.7 Ph.D 0.2 Other 0.2

Total 100% n 529

Table 7: Distribution of respondents by income

Income Percentage less than N20, 000 16.4 N21, 000 to N40, 000 17.2 N41, 000 -N60, 000 16.8 N61, 000-N80,000 12.0 N81,000 and above 37.6 Total 100% n 529

The academic attainment of the respondents as presented in table 6 shows two dominant categories. Respondents with first degrees account for 21.8% and 21.4% possess SSCE, while

3.7% of them had no formal education. This shows that the respondents are generally educated.

Table 7 also shows that a sizeable number of the respondents (37.6%) fall into the ―above

N81, 000‖ per month category; 12.0% of them earn between N61, 000 and N80, 000 monthly; respondents who earn between N21, 000 and N40, 000 are 17.2% while; 16.4% of

133 them earn less than N20, 000. This implies that nearly half of the respondents are fairly comfortable.

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Part Two – Research Questions

Research question 1: To what extent are pregnant women in the study areas exposed to communication campaign messages on the adoption of ITN?

Table 8: Respondents’ exposure to health/ITN programs in the mass media

Exposure to Radio % Television % Newspaper % campaign messages Yes 73.0 84.1 58.1 No 27.0 15.9 41.9 Total 100% 100% 100% n 529 529 529

Respondents’ frequency of exposure to health/ITN programs on television and radio

88.40% 90.00%

80.00%

70.00% 63%

60.00%

50.00% Television Radio 40.00%

30.00% 24.70%

20.00%

10.00% 6.00% 5.20% 5.60% 0 7.20% 0.00% Regularly Sometimes Rarely Never

Figure 4

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Data in table 8 and figure 4 are used to answer research question 1. Table 8 shows that majority of the respondents (84% for television; 73% for radio and 58% for newspapers) were exposed to health/ITN messages in the mass media. Figure 4, however, shows that the respondents were more exposed to television than radio and newspapers as majority of them (88%) said they watch health/ITN messages frequently on television, while (63%) said they listened to it on radio.

This implies that though respondents identify radio as an important medium of information on ITNs, television appears to be the more preferred medium among them and this again is not surprising, since television has been rated the most popular medium globally (McCombs and Becker, 1989).

Generally, the findings imply that the mass media still remain the most important channel for reaching out and disseminating information to audiences and this supports Waisbord‘s thesis that the mass media are extremely important in raising awareness about issues (2005).

Research question 2: What are the major sources of ITN information for pregnant women in the study locations?

Table 9: Respondents’ first source of information on the adoption of ITNs

Response Percentage Radio 23.3 Television 52.4 Newspaper 3.9 Magazine 1.0 Billboard 2.0 Handbill/poster 2.7 Hospital/health Centre/TBA 10.2 Family and friend 3.3 Mobile phone 0.2 Other 1.0 Total 100% n 529

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Respondents’ major source of information on ITNs

1.40% 22.30%

Mass media 76.30% Interpersonal networks Others

Figure 5

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Mass media of communication most frequently used by respondents as source of information on ITNs

70.00% 65.30%

60.00%

50.00%

40.00%

30.00% Series1 17.30% 20.00%

10.00% 5.10% 3.50% 2.10% 3.30% 1.80% 1.40% 0.40% 0.00%

Figure 6

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Table 10: Respondents’ most frequently used Interpersonal networks as respondents’ source of information on ITNs

Response Percentage Family member 18.5 Friends/neighbour 12.3 Village/community leader 0 Traditional birth attendant clinic 2.1 Hospital 56.0 Teacher 2.1 Town/village association/union 0 Market 0.2 Workplace 4.7 Hairdressing salon 1.6 Church 1.0 Other 1.6 Number of no response Total 100% n 529

Answers to research question 2 are contained in tables 9 & 10 and figures 4 & 5. In table 9, more than half of the respondents (52.4%) said television was their first source of information, radio was chosen by 23.3% of the respondents, while 10.2% of the pregnant women named hospitals and health centers.

Figure 5 indicates that majority of the respondents (76.3%), use the mass media more as their major source of information on ITN use than they use interpersonal networks (22.3%).

Figure 6 also shows that although the mass media are the preferred source of information, television is the most frequently used medium as respondents‘ source of information on ITNs (65.1%).

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In terms of interpersonal sources, table 9 shows that more than half of the respondents (56%) identify hospitals as their most frequently used source for information on ITNs.

These results imply that in terms of major sources of information on ITN for the respondents, the mass media and hospitals are the most popular, with television emerging as the most popular mass medium and hospitals as the major interpersonal source of information on ITN.

The result is consistent with that of the Focus group discussion which show that majority of the respondents get their information on ITNs from television and hospitals. On the whole, the result is an indication of the importance accorded to the media, especially television, by the respondents and while lending credence to the Melvin De Fleur‘s Media Dependency theory, it also underscores the popularity of television. In addition, it supports the views of scholars such as Wimmer and Dominick (2011), who assert that people are dependent on television for most of their information, as well as Tavoosi et al (2004), who identified television as the most important source of information on health issues.

Research question 3: What are the basic knowledge and attitudinal dispositions of sampled pregnant respondents to Malaria and ITN related issues?

Table 11: Basic Knowledge/Awareness of the deadly nature of Malaria and ITN related issues

Response Knowledge of Malaria as ITN Awareness % deadly disease % Yes 90.6 93.0 No 9.4 7.0 Total 100% 100% n 529 529

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Table 12: Respondents’ attitudinal dispositions to malaria and ITN related issues

Where SA=strongly agree, A=agree, U=undecided, D=disagree and SD=strongly disagree

Malaria/ITN related issues SA A U D SD Pregnant women and children under 5 are more vulnerable 61.8 22.3 5.5 7.2 3.1 to malaria than other groups Malaria causes anemia in pregnancy 53.1 27.5 10.2 5.7 3.5 Malaria causes low birth weight 43.0 33.1 9.8 8.8 5.2 Malaria is caused by supernatural forces and can only be 5.1 3.5 8.2 21.0 62.3 prevented or cured by supernatural means ITN can prevent malaria 56.5 35.8 4.7 1.4 1.6 It is cheaper to sleep under an ITN than to cure malaria 59.9 28.4 4.6 6.0 1.2 The insecticide in the ITN can kill my unborn child 4.5 5.5 4.7 24.2 61.0 Sleeping under ITN occasionally is enough to prevent 12.9 19.6 8.5 29.4 29.6 malaria ITN Kills mosquitoes 39.4 28.5 11.7 13.8 6.6 Local preventive and treatment measures such as Agbo and 6.7 12.6 11.6 23.6 45.5 Dogonyaro or other local herbs are more effective than ITN

Answers to research question three are displayed in tables 11 & 12. Data on table 11 show that majority of the respondents (90.6%) are aware of the danger posed by malaria, and 93% of them are familiar with ITNs. The implication of this result is that majority of pregnant women in rural and urban Lagos are aware of the deadly nature of malaria and the use of ITN for malaria prevention. Findings also support those of the several research efforts reviewed in chapter two of this study.

In answer to the question on attitudinal disposition of respondents to malaria/ITN related issues, table 12 shows that the respondents possess the desired positive attitudinal disposition towards malaria and ITN related issues, with majority of them strongly agreeing or just agreeing with several of the right or preferred options.

However, the fact that 32.5% of them still believe that sleeping under ITN occasionally and 20% of them are of the opinion that local preventive treatment measures are more effective

141 than ITN is an indication of existing gaps between communicator and communicatee, occasioned by some form of noise occurring during the communication process. This may be as a result of the use of certain medical terminologies which may lead to the inability of some members of the audience to understand the health information/education messages being disseminated. It may also be a pointer to incomplete information or other deficiencies in the message content.

Research question 4: What are the response patterns of pregnant women in the study locations to communication campaign messages on the adoption of ITNs?

Table 13: Relationship between household ownership and respondents who were sleeping under ITN

Response Household ITN Respondents who are ownership % sleeping under ITN % Yes 78.9 75.8 No 21.1 24.2 Total 100% 100% n 529 529

Table 14: Respondents’ frequency of sleeping under the ITN

Frequency of sleeping under ITN Response %

Everyday 47.1

Occasionally 49.3

Never 3.6

Total 100% n 529

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Table 15: Respondents who slept under the ITN the night before

Response Percentage

Yes 51

No 49

Total 100% n 529

Research question four is answered by data on tables 13, 14 & 15. Table 12 shows a high household ITN ownership (78.9%) and is in contrast to the various studies (FMOH, 2010; WHO 2010, 2010, NDHS, 2010 and; RBM Report, 2009), which put ITN ownership by Nigerian households at between 8- 20%.

Table 13 also shows that majority of the respondents (75.8%) who‘s household owned ITNs said they are sleeping under the bed nets. What this also means is that majority of the sampled pregnant women are adopting the recommended behaviour. Again, this contradicts the findings of earlier studies which put the percentage of pregnant women sleeping under ITN between 2007- 2011 at 5-17% (FMOH, 2010; WHO 2010, 2010, NDHS, 2010 and; RBM Report, 2009).

The analyzed data in table 14 shows that while ITN ownership is high, only 47.1% of the respondents said they sleep under the ITN every day, while 49% said occasionally. However, this result is also in stark contrast as it shows an increase from those of the earlier findings of both government and donor agencies which puts sleeping under ITNs by pregnant women in Nigeria at 5%.

Furthermore, table 15 shows that more than half of the respondents (51%) slept under the ITN the night before the study, also contradicting the earlier findings.

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RQ5. To what extent do social contexts influence the receptivity of pregnant respondents in the study locations to communication messages on the adoption of ITNs?

Table 16: Persons, places, things, institutions that influenced respondents’ responses to ITN messages

Persons, places and things Response %

Interpersonal networks 76.9

Mass media 23.1

Total 100% n 529

Table 17: Persons, things, institutions or places that influenced respondents’ decision most to sleep under the ITNs

Response Interpersonal networks Mass media % %

Yes 76.6 85.3

No 23.4 14.7

Total 100% 100% n 406 123

Table 18: Respondents who use ITNs because their friends or relatives are using them

Response Percentage

Yes 76.5

No 23.5

Total 100% n 529

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Table 19: Relationship between geographical location and sleeping under ITNs by respondents

Sleeping under ITN Urban LGAs Rural LGA

Response Ikeja Alimosho Ifako Ijaye Lagos Ibeju Lekki Island Yes 74.3% 67.4% 88.3% 74.3% 71.3%

No 25.7% 32.6% 11.7% 25.7% 28.7%

Total 100% 100% 100% 100% 100% n 101 43 94 109 115

Table 20: Relationship between geographical location and respondents’ frequency of sleeping under ITNs

Urban LGAs Rural LGA

Frequency of sleeping Ikeja Alimosho Ifako Ijaye Lagos Ibeju Lekki under ITN Island Everyday 27.9% 48.5% 30.7% 68.5% 58.9%

Occasionally 61.6% 51.5% 68.2% 27.0% 41.1%

Never 10.5% 0 1.1% 4.5% 0

Total 100% 100% 100% 100% 100% n 86 33 88 89 95

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Table 21: Relationship between respondents’ academic attainment and their sleeping under ITNs

Response

No No formal education Quarani education Primary school SSCE OND NCE HND B.Sc/BA M.A/MSc Ph.D Other Yes 100 0 80 64.8 67.3 91.4 71.2 76.4 91.5 100 0

No 0 10 20 35.2 32.7 8.6 28.8 23.6 8.5 0 100 %

Total

0 6

13 2 3 91 6

100% 100% 100% 100% 100% 100% 55 35 100% 100% 100% 1 47 100% 1 100% 1 100%

Table 22: Relationship between respondents’ academic attainment and their frequency of sleeping under ITNs

Response

No No formal education Quarani education Primary school SSCE OND NCE HND B.Sc/BA M.A/MSc Ph.D Everyday 53.8 0 33.3 39.0 60.0 51.5 50.0 52.3 38.3 0

Occasionally 46.2 0 66.7 61.0 37.5 48.5 42.3 40.9 59.6 0

Never 0 0 0 0 2.5 0 7.7 6.8 2.1 100

Total

100% 13 100% 0 100% 24 100% 82 100% 40 100% 33 100% 52 100% 88 100% 47 100% 1 100%

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Table 23: Relationship between respondents’ income and their sleeping under the ITNs

Response Less than N21, 000 – N41, 000 - N61, 000 – Above N81, N20, 0000 N40,000 N60, 000 N80, 0000 000

Yes 65.7 69.6 71.1 82.5 80.5

No 34.3 30.4 28.9 17.5 19.5

Total 100% 100% 100% 100% 100% n 67 69 76 57 164

Table 24: Relationship between respondents’ income and their frequency of sleeping under the ITNs

Response Less than N21, 000 – N41, 000 - N61, 000 – Above N81, N20, 0000 N40,000 N60, 000 N80, 0000 000

Everyday 25.9 52.8 52.6 63.0 44.8

Occasionally 70.4 45.3 45.6 35.2 49.7 Never 3.7 1.9 1.8 1.9 5.5 Total 100% 100% 100% 100% 100% n 54 53 57 54 145

In answer to research question 5, tables 16, 17, & 18 show that respondents are influenced by interpersonal networks to adopt the recommended behaviour.

The implication of these findings is that results reinforce the thesis by several scholars such as Melvin De Fleur, that interpersonal networks influence behaviour more than the mass media. More importantly, findings support Figueroa and Kincaid‘s CFSC theory which posit that members of social networks are key to influencing behaviour change.

Data in tables 19, 20, 21, 22, 23 & 24 show no relationship between respondents‘ demographics and their adopting the recommended behaviour as responses do not follow any

147 logical patterns. Although data in table 21 show that 100% of the respondents with no formal education as well as respondent with PhD education sleep under ITN, table 22 shows that respondents belonging to the OND educational category demonstrate a higher rate of sleeping under the ITN daily. These findings therefore fail to establish any relationship between demographic variables of respondents, such as their geographical location, income and educational levels and their responses to communication messages on the adoption of ITN for malaria prevention and therefore, reject the assumption of the CFSC theory that demographic variables influence behaviour change.

Research question 6: What are the barriers to the receptivity of pregnant respondents to communication messages on the adoption of ITNs?

Table 25: Barriers to pregnant women’s receptivity to communication messages on the adoption of ITNs

Barriers Percentage I don‘t know 40.0 Poses danger to unborn child 5.9 Causes heat 16.6 Lack of awareness among pregnant women 19.7 Pregnant women cannot afford it 9.6 Pregnant women do not know its benefits 3.6 Pregnant women do not just like it 4.5 Total 100% n 529

Data in table 25 were used to answer to research question 6, and show that the major barriers to respondents‘ receptivity to ITN messages include their belief that the chemical contained in the ITN poses danger to their unborn babies, as well as the heat generated by the nets which causes discomfort to them while sleeping under the ITNs. However, only 22% of the respondents share this fear.

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RESULTS OF FOCUS GROUP DISCUSSIONS

Table 26: MATRIX OF FGD SESSIONS WITH PREGNANT WOMEN IN THE FIVE SELECTED LGAs IN LAGOS STATE

Questiions Ikeja LGA Lagos Island Alimosho Ifako Ijaiye Ibeju-Lekki LGA LGA LGA LGA Most Television Television Television Television Television frequently used mass media Most Hospitals Hospitals Hospitals Hospitals Hospitals frequently used interpersonal source Most Influence of Influence of Influence of Influence of Influence of frequently family and family and family and family and family and mentioned friends friends friends friends friends reason for adoption of ITN messages Most Discomfort Discomfort Discomfort Discomfort Discomfort frequently due to heat due to heat due to heat due to heat due to heat mentioned barrier to adoption of ITN messages Most positive That ITN can That ITN can That ITN can That ITN can That ITN can belief about prevent prevent prevent prevent prevent ITN malaria malaria malaria malaria malaria Most That That That That That negative chemical in chemical in chemical in chemical in chemical in belief about ITN can kill ITN can kill ITN can kill ITN can kill ITN can kill ITN an unborn an unborn an unborn an unborn an unborn child child child child child

Most of the questions were designed to elicit answers to the six research questions that guided this study and to also determine some of the opinions, attitudinal dispositions and behaviors of the respondents that the survey method was unable to bring out. Since the participants were drawn from the respondents that had taken part in the survey interviews, their understanding of the questions was enhanced by the familiarity with the earlier survey questions.

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At the end of the FGDs, the general findings, though more detailed appeared to concur with the survey findings. There was no difference in the responses between the participants in the urban LGAs and those in the rural LGA. Most of the findings were characterized by participants‘ professed interest in the use of ITNs for malaria prevention. Even those who had just heard about it and received ITNs from the hospitals said they had been sleeping under the nets since they acquired them.

As with the survey, results of the FGD show that television is the preferred source of information among the respondents, while hospitals were their major interpersonal sources of information. Again, the FGD found that interpersonal networks influenced the responses of the respondents to the ITN messages.

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REFERENCES

Federal Ministry of Health. (2010). National malaria control programme: Advocacy,

communication, and social mobilization strategic framework and implementation

plan. Abuja: Federal Ministry of Health

Federal Ministry of Health. (2010). National policy on malaria diagnosis and treatment

Abuja: Federal Ministry of Health

Federal Ministry of Health. (2010). World malaria day: “Counting malaria out” “Count me in”. Abuja: Roll Back Malaria

Figueroa, M. E., Kincaid, D. L., Rani, M. & Lewis, G. (2002). Communication for social

change: An integrated model for measuring the process and its outcomes. In Brian

Bryd (Ed.). Communication for social change: Working paper series one. New York,

New York: The Rockefeller Foundation

McCombs, M. E. and Becker, L. (1979). Using mass communication theory. New Jersey;

Prentice Hall Inc.

Waisbord, S. (2001). Family tree of theories, methodologies, and strategies in development

communication. New York, New York: The Rockefeller Foundation.

Waisbord, S. (2005). Five key ideas coincidences and challenges in development

communication. In O. Hermer & T. Fufte (Eds.). Media and global change:

Rethinking communication for development, pp. 77-78. Buenos Aires: Nordicom

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Wimmer, R. D. & Domonick, J. R. (2006). Mass media research: An introduction. Belmont,

C.A.: Thomson Wadsworth.

Wimmer, R. D. & Dominick, J. R. (2011). Mass media research: An introduction ( 9th

Ed.). Belmont, C.A: Thomson Wadsworth.

World Health Organization (WHO), (2010). AIDS prevention and control: World summit of

ministers of health on programs for AIDS prevention, Oxford: Pergamon.

Internet Sources

RBM update (2011). The vision, the mission, the goal. Retrieved September 28, 2011, from

http://nmcpnigeria.org/f/ROLL%20BACK%20MALARIA%20IN%20NIGERIA-

update%20for%20HMH.pdf

Tavoosi, A., Zaferani, A., Enzevari, A., Tajik, P. & Ahmadinezhad, Z. (2004). Knowledge

and attitudes towards HIV/AIDS among Iranian students. Retrieved March 15, 2011,

from http://www.pibmedcentral.nih.gov/articlerender.fcg.?article420470

Tilson, D. (2007). The social marketing of insecticide-treated nets (ITNS) in Kenya: Cases

in public health communication & marketing. Retrieved January 27, 2011, from

http://www.casesjournal.org

World Health Organization. (2010). World malaria report 2010, retrieved January 27, 2011,

from http://www.who.int/malaria/world_malaria_report_2010/en/index.html

World Health Organization. (2010). World malaria report 2010, retrieved January 27, 2011,

from http://www.who.int/malaria/publications/atoz/9789241564106/.../index.html

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CHAPTER FIVE

SUMMARY AND DISCUSSION OF FINDINGS

Introduction

In an attempt to assess the receptivity of pregnant women in rural and urban Lagos to the communication campaign messages on the adoption of Insecticide Treated Nets for malaria prevention, this study examined pregnant women‘s patterns of exposure by identifying the various channels/media available to them, their major sources of information on ITN messages and the factors (persons, places, institutions and things) which influenced their adoption or rejection of the messages. It also tested the suitability some of the postulations of the CFSC theory in explaining the outcomes. Specifically, two research questions (RQ2- what are respondents‘ major source of information on ITN related issues?) and (RQ5- To what extent do social contexts influence respondents‘ adoption of ITN messages?), were generated to address this aspect of the inquiry.

On the whole, six research questions for the survey, 27 questions for the FGD and 15 questions for the in-depth interview guided the study. While data for the survey were analyzed using descriptive statistics- frequency tables and charts, the answers generated from the FGDs and in-depth interviews were qualitatively analyzed using the narrative or prose form.

Summary

The summary of findings includes the following:

1. Pregnant women in urban and rural Lagos have high exposure to communication campaign messages on the adoption of ITNs

2. The mass media are the major sources of ITN information for pregnant women in urban and rural Lagos. 3. Pregnant women in both urban and rural Lagos are knowledgeable and have the right attitudinal dispositions to malaria and ITN related issues

4. Pregnant women in both rural and urban locations were significantly adopting the use of ITNs for malaria prevention

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5. Social context factors such as interpersonal networks and the mass media significantly influenced the responses of pregnant women in the study sites to communication campaign messages on the adoption of ITNs, while no positive relationship was established between social context factors such as income, educational levels and geographical location and the responses of pregnant women to ITN Messages. 6. Barriers identified include discomfort caused by heat, allergy to chemical contained in the ITN, fear of the chemical poisoning their unborn babies as well as limited knowledge of the benefits and the skills required to put up the ITNs.

Discussion

Given what had been gathered from the literature search and the support offered by the evidence obtained from the study, discussion of the findings are presented below.

Extent of pregnant women’s exposure to communication campaign messages on the adoption of ITNs for malaria prevention

The results showed that majority of the pregnant women across the geographical locations were significantly exposed to communication campaign messages on the adoption of ITNs. Although respondents from Lagos and Ikeja LGAs, which may be considered to be high brow locations, had higher exposure, the differences are not considered significant.

Though classified by the Lagos State Government as urban areas, Alimosho and Ifako- Ijaye Local Government Areas are still categorized as semi- urban or even rural by some scholars who argue that they still possess some elements of rurality. It is not surprising therefore that the pregnant women surveyed in the hospitals in Ikeja and Lagos Island Local Government Areas had slightly higher exposure levels.

Though not significant, reasons for this may include factors such as higher socio economic status which predisposes them to greater availability and access to multiple channels of information, hence higher awareness and, better educational opportunities, the result of which is more knowledge and understanding of the benefits of ITN use for malaria prevention.

The high exposure among majority of respondents across all the study locations was found to have influenced their positive responses and this supports Snyder‘s view that exposure to campaign messages severely increases the possibility of the campaign changing behaviour (2003).

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Major Sources of information for pregnant women in urban and rural Lagos

The mass media were found to be the major sources of information on the adoption of ITN for malaria prevention among pregnant women in urban and rural Lagos. Results of the survey, show that across all the study locations, mass media, particularly television were chosen by about three quarters of the pregnant women as respondents said they heard about ITNs from either the mass media or interpersonal networks. However, television led the pack with hospitals coming a distant second.

Findings of the FGDs also lent support to those of the survey as nearly 80% of the participants said they first heard about the ITN from television. One of the participants said, ―I got to know about ITNs from advertisements on television, radio and Billboards which I see in several locations and the messages were convincing enough.‖

This assertion represented the views of most of the pregnant women. However, a sizeable others said they heard about it during antenatal visits in the hospitals and a few others from their friends, family members and colleagues in the office place.

These findings bear witness and underscore the power of the media to provide information. They also support the contributions of Tavoosi and his colleagues (2004), which identified television as the most important source of information on health issues and Wimmer and Dominick‘s assertion that television is without doubt what most people get their information from (2011). They further agree with Schramm (1962) as cited in Snyder, (2003) when he posits that the media can act as ―magic multiplier‖ to rapidly spread information throughout a population.

Of importance also, is the support given to the CFSC theory which identifies the mass media as catalysts which stimulate dialogue and collective action.

In spite of this, a sizeable number of pregnant women identified interpersonal networks as their major sources of information. This implies that though in varying degrees, both the mass media and interpersonal networks were used by pregnant women across the study centers as their sources of information on ITNs. This also agrees with Lettenmaier‘s assertion, as cited in the RBM report (2008- 2010), that the coordinated use of interpersonal communication, community mobilization, advocacy and mass media have been effective in a variety of other public health agendas and highlights the effective role malaria communication will play when a multi- sectoral approach is adopted. He also notes that communication, through a variety of

155 channels is the best way to change individual and community attitudes and practices that act as barriers to effective malaria control. Using multi-channel communication, such as interpersonal, community, electronic and print media, and malaria programmes makes it easier to convince the public of the safety of ITNs for children and pregnant women. Findings also supports McCombs and Becker‘s (1989) assertion that people also get their information from interpersonal sources such as opinion leaders who themselves are high media users, This is also consistent with the two- step flow of communication theory (Folarin, 2005).

Knowledge and attitudinal dispositions of pregnant women in Lagos State to malaria and ITN related issues

Results of the study revealed that pregnant women across all the study locations were knowledgeable about Malaria and ITN related issues. An overwhelming majority of the pregnant women (93%) was knowledgeable about the cause and deadly nature of the malaria disease, the use of ITN as the best preventive method, and the ability of ITNs to kill mosquitoes. They were also aware that pregnant women and children under 5 years are more vulnerable to malaria than other groups, that Malaria causes anemia in pregnancy, that the disease causes low birth weight and that it is cheaper to sleep under an ITN than to cure malaria. Furthermore the respondents disagreed with the statements ―Malaria is caused by supernatural forces and can only be prevented or cured by supernatural means‖; ―the insecticide in the ITN can kill my unborn child‖; and ―local preventive and treatment measures such as Agbo and Dogonyaro or other local herbs are more effective than ITNs‖.

These results were supported by those of the FGD sessions held with the respondents. A high knowledge level about malaria and ITN related issues was discernible among the respondents as well as their positive attitudinal perceptions. All the respondents said they had heard about ITNs and demonstrated clear knowledge of the cause of malaria and benefits of ITN in the prevention of malaria. Not only were they aware that malaria can kill, they also know that pregnant women, as well as children under the ages of five, are the most susceptible group to malaria. Though, a few of them were ignorant of the fact that malaria causes anemia (shortage of blood), majority of them had the awareness.

As regards knowledge of the existence of ITNs, while most were familiar with it, others said

156 they were not until they received them from hospitals. Some of the reasons advanced included geographic variables as determinants of exposure to the messages on ITNs. One participant complained that many awareness programmes do not involve people from the core rural areas where there is little or no knowledge of ITNs. In her words

―In Shasha barracks where I live, so many people are still ignorant of the use of ITNs, but in places where there are community health talks, people are aware. For example, the Air Force Hospital where I attend antenatal care holds health talks, they tell us about the benefits of ITN, and most of us are sleeping under it.‖

Another participant testified to the effectiveness of the ITNs when she said that the frequency of malaria incidence for her husband whose genotype is AA and suffered from frequent bouts of malaria as well as herself, had reduced significantly since they both started using the ITN after the delivery of their first child in 2008.

Findings indicate high awareness and knowledge about malaria and ITN related issues among the respondents. This may be attributed to the environmental contexts of Lagos State which differ from those of other states in Nigeria, particularly in the areas of technology diffusion and penetration. For example the mass media and other modern means of communication, as well as health care facilities, enjoy wide reach and access and this facilitate rapid dissemination of information.

Findings of this study while partially supporting Abasiattai et al‘s 2009 study conducted on two hundred and fifty pregnant women at the maternity unit of the University of Uyo Teaching Hospital, which revealed 71.2% knowledge of the adverse effects of malaria in pregnancy, also shows a higher awareness about Malaria and ITN related issues among pregnant women in Lagos. This difference may be attributable to unique social and environmental factors of Lagos.

However, a few of the respondents in Lagos State have limited awareness. For example, a sizeable percentage of them believe that sleeping under ITN occasionally is enough to prevent malaria and that ITN cannot kill mosquitoes. This is an indication of gaps in health education and awareness diffusion.

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Responses of pregnant women to messages on the adoption of ITNs for malaria prevention

Results show that pregnant women in the both rural and urban locations do not differ in their responses to the RBM communication campaign messages on the adoption of ITNs for malaria prevention. Pregnant women across all the study locations were found to be adopting the ITNs. Over three quarters of the respondents said their households owned ITNs and this stands in stark contrast to the various studies on ITN ownership by Nigerian households. For example the Nigeria Demographic and Health Survey (NDHS, 2008- 2010) reported that 12% of all households own at least a net (any type) while only 2% own at least one ITN. The latest Nigeria Malaria Indicator 2010 Survey puts ITN nationwide household ownership at 42% and Southwest ITN ownership at 20% (NMCP, 2011). Explanation for the sharp contrast may be the ongoing free distribution of ITNs to all pregnant women in Lagos State on their first antenatal visit to hospitals.

However, ownership of ITNs does not necessarily translate to sleeping under ITN. One of the RBM targets is to get 80% of pregnant women and under five children sleeping under ITNs everyday by the year 2013. Findings of this study show that although 75.8% of the sampled pregnant women said they were sleeping under ITNs, 47.1% of them said they were sleeping under the ITN every day, while 49% said they slept under the ITN the night before.

This finding also indicates a significant increase from those of the previous studies which put sleeping under ITN daily at 5% and also contradicts the latest Nigeria Malaria Indicator 2010 Survey which puts the percentage of pregnant women who slept under the ITN the night before at 17%, a difference of 32% (NMCP, 2011).

Although insignificant, results show that more pregnant women in the rural areas slept under the ITNs than their counterparts in the urban areas. This finding supports the NDHS, 2009 and FMOH, 2008 report that pregnant women in rural areas are more likely to sleep under an ITN than their urban counterparts.

These results are upheld by those of the FGD discussion during which majority of the respondents said they owned ITNs. A few of them said that they received the nets from the Lagos state government hospitals during antenatal care visits. Some others said they received theirs from the federal government and private hospitals. It is interesting to note that seven of the discussants said they had bought ITNs before they received those distributed free in the hospitals. Five of these participants said they had heard about ITNs on television, while the

158 other two said they heard from friends.

Again, nearly all the participants said they were sleeping under the ITNs regularly except when there is no electricity to power the air conditioners and fans. In spite of the difficulties some of them identified, others described the ITNs as comfortable and preferable to the noise of mosquitoes and insecticide sprays and one of the women said she had been using the ITNs consistently for two years. As one participant put it-

―We hardly use sprays these days because we are used to treated nets and we are so confident that these nets are very good that we even took some home to our people in the village‖

Another participant said she had been using ITNs with her family since the early 90s when the Future Group, an NGO, had come to Nigeria. According to her, the ITNs have been very effective and the only time they suffered from malaria was when the family travelled to their home town and forgot to take the ITNs along.

While seven of the participants admitted that although they own ITNs, they do not use it frequently, four others said they had never slept under an ITN. These women said they preferred insecticide sprays as alternatives even though they agreed that the ITNs are more effective. One participant had only heard about ITNs the week before the FGD and had just obtained a free ITN a day before the discussion and plans to sleep under it every night.

The significant increase in both ownership and usage of ITNs among pregnant women may among other factors, be attributed to the modified ITN Massive Promotion and Awareness Campaign (IMPAC), under which pregnant women attending antenatal clinics are given ITN education and receive free ITNs at first attendance and children receive an ITN on completion of their third dose of the diphtheria, pertusis and tetanus vaccine (DPT3). This programme is implemented nationwide using routine health services and employing communication campaign approaches to create awareness about the innovation and bring about behavior change (RBM Concept Paper, 2003; NDHS Survey, 2009). This programme, in addition to several others has covered several LGAs in Lagos State (Interview held on June 2, 2011, with Caroline Akoshile, UNICEF Communications Officer, Lagos). The researcher witnessed the actual distribution of ITNs at the Antenatal Clinics as well as house to house distribution in course of the administering of her research instruments.

Thus, learning, which Weinreich (1999) views as the process by which behaviour changes as a result of experience or practice may also be identified as one of the factors responsible for

159 the increase in adoption of the recommended behaviour. Health education with hands on demonstrations of how to put up the nets, live testimonies of people who have become free of malaria attack after sleeping under ITNs as well as free ITN distribution to pregnant women during Antenatal visits appear to have contributed as effective motivators for the desired behaviour change.

These findings support Snyder‘s study which shows evidence that in the United States, mediated health campaigns record larger increases in behaviour change particularly with campaigns that promote commencement of a new behaviour (2003), which in this instance is the adoption of ITN for malaria prevention.

Although this is a remarkable leap from the findings of earlier studies some of which put the number of pregnant women sleeping under ITN between 2007- 2009 at 5% and others between 8- 20%, this finding may be peculiar to Lagos State and may not be a true representation of the entire nation.

Influence of social contexts on the responses of pregnant women to communication campaign messages on the adoption of ITNs

This study identified and categorized social context factors into two. In the first category are interpersonal networks comprising social networks such as family, friends, opinion leaders and healthcare workers, and the mass media; Category two comprising socio- demographic variables such as income, educational attainment and geographical location of respondents. While results show that the social context factors in category one- social networks such as family, friends, opinion leaders and healthcare workers, and the mass media significantly influenced the positive responses of sampled pregnant women to communication campaign messages on the adoption of ITNs, the variables in category two which include income, educational attainment and geographical location did not. Category one social contextual factors were shown to have significantly influenced the pregnant women at the study locations to sleep, not just occasionally but daily, under ITNs. These results are also supported by those of the FGDs.

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Influence of Category one variables- interpersonal networks and mass media on the responses of pregnant women to communication campaign messages on the adoption of ITNs for malaria prevention When asked, majority (77%) of the pregnant women said they were either influenced by their relatives, friends, healthcare workers or the mass media (23%) to own and sleep under ITN. Majority of them also acknowledged that they would readily sleep under the ITNs because their friends were doing it and a sizeable proportion of them said they were advocating the use of ITNs among friends, colleagues and relations who were not doing so. Results of the study also reveal that these discussions were taking place in their neighborhoods, offices, hair salons, churches and hospitals. In fact, the hospitals were picked as the place or institution that had their discussions most. This is not surprising, given that they are regularly given health talks during Antenatal visits with follow up visits by the hospitals to ensure compliance. This finding is in consonance with those of Ajibade (2010), in his study on the responses of mothers to Polio eradication campaign in selected Nigerian states, which found that social networks influenced the decision of mothers to immunize their children.

Similarly, the FGD discussions with respondents showed that respondents‘ social contexts influenced their adoption of the messages. Over 70% of participants at the FGD sessions claimed to have been influenced by interpersonal networks, and 25% said they found the media messages convincing enough to adopt the recommended behaviour. One participant said that she had been influenced to use ITNs by her friends especially those that had given birth earlier. She said that these friends had advised her to get the ITN after terrible bouts of malaria during their pregnancies. Sequel to this, she had also discussed it with her own neighbours and other friends, telling them about the effectiveness of ITNs in the fight against malaria as compared to insecticide sprays. According to her, the advice proved effective as one of her friends purchased the ITNs immediately after the discussion.

Indeed this participant appeared to summarize the responses of all the members of the FGD groups because when asked if they had discussed ITN with their friends, there was general assent. Apart from those who said they were influenced by mass media messages and health care workers, the rest of them said they were influenced by their friends and family.

One of them said that although she had heard about it initially from the hospital, she had been encouraged by her husband to start sleeping under the ITN.

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Another discussant identified mass media advertisement as both her major source of information and influenced her to adopt ITN use. In her words, ―I got to know about ITNs from advertisements on television, radio and Billboards which I see in several locations and the messages were convincing enough, so I decided to try it out and have not regretted since then. Since then I have encouraged several of my friends to get one. I have even personally taken the ITNs to the village to enlighten villagers of the effectiveness of ITNs in the treatment of malaria. ‖

In another participant‘s own words: ―I just use to see the ITN adverts on television and I decided to try it out‖

In spite of the claim by the respondents that the hospitals are their major source of interpersonal information, their decision to adopt ITNs was more influenced by family and friends. What this implies is that after getting the awareness from the hospitals, they still consult with family and friends before reaching a decision on whether or not to adopt the recommended behaviour. Majority of respondents also said that they got their information mostly from the mass media, and although the mass media and interpersonal networks were both found to have influenced the responses of the pregnant women to communication messages on the adoption of ITNs, their decision to use ITNs was more influenced by interpersonal networks. This finding conforms to McCombs and Becker‘s view that the mass media are more effective in creating awareness than influencing decisions (1989); Baran & Davis, (2009) who observe that the mass media are more effective in creating awareness than in changing behavior; and Figueroa and Kincaid‘s CFSC theory (2001), which identifies the mass media as the catalyst which stimulates the dialogue on an issue; and the Dependency theory which posits that people depend on the mass media for information about their needs.

These findings support the following hypotheses of the CFSC Model:

 Individual behaviours and choices are often mediated and structured by social relationships, which are in turn are influenced by important differences of community, social status, educational levels, class, group affiliations and other structural differences such as gender and age. Thus, individual behavior is always contextualized and socially embedded.  There is social influence for individual behavior changes where individuals who adopt new health behaviour publicly advocate its adoption to other individuals so that the rate of change (decline) in the prevalence of the disease increases.

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 Dialogue represents a horizontal, symmetrical relationship among two or more participants that is created by sharing information. The outcomes of information processing by the participants are social — mutual understanding, agreement and collective action as well as individual perceiving, interpreting, understanding and believing.  The CFSC also recognizes the power of social categories in the behavior and social change process. It acknowledges that people who belong to the same group or categories are more likely to respond similarly to communication messages. This assumption has been upheld in this study as the sampled pregnant women, in spite of the differences in their geographical locations have been bonded by a union and friendship developed at the antenatal clinics and health education classes. This is demonstrated in their almost uniform responses to the communication messages on the adoption of ITNs for malaria prevention.

Influence of Category two variables- socio-demographic factors on their responses to communication campaign messages on the adoption of ITNs

Findings of the study show that socio-demographic factors including income, educational levels and geographical locations did not significantly influence respondents‘ answers to communication campaign messages on the use of ITNs for malaria prevention.

Educational Attainment

Results show that academic attainment did not affect pregnant women‘s responses to communication campaign messages on the adoption of ITNs since majority of the respondents across the various educational levels owned ITNs and demonstrated no logical pattern when it came to sleeping under the ITNs.

For example, respondents with no formal education, quaranic education and PhD said they had never slept under. A similar pattern was evident among respondents with OND, NCE, HND and BA/BSc. Only about one third of respondents with MA/MSC., Primary School Certificate and SSCE said they were sleeping under the ITNs every day. Consequently, while the general results show that educational attainment did not influence pregnant women in the study locations to sleep under the ITNs. The frequency of sleeping under ITNs was also unevenly distributed and did not follow any definite pattern.

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Income

Results show a high rate of ITN ownership among the respondents across all the income categories. Similarly, evidence reveals the same trend in usage of ITNs with majority of the respondents across all the income levels sleeping under ITNs, in comparable regularity.

Further findings demonstrate a similar pattern with over half of the middle range income respondents claiming that they slept under the ITN every day, while only one quarter of respondents who earned less said that they slept under the ITN every day. A little below half of the respondents in the high income category were sleeping everyday under the ITN. While the general results do not indicate a definite pattern, more of the middle range income earners appear to be sleeping more regularly under the ITNs.

Geographical Location

Results of this study show that geographical location did not influence respondents‘ responses to communication messages on the adoption of ITNs. This contradicts the position of some Social scientists who observe that beyond an individual‘s own social network, aggregates or categories, there are larger structural and environmental determinants that affect health behaviour such as living conditions related to one‘s employment and family life (Cullen, 2009; Figueroa et al, 2002). For example geographical location and living conditions, which may influence availability and access to healthcare facilities and hence ITNs, Mass media and adequate literacy to enable understanding and appreciation of the benefits of sleeping under ITNs,

The results negate the findings of Cullen‘s study which shows that the percentage of pregnant women who slept under ITN‘s generally increased with increasing level of education and wealth quintile. It also goes contrary to Ribera and colleague‘s observation that demographic variables such as socioeconomic class, and educational levels, influence behaviour (RBM Concept paper, 2003).

The implication of this finding for this study is that while some assumptions of the CFSC Model were upheld, others were rejected. The disparity in influence may stem from the unique nature of Lagos with high mass media and ICT diffusion and access, high availability and access to health care facilities all of which translate to higher exposure to information and education about the existence and benefits of ITNs, higher ownership

164 due to free distribution, thus setting the stage for adoption of the recommended behaviour. It is therefore not logical to tie ITN ownership to level of education or wealth quintile, since ITNs are distributed free to all pregnant women attending Antenatal Clinics in Lagos States, especially the government hospitals. Sleeping under them is however another issue and here results show that the socio- demographic variables measured have not influenced the adoption of ITN messages.

Barriers to pregnant women’s receptivity of the messages on the adoption of ITNs

Although majority of the pregnant women said they were using ITN, 47% of them were sleeping under it every night. This suggests that there may be inhibitory factors causing the rejection or non receptivity of the messages on the adoption of ITN. Among the factors identified as barriers include discomfort caused by heat, allergic reactions to the chemical contained in the ITNs, fear of the chemical harming respondents‘ unborn babies, skills required to put up and maintain the nets as well as ignorance of the benefits of using ITNs for malaria prevention.

Contrary to the views expressed by several scholars in course of researcher‘s literature review, that traditional practice, constitute barriers to the adoption of the recommended bebaviour, findings of this study suggest otherwise. Majority of the pregnant women said that there were no traditional practices forbidding them from sleeping under ITNs. Their major complaints were largely in the areas of knowledge of the processes involved in putting up and maintaining ITNs as well as the belief that the chemical in the ITN can kill unborn babies. Furthermore, respondents identified discomfort due to heat while sleeping under the ITN, and these are all in consonance with the findings of the FGDs during which participants when asked why some of them were not sleeping under the ITN daily or sleeping at all, they gave a number of reasons including heat, allergy to the chemical in the ITN, difficulty in constructing where to fix the ITNs and sometimes sheer laziness. Some of them also expressed reservations about the safety of the chemicals in the ITNs when inhaled by humans, while some others said they believed that the chemical can kill their unborn babies.

In the words of one of them: ―There is the issue of heat which makes it uncomfortable to use ITN when there is no light. Apart from that, there is that of treating the nets, after the first washing, washing might be difficult due to lack of access to the chemical although they are

165 said to be available at pharmaceutical stores. The last time I re-treated the nets with tablets which I obtained from a pharmacy‖

Another participant claimed: ―I told my mother-in-law and my mother too about it, but my mother-in-law complains that it makes her face feel ―peppery‖ when she sleeps under it but after some time the reaction wanes. I also react to it but the benefit outweighs the disadvantages‖

Others had no complaint about it and said they had resolved that the complaints of other people would not stop them from using the ITN.

Asked why some of them had to wait until they were given free ITNs before owning or sleeping under ITN, they attributed it to the prevalence of fake ITNs in the market and difficulty in identifying the original products. One of them said ―I discussed ITN use with my friends and family members and while some of them agreed that ITNs are effective, they expressed fears about differentiating the fake nets from the genuine ones.‖

Other barriers included confusion about the method of use of the ITNs. While one participant said that although it was not indicated in the manual, she was advised by friends to spread the net for four hours before using it, another said she was told to spread it under a shade, even though she was not told to do so by the health care workers.

One of the participants observed that pregnant women in the villages were not aware of the control method as there were no community meetings where such issues are talked about while those who went for ante-natal sessions were not given the nets for free.

These findings indicate a knowledge gap among the audiences of the RBM ITN campaign and suggest a near absence of planned communication messages which should be used as a tool to create awareness and knowledge among audiences about the benefits of sleeping under the ITNs as well as teach them the required skills. Furthermore, it appears to authenticate the information that the communication element was in the past not part of the initial RBM campaign planning (interview conducted with UNICEF Communication Officer, Lagos, on the 2nd of June, 2011) It also lends support to the assertions of Ribera et al (2003) that communication should form part of the original campaign plan and not added as an afterthought.

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REFERENCES

Abasiattai, A. M., Etukumana, E. A. & Umoiyoho, A. J. (2009). Awareness and practice of

malaria prevention strategies among pregnant women in Uyo, South- South Nigeria,

The Internet Journal of Gynaecology and Obstetrics, vol. 11(1)

Baran, J. & Davis K. (2009). Mass communication theory: Foundations, ferment and future

(5th ed.). Belmont, C A: Wadsworth.

Baran, S. J. (2010). Introduction to mass communication: Media, literacy and culture (6th

ed.). New York: McGraw Hill

Figueroa, M. E., Kincaid, D. L., Rani, M. & Lewis, G. (2002). Communication for social

change: An integrated model for measuring the process and its outcomes. In Brian

Bryd (Ed.). Communication for social change: Working paper series one. New York,

New York: The Rockefeller Foundation

McCombs, M. E. and Becker, L. (1979). Using mass communication theory. New Jersey;

Prentice Hall Inc.

Synder, L. B. (2003). Development communication campaigns, In B. Mody. (Ed.),

International and development communication: A 21st century perspective, pp. 167-

167

Internet Sources

Cullen, T. (2009). Health communication theories: Implications for HIV reporting in Asia and the Pacific. Asia Pacific media monitor, vol. 19(10), pp. 99-111. Retrieved March 20,

2011, from http://ro.uow.edu.au/apme/vol1/iss19/10

Federal Ministry of Health Nigeria (2008). A strategy for behaviour change communication

in the Roll Back Malaria Programme, Nigeria, Retrieved June 19 2011 from

http://nmcpnigeria.org/f/acsm/BCC

Ribera, J. M., Hausmann- Muella, S., D‘Alessandro, U. & Grietens, K. P. (2007). Malaria in

pregnancy: What can social sciences contribute? Retrieved June 18, 2011, from

www.plosmedicine.org/article/info:doi/10.../journal.pmed.0040092

Roll Back Malaria concept paper, (2003) Retrieved October 8, 2010, from

http://www.rbm.who.int

RBM update (2011). The vision, the mission, the goal. Retrieved September 28, 2011, from

http://nmcpnigeria.org/f/ROLL%20BACK%20MALARIA%20IN%20NIGERIA-

update%20for%20HMH.pdf

Tavoosi, A., Zaferani, A., Enzevari, A., Tajik, P. & Ahmadinezhad, Z. (2004). Knowledge

and attitudes towards HIV/AIDS among Iranian students. Retrieved March 15, 2011,

from http://www.pibmedcentral.nih.gov/articlerender.fcg.?article420470

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CHAPTER SIX

CONCLUSIONS, RECOMMENDATIONS AND CONTRIBUTIONS TO KNOWLEDGE

Conclusion

This study investigated the receptivity of pregnant women in Lagos State to communication campaign messages on the adoption of ITNs for malaria prevention. It also examined the effectiveness of the CFSC Model in explaining the responses of the pregnant women. The CFSC theory assumes that though the mass media act as catalysts, social context factors will influence behaviour change, such as the decision to adopt or reject ITNs for malaria prevention, particularly in the developing nations. From the results of the study, the following conclusions have been reached:

Majority of the pregnant women in rural and urban Lagos State did not differ in their exposure patterns to mass media messages on the adoption of ITNs for malaria prevention. The researcher concludes therefore that the similarity in patterns of exposure across the LGAs in Lagos State is attributable to the predominantly metropolitan and elite nature of Lagos, its widespread technology diffusion and penetration, mass media plurality, and abundance of and access to healthcare facilities.

Television in this study has been shown to be the major source of information on health and ITN related issues among pregnant women in Lagos State, but did not exert as much influence as interpersonal networks such as family and friends. This means that in spite of the dependence on the media as sources of information, interpersonal networks still have more direct influence on audiences.

Although Limited Effects scholars argue that that the power of the media is limited, (Folarin, 2005), television is shown to have created better awareness about the ITN than any other channel of information, while influencing about one quarter of the pregnant women to adopt the recommended behaviour. The conclusion therefore, is that awareness creation and media dependence on their own are very strong and powerful effects. And like the Agenda Setting function of the media which scholars consider a powerful effect because the media, purposely or inadvertently determine what is important in society, awareness creation and media dependence are also powerful because they set the stage for behaviour change.

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ITN ownership and usage among pregnant women in Lagos State is significantly higher than has been severally reported by FMOH, WHO, UNICEF, RBM and other agencies which have put ownership at between 8- 20% and usage at between 5- 17%. Again the conclusion from this is that the elite nature of Lagos, with its unique social and technological environment places it at an advantage when compared with several other States in the country and accounts for the disparity in levels of adoption.

The finding that social contexts, including family, friends, neighbours and opinion leaders significantly influenced the decision of pregnant women to adopt ITNs for malaria prevention, while socio- demographic factors such as income, educational attainment, and geographical location were found to have little or no effects on the adoption or rejection of the messages. While the former finding supports the CFSC as an appropriate theory for explaining the responses of target populations to communication messages on behaviour change, the latter rejects the related assumption. Although it is unknown if in other parts of the country results of the latter may support the related CFSC tenet, the conclusion here is that no single theory has all answers to all the communication problems all of the time and in all of the situations and, therefore, cannot be regarded as ―the ideal theory‖.

Among the barriers mentioned by respondents as inhibiting the adoption of ITN for malaria prevention are lack of knowledge and skills required to put up and maintain the ITN as well as the belief among some of the respondents that the chemical in the ITN is poisonous and capable of killing their unborn babies. The conclusion that can be drawn from this is that the knowledge gaps existing among the respondents is attributable to the flaws in the communication strategies and messages used in the RBM Campaign which cause the target populations to receive mixed, unclear and conflicting messages.

In view of these conclusions, the following recommendations are offered:

Recommendations

1. Disseminating information through the mass media and interpersonal networks is not just enough. Messages should be planned, designed and harmonized to achieve uniformity and clarity. That way, target populations would be able to clearly understand the messages. 2. Communication should be included as part of the campaign strategies from the outset and not as an afterthought. During the planning stages of the campaign, formative

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research should be used to segment populations into homogeneous groups and a decision made as to the content and tenor of the communication messages and appropriate channels. These messages should be pretested to ascertain their clarity of meaning and harmony across all channels of communication. This is to avoid mixed messages which may lead to misinformation, conflicts and confusion. 3. Community dialogue should be stepped up, particularly in high brow or elite neighbourhoods. Apart from the community outreach carried out by the NAF hospital Shasha, in Oguntade community in Alimosho LGA, results of the survey and FGDs across all the five LGAs did not indicate any form of community dialogue and collective action taking place in Lagos State. Even the house to house distribution of ITNs to majority of the LGAs in Lagos State can be considered selective, as LGAs like Eti- Osa which are considered elite did not receive free ITNs, at least not to the knowledge of the researcher who happens to live there. 4. Programme officers and health care workers involved in social change projects such as the RBM programme and who possess enough education to understand the messages themselves should be carefully selected, trained and retrained in the area of interpersonal communication. This will equip them with the knowledge and skill to disseminate the messages in ways that would be understood by their audiences. 5. The CFSC Model should be popularized as a framework for communication planning in health and behaviour change programmes.

CONTRIBUTIONS TO KNOWLEDGE

1. Results of this study have thrown more light on the current situation in Nigeria as regards the receptivity of pregnant women to the communication campaign messages on the adoption of ITNs for malaria prevention, at a time when global medical care (including Nigeria‘s) is experiencing a shift in paradigm, from treatment to prevention of diseases. Contrary to earlier findings that Nigeria has only 8% ITN ownership, with 5% of pregnant women sleeping under the nets (FMOH, 2010; WHO, 2010; UNICEF, 2010, NDHS, 2009); and the recent findings of 20% ITN ownership in the South West of Nigeria and 17% of pregnant women in Nigeria sleeping under ITN, this study found 78.9% ownership, with 47% of pregnant women sleeping under the ITN daily.

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This implies that Nigeria has recorded gains and is poised to meet the 2013 new RBM target of getting 80% of pregnant women to sleep under ITNs daily.

2. The CFSC theory which formed the framework of analysis for this study is a new and evolving theory and in response to the call for its empirical evaluation by its creators (Kincaid and Figueroa, 2002), some of its assumptions were tested and while some were upheld others were rejected. Findings established a strong link between CFSC based communication strategies and the response of pregnant women to the ITN messages. The period of use of this model coincided with the increase in the adoption of the recommended behaviour among pregnant women. It also underscores the importance of socio- cultural factors in decision making in the Nigerian society. Thus: a. The assumption that social context factors such as family/friends, neighbours, opinion leaders, healthcare givers and the mass media significantly influence people‘s responses to communication messages was validated b. The assumption that the mass media, policies, health care givers and other social networks serve as catalysts in the behaviour change process was also validated while; c. The assumption that socio-demographic variables which include, income, educational level, and geographical location influence people‘s responses to behaviour change messages was rejected.

3. The study generated ideas that informed the addition of some elements which the researcher reflected in a modified model. It is hoped that this modified model will be of use to researchers in the field of communication for behaviour change.

4. Another key contribution of this research to the body of knowledge rests in its findings which refutes the prevalent notion about the minimal power of the media, and adds weight to the expanding propositions for a return to the ―Powerful Effects‖ paradigm by scholars such as Elizabeth Noelle Newmann and Babatunde Folarin (Baran and Davis, 2003; Folarin, 2003). While 76% of the sampled pregnant women said the mass media especially television were their major source of information on ITNs, nearly a quarter of them (24%) said they were influenced by the media to adopt the recommended behaviour.

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5. Findings of this study provide an invaluable resource and reference point for planning public health campaigns by governments and international donor agencies particularly in the area of preventive medicine as well as increasing the literature in the area of behaviour change communication.

Suggestions for future research

Although this study investigated a segment of society, it only studied pregnant women in Lagos State, and even at that, it studied only five out of the twenty LGAs in Lagos State. In view of this, the following suggestions are made for future research:

 Further studies covering the other 35 states in Nigeria as well as the remaining 15 LGAs in Lagos State should be conducted.

 Similarly, media exposure patterns and media use among pregnant women should be investigated in the other parts of the country to determine if and why there are differences

 Although socio- demographic factors including income, educational attainment, and geographical location were found to have little or no effects on the adoption or rejection of the messages by sampled pregnant women, it is unknown if similar results will be found in other parts of the country. It is therefore necessary to subject the CFSC theory to further test in other states in the country, to ascertain its applicability across elite and non elite states.

 Furthermore, studies on the nature of social networks and their influences on decision making and behaviour change in the different parts of the country should be carried out. This is to enable policy makers, advocacy groups, governments and international development agencies identify the major influencers in various segments of the population for different intervention programmes.

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BIBLIOGRAPHY

Abasiattai, A. M., Etukumana, E. A. & Umoiyoho, A. J. (2009). Awareness and practice of

malaria prevention strategies among pregnant women in Uyo, South- South Nigeria,

The Internet Journal of Gynaecology and Obstetrics, vol. 11(1)

Adebiyi, E. (2011). Code malaria: Eradication developments for the decade, An Inaugural

lecture series, vol. 1(1), delivered at Covenant University, Ota, Nigeria in March,

2011.

Airhihebunwa, C. & Obregon, R. (2006). A critical assessment of theories/models used in

health communication for HIV/AIDS: Theories and models of behavior change. In A.

Gumucio- Dagron & T. Tufte (Eds.), Communication for social change anthology:

Historical and contemporary readings, pp. 623- 628. South Orange, NJ:

Communication for Social Change Consortium

Ajala, V. O. (2009). Scholarly writing guide for researchers. Ibadan: Maybest Publishers

Ajibade, O. (2010). Perspectives in modernization and the role of the mass media in the

development of Third World Countries. Journal of Communication review, vol. 4(2),

pp.41- 59, Lagos: Department of Mass Communication, University of Lagos.

Akinfeleye, R. A. (2007). Essentials of journalism: An introductory text for the beginner. 3rd

edition, Lagos: Unimedia Publishers

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