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CHAPTER TWO LITERATURE REVIEW 2.1 Introduction This chapter presents the summary of past studies on behavioral change communication strategies and implementation of school net programmes. Various pieces of knowledge from different authors have been discussed to produce helpful information relevant to this study. The section includes definitions of key terms and concepts, theoretical literature review, empirical literature review, research gap and conceptual framework. 2.2 Definitions of Key Terms This subsection presents operational definitions of key terms. The terms included behavior change, behavior change communication and insecticide-treated mosquito nets (ITNs). The terms have been defined based on the context of other studies and scholars and the general understanding of the researcher. 2.2.1 Behavior Change According to Hunter et al., (2016) refers to temporary or permanent effect which is considered a change to personal behavior when compared to past behavior. Chinosengwa (2020) defines behavior change as transformation of human behavior. Kebede et al., (2020) defines behavior change as change that may happen spontaneously and involuntarily without any intervention or be systematic and motivated as prompted by conditioning. Starmer et al., (2014) defines behavior change as altering of habits for the long term. In this study, behavior change is defined as modification in human behavior on using insecticide-treated mosquito nets that happen voluntarily and involuntarily after an intervention. 2.2.2 Behavior Change Communication Ngigi & Busolo (2018) defines behavior change communication as use of different forms that appeal to and resonate with individuals or groups to change their behaviors toward a particular health problem. Nyirongo (2014) defines behavior change communication as the use of communication as potential tool for promoting positive health behavior amongst populations to prevent and control the spread of diseases and illnesses. Kilian et al., (2016) defines behavior change communication as the identified communication models that can guide the development and formulation of strategies that foster protection, reduce risky behaviors, and encourage adopting and maintaining positive behaviors. Koenker & Lynch (2014) defines behavior change communication as communication system that is used in public health education to create awareness, reduce stigma, and stimulate behavior change to address public health problems. WHO encourages use of behavioral change communication for diseases that are rooted from human behaviors. So, effective behavior communication is necessary to combat diseases (WHO, 2019). In this study, behavior change communication is defined as use of alternative communication strategies that appeal to and resonate with the engaged audience to trigger attitudes that will bring about adopting new traits and changed behavior. 2.2.3 Insecticides Treated Nets (ITNs) According to Kramer et al., (2017) insecticide-treated nets (ITNs) are the foremost powerful malaria control tool to be developed since the initiation of indoor residual spraying (IRS) and chloroquine during the 1940s; and intrinsically, they have been a vital component for universal and national policies for malaria control since the mid-1990s. Yet a decade later, coverage is still unacceptably low: only 3% of African children are currently sleeping under an ITN, and only about 20% are sleeping under any kind of net (Scates et al., 2020). This analysis maps the Programmatic, policy, and scientific evolution of ITNs over the last 10 years. Evidence exists of various Programmatic delivery mechanisms used at the country level alongside the critical policy debates that have contributed to the evolution of ITN delivery approaches and strategies over the past decade (Scates et al., 2020). In this study, ITNs are defined as mosquito nets treated with long-lasting medicine that enable malaria prevention and position them as the most reliable malaria control tool. 2.3 Theoretical Review The study was guided by health belief model (HBM) and ideation model. The theories cover the context of the study objectives and what the research aims to unveil. 2.3.1 Health Belief Model (HBM) Health belief model (HBM) was firstly put forward in 1950s by a group of social psychologists working in the U.S. Public Health Services, comprising Irwin M. Rosenstock, Godfrey M. Hochbaum, S. Stephen Kegeles, and Howard Leventhal. The HBM was created to explain failure of people participating in Programmes to detect and prevent disease. HBM was developed after failure of free tuberculosis (TB) health screening Programme. Despite the efforts to deploy mobile X-rays to neighbourhoods, few people were willing to screen for TB. Therefore, HBM was generated to hypothesize that public health messages achieve optimal behavior change if they focus on six variables i.e. risk susceptibility, risk severity, benefits to action, self-efficacy, and cues to action. (Glanz, 2015; Ngigi & Busolo, 2018). The HBM assumes that people will take action to control or prevent ill-health if they regard themselves as susceptible to the condition (i.e. perceived suceptability), if they believe it would have potential serious outcomes (i.e. perceived severity), if they belive that a certain course of action available to them would reduce the severity or suceptability or lead to other postive consequences (i.e. perceived benefits), and if they perceive few negative aspects related to the health action (i.e. perceive barriers). The stregth of HBM is that it can be used to guide health promotion and disease prevention Programme. It can be used to predict and explain individual changes in health behaviors (Glanz, 2015). The HBM is relevant to this study because it helped the researcher to understand the action taken by school net Programme to control or prevent malaria, the belief of people on potential consequences of malaria in proportional to school net Programme, people’s usage of ITNs to reduce their suceptability to malaria, and negative aspects related school net Programme. Moreover, HBM is relevant becsues it explain and predict individual changes in health behaviors in usage of ITNs provided by school net Programme. Furthermore, it is relevant because it focus on individual beliefs about health conditions in proportion to school net Programme, which explain individual’s health-related behaviors. The HBM has proved to be useful in this study because it has been applied in health behavioral campaigns, including sexual risk behaviors and the transmission of HIV/AIDS. The HBM holds that individual behavior depends on several beliefs about threats to well-being (University of Twente, 2017). The HBM model was also applied in campaigns for response to the swine flu outbreak in India in 2009. Television and radio campaigns were run to deliver messages such as ‘Don’t spread flu, don’t get flu’ (Jones et al., 2015). Thus, it guided the study to examine the implementation of the School Net Programme and to examine the applicability Behavioral Change Communication Strategy in implementing the School Net Programme in Bukoba municipal council. Since HBM has weaknesses such as exclusion of behaviors that are habitual and behaviors that are performed for non-health related reasons such as social acceptability (Ngigi & Busolo, 2018). Thereby theory of ideation model was adopted to overcome the weaknesses. 2.3.2 The Ideational Model Ideation model of strategic communication and behavior change was developed by John Locke in 1996. The model explains the relationships among communication forms, knowledge and skills, environmental situations, creativity, behavior change, and health outcomes. It states that instructive communication can teach skills and knowledge needed to perform an action. Figure 2.1 shows that communication leads to generation of skills and knowledge, which further promotes behavior change and attainment of good health in proportional to environmental context, support and constraints. Figure 2.1: Ideation Model of Strategic Communication and Behavior Change Source: Storey et al., (2018) The model assumes that it’s important to recognize the challenge before solving a problem, since ideas are true but can be dangerous when they are not backed up with evidence. The strength of the model is that it determines solution for the problems and enables to make solutions for the future. Also, it involves amending of existing ideas or combining of two or more ideas to finalize an idea. Moreover, it provides a room for uncovering and exploring new angles and avenues to think outside the box for the sake of innovation and creativity. The model is relevant to this study because it helped the researcher to understand how instructions/behavior change communication under school net Programme are provided through directive measures (i.e. promotion, dissemination or prescription), non-directive measures (i.e. entertainment, counselling, dialogue or social networks) and public measures (i.e. advocacy or regulation). Moreover, it is relevant since it provides the cognitive, emotional and social indicators for measuring the skills and knowledge of households that received the Programme. Furthermore, it is relevant since it provides the individual and collective behavior the community members needed to reach under school net Programme. The ideation model complemented with health belief model in a manner that both explains that change in human behavior can be attributed by external aspects including communication. The ideation model supplemented the weaknesses of health belief model. Therefore, it was guided the study to evaluate the contribution of the in Bukoba municipal council.