title: The use of mediation analysis to assess the effects of a behaviour change communication strategy on bed net ideation and household universal coverage in Tanzania.
abstract: BACKGROUND
  SBCC campaigns are designed to act on cognitive, social and emotional factors at the individual or community level. The combination of these factors, referred to as 'ideation', play a role in determining behaviour by reinforcing and confirming decisions about a particular health topic. This study introduces ideation theory and mediation analysis as a way to evaluate the impact of a malaria SBCC campaign in Tanzania, to determine whether exposure to a communication programme influenced universal coverage through mediating ideational variables.
  
  
  METHODS
  A household survey in three districts where community change agents (CCAs) were active was conducted to collect information on ITN use, number of ITNs in the household, and perceptions about ITN use and ownership. Variables relating to attitudes and beliefs were combined to make 'net ideation'. Using an ideational framework, a mediation analysis was conducted to see the impact exposure to a CCA only, mass media and community (M & C) messaging only, or exposure to both, had on household universal coverage, through the mediating variable net ideation.
  
  
  RESULTS
  All three levels of exposure (CCA, M & C messaging, or exposure to both) were significantly associated with increased net ideation (CCA: 0.283, 95% CI: 0.136-0.429, p-value: <0.001; M & C: 0.128, 95% CI: 0.032-0.334, p-value: 0.018; both: 0.376, 95% CI: 0.170-0.580, p-value: <0.001). Net ideation also significantly increased the odds of having universal coverage (CCAOR: 1.265, 95% CI: 1.118-1.433, p-value: <0.001; M & COR: 1.264, 95% CI: 1.117-1.432, p-value: <0.001, bothOR: 1.260, 95% CI: 1.114-1.428, p-value: <0.001). There were no significant direct effects between any exposure and universal coverage when controlling for net ideation.
  
  
  CONCLUSIONS
  The results of this study indicate that mediation analysis is an applicable new tool to assess SBCC campaigns. Ideation as a mediator of the effects of communication exposure on household universal coverage has implications for designing SBCC to support both mass and continuous distribution efforts, since both heavily rely on consumer participation to obtain and maintain ITNs. Such systems can be strengthened by SBCC programming, generating demand through improving social norms about net ownership and use, perceived benefits of nets, and other behavioural constructs.
authors.affiliation: Johns Hopkins Center for Communication Programs, Johns Hopkins Bloomberg School of Public Health, 111 Market Place Suite 310, Baltimore 21202, MD, USA. ericotta@jhu.edu.
authors.forename: Emily E
authors.initials: EE
authors.lastname: Ricotta
authors.forename: Marc
authors.initials: M
authors.lastname: Boulay
authors.forename: Robert
authors.initials: R
authors.lastname: Ainslie
authors.forename: Stella
authors.initials: S
authors.lastname: Babalola
authors.forename: Megan
authors.initials: M
authors.lastname: Fotheringham
authors.forename: Hannah
authors.initials: H
authors.lastname: Koenker
authors.forename: Matthew
authors.initials: M
authors.lastname: Lynch
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001521:Behavior Therapy / Q000379:methods*; D018562:Disease Transmission, Infectious / Q000517:prevention & control*; D005192:Family Health; D005260:Female; D058015:Health Communication; D006801:Humans; D057148:Insecticide-Treated Bednets / Q000706:statistics & numerical data; D008288:Malaria / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D013636:Tanzania; D019472:Universal Health Insurance; D055815:Young Adult