Applying the COM-B behaviour change model in social and behaviour change message development towards increased uptake of Perennial Malaria Chemoprevention (PMC) delivered through routine immunization platform in Osun State, Nigeria

This paper demonstrates how the COM-B behavior change model was applied to a qualitative study in Osun State, Nigeria, to identify key drivers and barriers and subsequently design targeted social and behavior change messages that enhance the uptake of Perennial Malaria Chemoprevention through the routine immunization platform.

The Gist

Imagine you are trying to get a group of people to do something new and important for their health, like taking a special medicine every month to stop malaria. You can't just shout, "Take this pill!" and expect everyone to listen. You have to understand why they might say no, and what would make them say yes.

This paper is a story about how a team in Osun State, Nigeria, used a clever "behavioral detective" tool called the COM-B Model to figure out how to get more families to use a new malaria prevention program called PMC (Perennial Malaria Chemoprevention).

Here is the breakdown of the story, using simple analogies:

1. The Problem: The "Malaria Monster"

Nigeria has a huge problem with malaria. It's like a relentless monster that makes children sick and can even kill them. The government introduced a new shield: PMC. This is a medicine given to babies alongside their regular vaccines to stop them from getting sick all year round.

But, just like a new video game console, having the game isn't enough; people have to actually play it. Many families weren't showing up to get the medicine. The team needed to figure out why.

2. The Detective Tool: The "COM-B" Engine

To solve the mystery, the team used a model called COM-B. Think of this model as a three-part engine that needs to be running for a car (the behavior) to move. If one part is broken, the car won't go.

• C = Capability (The Driver's Skills): Does the person know how to do it? Do they have the knowledge?
• O = Opportunity (The Road Conditions): Is the path clear? Do they have the time, money, and support to do it?
• M = Motivation (The Gas in the Tank): Do they want to do it? Is it worth the effort?

3. The Investigation: Listening to the Community

The team didn't just guess. They went into the community and held "town hall" style meetings (Focus Group Discussions) with 120 people: mothers, fathers, grandmothers, community leaders, and doctors. They asked, "What stops you from bringing your child for the medicine?"

Here is what they found, mapped to the COM-B engine:

Capability: "I forgot!"

• The Issue: Many parents knew malaria was bad, but they were like drivers who forgot their appointment time. They simply forgot when to bring their child back for the next dose.
• The Fix: The team realized they needed better "reminders." They decided to create a Community Dialogue Flipbook (a picture book for facilitators) to help remind parents. They also suggested using phone calls and text messages as "digital alarm clocks."

Opportunity: "The road is too bumpy."

• The Issue: Even if parents wanted to go, the "road" was full of potholes.
  • Long Waits: Clinics were crowded. Parents had to wait hours, which was hard for moms who had to work or cook.
  • Lack of Support: Some husbands didn't know they needed to help.
  • Transport: Getting to the clinic was hard without a car or bus fare.
• The Fix: The team realized they needed to fix the "road." They encouraged husbands to be "co-pilots" (providing money and transport). They also pushed for more doctors so the waiting lines would be shorter.

Motivation: "Is it really worth it?"

• The Issue: Some parents thought, "My child looks healthy right now, so why bother?" They didn't feel the urgency.
• The Fix: The team used stories to fill the gas tank. They shared real-life stories from fathers who said, "Since we started this, my child hasn't been sick!" They also reminded everyone that malaria is a silent killer that can strike even when a child looks fine. They used the fear of losing a child to spark action, but balanced it with the hope of a healthy, thriving child.

4. The Solution: The "Community Dialogue" Workshop

Once they understood the engine, they built a new map. They held a workshop to create a Community Dialogue Flipbook.

Think of this flipbook as a script and a visual guide for community leaders. Instead of just lecturing people, these leaders would use pictures and stories from the book to have a conversation.

• The Message: "PMC is the gateway to your child's healthy growth."
• The Strategy: They trained 81 community mobilizers (mostly women) to go door-to-door and into villages to use this book, remind people, and encourage husbands to help.

5. The Result: A Smoother Ride

By using the COM-B model, the team didn't just guess what to say. They built a strategy that:

1. Taught people the schedule (Capability).
2. Encouraged families to support each other and fix clinic wait times (Opportunity).
3. Inspired parents with the fear of malaria and the joy of a healthy child (Motivation).

The Bottom Line

This paper teaches us that to change behavior, you can't just use one hammer. You have to fix the skills (Capability), clear the path (Opportunity), and fill the tank (Motivation).

In Osun State, they used this "three-part engine" to turn a confusing, forgotten medicine into a life-saving habit for thousands of children. It's like tuning a car so it doesn't just sit in the garage, but actually drives down the road to safety.

Technical Summary

1. Problem Statement

Despite malaria being preventable and treatable, it remains a leading cause of morbidity and mortality in Nigeria, which accounts for approximately 24.3% of global malaria cases. Children under five and pregnant women are the most vulnerable groups.

• The Intervention: Perennial Malaria Chemoprevention (PMC), formerly known as Intermittent Preventive Treatment in infants (IPTi), involves administering preventive antimalarial drugs (Sulfadoxine-Pyrimethamine) to children under two years of age. It is delivered via the Routine Immunization (RI) platform.
• The Challenge: Uptake of malaria interventions is heavily influenced by human behavior. Barriers such as lack of knowledge, misconceptions, cultural norms, gender dynamics, and logistical issues (e.g., long wait times) hinder the adoption of PMC.
• The Gap: There was a need to design culturally sensitive, evidence-based Social and Behaviour Change (SBC) messages to drive the uptake of PMC during its pilot study in Osun State, moving beyond simple information dissemination to addressing specific behavioral drivers.

2. Methodology

The study employed a mixed-methods approach grounded in behavioral science theory to design the SBC intervention.

• Study Setting: Two Local Government Areas (LGAs) in Osun State, Nigeria: Ede and Obokun.
• Theoretical Framework: The COM-B model (Capability, Opportunity, Motivation – Behaviour) was the primary framework, supplemented by the Health Belief Model (HBM).
  • Capability: Psychological and physical ability to engage in the behavior.
  • Opportunity: External factors (social and environmental) that make the behavior possible.
  • Motivation: Brain processes that energize and direct behavior.
• Data Collection:
  • Qualitative Study: 12 Focus Group Discussions (FGDs) were conducted with 120 participants, including mothers of children under two, pregnant women, men, Ward Development Committee (WDC) members, community mobilizers, and health workers.
  • Analysis: Thematic analysis was conducted using the COM-B model to categorize barriers and enablers.
• Intervention Design:
  • A three-day SBC workshop was held with stakeholders to translate qualitative findings into actionable messages.
  • Outputs: Development of a Community Dialogue Flipbook and a Facilitator's Guide.
  • Target Audiences: Primary (mothers/caregivers, pregnant women, WDCs, TBAs) and Secondary (fathers, health workers, community leaders).
• Implementation: 81 community mobilizers were trained to deliver the community dialogues across 80 communities in eight LGAs between November 2024 and August 2025.

3. Key Contributions

• Operationalization of COM-B in Malaria Control: The paper demonstrates how the COM-B model can be practically applied to deconstruct complex health behaviors (PMC uptake) into actionable components (Capability, Opportunity, Motivation) for message design.
• Integration of HBM and COM-B: It successfully bridges the Health Belief Model (perceived susceptibility/benefits) with the COM-B framework to create a robust SBC strategy.
• Participatory Message Development: The study utilized a participatory approach where local stakeholders (health workers, community leaders, and caregivers) co-created the flipbook and facilitator guide, ensuring cultural relevance and acceptability.
• Holistic Stakeholder Engagement: The research explicitly included men (fathers) and community structures (WDCs) in the analysis, highlighting their critical role as enablers rather than just focusing on mothers.

4. Key Results

The study identified specific barriers and enablers mapped to the COM-B domains:

A. Capability (Knowledge and Skills)

• Enablers: High awareness of malaria symptoms (fever, convulsions, lethargy) and the severity of the disease.
• Barriers: Forgetting appointment dates was a significant capability gap. Caregivers often lacked the psychological tools (memory aids) to adhere to the monthly PMC schedule.
• Solution: Simplified messages and the use of reminder cards/mobile prompts.

B. Opportunity (Social and Environmental Factors)

• Enablers:
  • Spousal Support: Men providing transport, financial support, and reminders significantly increased uptake.
  • Community Networks: WDCs and mobilizers effectively disseminated information through churches, mosques, and word-of-mouth.
  • Health Worker Trust: Caregivers trusted health workers as primary information sources.
• Barriers: Long waiting times at health facilities due to staff shortages and high patient loads discouraged attendance, particularly for women balancing livelihoods.
• Solution: Promoting social support structures and advocating for increased staffing/efficiency.

C. Motivation (Beliefs and Emotions)

• Enablers:
  • Perceived Severity: Fear of malaria causing death or severe illness drove action.
  • Visible Benefits: Caregivers and health workers observed a tangible reduction in malaria cases in children receiving PMC, reinforcing the intervention's value.
  • Testimonials: Fathers reporting improved family health acted as powerful motivators for other men.
• Barriers: Lack of perceived urgency when children appeared healthy; some caregivers did not see the need for preventive medicine if the child was not currently sick.
• Solution: Emotional appeals focusing on child survival and testimonials of health improvements.

Outcome: The resulting SBC materials were centered on the positioning statement: "PMC is the gateway for child healthy growth and thriving."

5. Significance and Implications

• Strategic Framework for Scale-up: The study provides a replicable blueprint for using behavioral science to design interventions for new malaria strategies in high-burden settings.
• Addressing Systemic Bottlenecks: By identifying "long wait times" as an opportunity barrier, the study highlights that SBC cannot succeed in isolation; it must be paired with health system strengthening (e.g., staffing improvements).
• Male Engagement: The findings underscore that engaging men as active supporters (financial and logistical) is crucial for maternal and child health interventions, shifting the paradigm from viewing mothers as the sole decision-makers.
• Sustainability: The use of visible health gains (reduced malaria cases) as a motivator suggests that once the benefits of PMC are demonstrated, community demand may become self-sustaining.
• Limitations & Future Directions: The authors acknowledge limitations regarding generalizability (only two LGAs) and the lack of quantitative data linking the SBC intervention directly to uptake rates. They recommend future longitudinal studies to measure epidemiological outcomes.

In conclusion, the paper validates the COM-B model as an effective tool for translating qualitative insights into targeted, culturally appropriate SBC messages, ultimately aiming to increase the uptake of life-saving malaria chemoprevention in Nigeria.