Couple concordance related to ITN use in Malawi

The shift to universal insecticide-treated nets (ITN) coverage in Malawi creates opportunities for establishing effective social and behavior change (SBC) interventions which target general populations, including couples. However, couple concordance in ITN use has not been well analyzed. We explored couple dynamics and concordance related to ITN use in Malawi to inform the potential role of couple-centered SBC approaches to improve consistent ITN use.

The analysis focuses on 1213 male-female couples or dyads, a subset of a nationally representative survey. Key variables for both members of the couple included consistent net use and ITN Ideation, the combination of cognitive, social, and emotional factors related to a behavior measured as a composite score of several psychosocial factors. We assessed concordance (level of agreement) between men and women in the couple using Cohen's Kappa statistic (K). Crude and adjusted logistic regressions identified factors associated with couples' concordance in ITN ideation and consistent net use, adjusting for household and couple characteristics.

Over one-half (54%) of couple dyads reported consistent ITN use among both partners (k = 0.81). Factors significantly associated with couples' concordance in high ITN ideation included residence in Central (adjusted odds ratio [aOR]: 2.27: 95% confidence interval [CI] 1.59-3.25) or Southern (aOR: 2.35; 95% CI 1.42-3.91) regions of Malawi compared to the North; wealthier households (aOR: 2.05; 95% CI 1.20-3.51); and having a primary education (aOR: 1.59; 95% CI 1.15-2.20). The most important couple-level factor associated with concordance in net use was concordance in ITN ideation (aOR: 1.66; 95% CI 1.08-2.55).

Our study demonstrated couples are likely either to jointly use or not use ITNs consistently, suggesting a couples' approach may be worth exploring when designing and implementing SBC programs to promote consistent ITN use. This may necessitate addressing norms regarding couples' use of ITNs to encourage discussion of malaria prevention and ITN use among couples.