Behavior Change After 20 Months of a Radio Campaign Addressing Key Lifesaving Family Behaviors for Child Survival: Midline Results From a Cluster Randomized Trial in Rural Burkina Faso

"The radio campaign had a positive effect on appropriate responses for diarrhea and fast/difficult breathing, but there was no evidence of an effect on other behaviors."

Development Media International (DMI) is conducting a 35-month radio campaign, which was launched in 2012 and is focused on behaviours related to child health. The campaign is being evaluated by the London School of Hygiene and Tropical Medicine (LSTHM) and Centre Muraz using a cluster randomised controlled trial to assess whether messages broadcast can change behaviours on scale large enough to result in measurable reduction in under-five child mortality. (See Related Summaries, below.) Fourteen community radio stations in 14 geographic areas were selected based on their high listenership. ("The use of television, which is broadcast nationally, would have made a randomized design difficult, if not impossible.") Briefly, short spots, of 1-minute duration, were broadcast in the predominant local language approximately 10 times per day, and interactive long-format programmes of 2-hours' duration were broadcast 5 days per week. The spots were designed to be entertaining and informative and were developed and pretested based on qualitative formative research. Behaviours covered by spots changed weekly, while the long-format programme changed daily, covering 2 behaviours a day.

Cross-sectional surveys were performed in all clusters at 3 time points: At baseline, from December 2011 to February 2012, before the launch of the campaign; at midline, in November 2013, after 20 months of campaigning; and at endline, between November 2014 and April 2015, at the end of the campaign. (Endline results will be reported separately.) Here summarised, and available in full in the PDF file below, are the midline results, which provide an indication of the extent to which the intervention has changed the target behaviours (see Table 1 in the report) after 20 months of broadcasting. At the time of the midline survey, no radio campaigns of comparable intensity were being broadcast in any of the clusters included in the trial.

At midline, 75% of women in the intervention arm reported recognising radio spots from the campaign, though a relatively high proportion of women in the control arm (25%) reported recognising spots, too (25%). There was some evidence of the campaign having positive effects on care seeking for diarrhoea (adjusted difference in difference (DiD), 17.5 percentage points (pp); 95% confidence interval (CI), 2.5 to 32.5;P=.03), antibiotic treatment for fast/difficult breathing (adjusted DiD, 29.6 pp; 95% CI, 3.5 to 55.7; P=.03), and saving money during pregnancy (adjusted DiD, 12.8 pp; 95% CI, 1.4 to 24.2; P=.03). For other of the 19 target behaviours (e.g., antenatal care consultations, facility delivery, delayed bathing, early initiation of breastfeeding, care-seeking for and treatment of fever, bednet use, nutrition, or sanitation-related behaviours), there was little or no evidence of an impact of the campaign after adjustment for baseline imbalances and confounding factors. There was weak evidence of a positive correlation between the intensity of broadcasting of messages and reported changes in target behaviours. Routine health facility data were consistent with a greater increase in the intervention arm than in the control arm in all-cause under-5 consultations (33% versus 17%, respectively), but the difference was not statistically significant (P=.40).

An excerpt from the Discussion section follows: [footnote numbers have been removed]
"...Why does the intervention appear to have had an impact on some behaviors but not others? First, intensity of the intervention is likely to be critical. Although the number of spots broadcast per day was high, on average 10 spots a day, and the long-format program was on air 5 days a week, the intensity allocated to each behavior varied substantially, from 1 week of spots for delayed bathing to 12 weeks of spots for management of diarrhea up to the month preceding the midline survey (Table 1). The dose-response analysis is consistent with those behaviors subject to the greatest number of weeks of spots tending to show the largest changes, although the statistical evidence for this is weak. There is no such pattern, however, for the number of long-format modules....

Another possible explanation for the mixed results may lie in the nature of the behaviors themselves. Changes may be difficult to achieve when they face habitual or normative practices that bear the weight of tradition and strong cultural beliefs....Perhaps more importantly, many preventive behaviors must be performed on a daily basis, with no immediately obvious benefit. Nutrition and hygiene-related behaviors, for example, share these characteristics and changing them may require more time and effort. This challenge to changing preventive behaviors may apply in many settings and across different behavior change approaches. In rural Burkina Faso, all behaviors for which we found some evidence for an intervention effect were episodic...

DMI's messages, rather than providing information alone, use health-related storylines, which provide examples for people to aspire to, imitate, and elicit either positive or negative feelings about target behaviors. By combining information and entertainment, the campaign may act not only through the 'capability' component of behaviors (knowledge) but also through 'motivation,' by affecting both emotional responses and analytical decision making. In addition, the immediate social circle of women and other members of their community were also exposed to the campaign. While husbands influence birth preparedness through permitting (or not) expenditures, female family members, such as mothers-in law, aunts, or grandmothers, are frequently present at the time of birth, provide guidance during the first months of the baby's life, and influence breastfeeding practices. Beside beliefs about disease etiology and perceived severity of illnesses, family members also influence decisions about whether and where to seek care in the event of childhood illnesses. By reaching a large audience, the campaign may also have triggered dialogue in the community and brought changes in the social norms or 'social opportunity' component of behaviors, defined as the 'cultural' milieu that dictates the way people think about things.

On the other hand, the 'physical opportunity' component of behaviors, defined as the external conditions that make behavior change possible, was unaffected by the campaign and this needs to be considered when interpreting results...

Finally, it should also be borne in mind that in this campaign exposure is largely passive, although the long-format programs did give listeners the opportunity to phone in. Other behavior change interventions have often used interpersonal communication that involves face-to-face interaction between health promoters and caregivers. Face-to-face encounters provide some opportunity to tailor information to caregivers' needs and to use persuasion and social influence. It has been suggested that programs in which mass media is part of a multifaceted intervention strategy are more likely to be successful than mass media alone. However, such programs are generally far more costly to implement effectively on a large scale..."