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Ethiopia, a country with high rates of maternal and newborn mortality, is strongly committed to meeting Millennium Development Goals 4 and 5 to substantially reduce maternal and child mortality by 2015 from the current high figures (maternal morality ratio, 676/100,000 live births; neonatal mortality rate, 37/1,000 live births). A number of factors retard goal attainment, however. Distance to functioning health centers and financial barriers are major structural factors. In addition, deeply engrained cultural norms continue to deter birth in health facilities. Such norms promote involvement of family members and traditional birth attendants (TBAs, rather than skilled attendants) and the use of detrimental practices such as breastfeeding delay, providing food other than breast milk, discarding of colostrum, immediate bathing of newborns, and applying substances like butter or cow dung to the umbilical stump that lead to newborn morbidity and mortality.
There is consensus that a package of evidence-based practices, beginning with pregnancy identification and appropriate antenatal care and leading to adequate birth preparation, continuing through a core set of birth practices, and extending through near-term postnatal care with access to adequate emergency care, is the minimum necessary for maternal and newborn survival and well-being. Implementing such maternal and newborn health practices requires strategies that account for the actualities in low- to moderate-income, largely rural, often very traditional societies. In particular, women's and families’ awareness of and demand for skilled care before, during, and after birth needs to be expanded.
Supported by the Bill and Melinda Gates Foundation, the Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) project undertook to ensure that the package of evidence-based practices would be provided to every woman every time immediately prior to birth, at birth, and within 48 hours after birth. MaNHEP focused on a set of 51 kebeles, lower administrative units below a district/woreda. Each kebele has an average population of 5000 people or 1000 households, in 2 regions: Amhara and Oromia. As part of its overall strategy, the MaNHEP project implemented a series of behavior change communication strategies to increase women's demand for and use of antenatal, birth, and postnatal care services and resources.
Behavior change communication interventions are often deployed in conjunction with other methods to bring about changes in the health behaviors of targeted populations. They can employ a number of media (eg, print, broadcast, video) to convey their message. Numerous observational studies, a typical evaluation strategy,5-7 have shown credible associations between changes in behavior and exposure to behavior change communication.8-10 A number of theoretical frameworks undergird behavior change communication efforts. Those that appear to have the greatest success attempt to create an emotional link between the target viewer and the message so that the viewer can imagine himself/herself in the situation of those being portrayed and can act in the ways that are recommended. This emotional “transportation” is meant not only to delineate a proper course of action but also to create a predisposition toward and confidence in one's ability to carry out that course of action.12-15 In general, there is growing consensus that a given behavior is more likely to occur if the intention to practice that behavior is strong, if there are no environmental barriers to performing it, and if the individual has the skills to perform the behavior.
There are challenges to implementing behavior change communication in Ethiopia, especially because of the poor access and exposure to mass media in Ethiopia. According to the 2011 Ethiopian Demographic and Health Survey, only 41% and 10% of households have radio and television, respectively; 25% have mobile telephones; and 5% have nonmobile telephones. Respondents were more likely to listen to the radio (22% of women and 38% of men) than to watch television (16% of women and 21% of men) or to read newspapers (5% of women and 11% of men) at least once a week. Surprisingly, 68% of women and 54% of men have no exposure to any of the 3 mass media modalities. Moreover, the adult literacy level in 2011 was low in Ethiopia (59.1%), and only half of female adults (50.6%) were literate.
Seeking to reach underserved segments of the population, MaNHEP produced a one-hour and 40-minute mobile video, “The Road to Life and the Road to Death,” available in Amharic and Afan-Oromo, the dominant languages of the project's target regions. The video compares the pregnancy and birth experiences of 2 fictional families. In the first family, the pregnant woman, along with her husband and other family members, attends meetings similar to MaNHEP's Community Maternal and Newborn Health (CMNH) family meetings, which educate the family on common problems related to maternal and newborn care and actions for those problems in 4 rounds by volunteers. As a result, the woman and her family are prepared for birth and know what to do to ensure the health of the woman and her newborn. This mother and newborn receive help from her husband, a health extension worker, and a trained community health volunteer during the postnatal period, and all goes well. The husband in the second family—an autocratic person addicted to alcohol—does not allow the mother to attend CMNH family meetings, will not accept offered help from a health extension worker or her friend (a trained community volunteer), provides no care for her, and makes her work hard late into pregnancy. This woman and her newborn die, after which the husband changes and promises to teach the community through his example.
MaNHEP outsourced production of the video. The script was developed in consultation with the project team and used MaNHEP's technical materials (eg, the Take Action Cards—pictorial presentation of problems and actions that need to be taken before, during, and after birth). Local residents and well-known artists were recruited for the filming. A draft version of the video was reviewed by the project team and pretested at selected intervention sites. A final version incorporated the comments of the staff and community members.
The video was shown in 51 kebeles, from December 2011 through February 2012, using projection equipment housed in a mobile van. Shows were held at a variety of locations, including school compounds, farmers’ training centers, kebele administration buildings, and open spaces. Local teams composed of community volunteers, kebele administrators, health extension workers, health center and woreda health office coaches, and MaNHEP staff organized and conducted the shows and the follow-up session. To ensure standard presentation, each MaNHEP staff member received an orientation and a written guide on how to organize the show. After the video was shown, the coaches and MaNHEP staff led an objective-reflection-interpretation-decision (ORID) exercise in which the audience was encouraged to comment on the content of the video, link the video to their own knowledge and practices, and discuss the role they were likely to play in birth events.
This article reports on the use and outcomes of the mobile video show and accompanying participatory discussion exercises and the influence they exerted on participating communities’ knowledge, attitudes, and beliefs regarding maternal and newborn care, especially with regard to care-seeking behavior and use of a skilled birth attendant for birth and postnatal care.
Use of mobile video promotes access to behavior change communication for “media-dark” rural populations.
Well-developed mobile video (professionally produced with input and guidance from content experts) can create a translation effect: participants will relate personally to the material and identify with its relevance to their lives.
An effective behavior change communication intervention will empower its audience to imagine solutions and commit to making them happen.
Key messages were retained by the attendants of the show.
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The mobile video show had excellent audience penetration: based on the report, a total of 28,389 people attended the show from the 51 kebeles (an area where 12,000 births were expected). The attendance tally sheet depicted the number of attendance in each group by type of provider, age of community member, and number of pregnant women. Most of the attendants were young or adult females (Table 2).
Table 2. Attendants at the Mobile Video Show by Region and Type of Audience in Amhara and Oromiya Regions, December 2011 to January 2012
| || ||Elders (>65 years)||Youth (15-30 years)|| || ||Adult|| |
|Site Name||Pregnant Women||M||F||M||F||Children||Guide and QI Teams||M||F||Total|
Of the total 510 respondents included in the endline survey, nearly one-third of them reported having attended the mobile video show (Table 3). The most frequently recollected messages from the mobile video show were women and newborn problems (69%), birth preparedness (63%), and labor and birth notification (54%), all key MaNHEP themes. Of greatest importance, those who attended the mobile video show (vs nonattenders) reported significantly (P < .001) higher rates of recall of key MaNHEP messages about the use of health extension workers, including pregnancy registration, start of labor notification, and birth notification (Table 4).
Table 3. Characteristics of Adult Community Members (Men and Women Aged 18 Years and Older) in Amhara and Oromiya Regions, MaNHEP Adult Endline Survey (May-July 2012)
| ||Amhara, n (%)||Oromiya, n (%)||Total, n (%)|| |
|Characteristics||(n = 240)||(n = 270)||(n = 510)||P Value|
|Saw the BCC video drama||62 (26.1)a||110 (40.7)||172 (33.9)||<.001|
|Topics recalled, among those who saw the dramab|| || || || |
|Pregnancy identification||28 (45.9)||39 (35.5)||67 (39.2)||.19|
|Birth preparedness||37 (60.7)||70 (63.6)||107 (62.6)||.74|
|ANC registration||31 (50.8)||48 (43.6)||79 (46.2)||.42|
|CMNH meeting attendance||12 (19.7)||52 (47.3)||64 (37.4)||<.001|
|Women and newborn problems||41 (67.2)||77 (70.0)||118 (69.0)||.73|
|Labor and birth notification||26 (42.6)||67 (60.9)||93 (54.4)||.03|
|Bleeding too much||33 (54.1)||46 (41.8)||79 (46.2)||.15|
|Woman and referral||19 (31.2)||38 (34.6)||57 (33.3)||.74|
|Postnatal care visits||7 (11.5)||36 (32.7)||43 (25.2)||.002|
|Other MaNHEP BCC activities experiencedc|| || || || |
|Where heard of key health messagesd|| || || || |
|Health center/hospital staff||66 (28.5)||8 (3.9)||74 (16.9)||<.001|
|HEW||195 (84.1)||132 (64.1)||327 (74.7)||<.001|
|TBA||52 (22.4)||5 (2.4)||57 (13.0)||<.001|
|CHDA||82 (35.3)||74 (35.9)||156 (35.6)||.92|
|Guide team||26 (11.2)||14 (6.8)||40 (9.1)||.13|
|Quality improvement team||11 (4.7)||15 (7.3)||26 (5.9)||.31|
|Spouse||16 (6.9)||1 (0.5)||17 (3.9)||<.001|
|Other relative/friend/neighbor||22 (9.5)||13 (6.3)||35 (8.0)||.29|
|MaNHEP BCC video/song||26 (11.2)||53 (25.7)||79 (18.0)||<.001|
|Social gathering or event||24 (10.3)||4 (1.9)||28 (6.4)||<.001|
|1-in-5 Network model family||2 (0.9)||2 (1.0)||4 (0.9)||1.0|
|Other||7 (3.0)||1 (0.5)||8 (1.8)||.07|
Table 4. Health Messages Heard of Among Adult Community Members (Men and Women Aged 18 Years and Older) in Amhara and Oromiya Regions by Mobile Video Show Exposure, MaNHEP Adult End line Survey (May-July 2012)
| ||MVS, n (%)||No MVS, n (%)||Total,a n (%)||P Value|
|Health Messages Heard||(n = 172)||(n = 336)||(n = 508)|| |
|Pregnancy registration with HEW||166 (96.5)||283 (84.2)||449 (88.4)||<.001|
|Birth assistance notification to HEW at start of laborb||170 (98.8)||284 (89.6)||454 (92.8)||<.001|
|When HEW should be notified, among those who had heard of notification|| || || ||.87|
|During labor||166 (97.7)||273 (96.1)||439 (96.7)|| |
|Birth to ≤2 days||4 (2.4)||8 (2.8)||12 (2.6)|| |
|>2 days after birth||0 (0.0)||1 (0.4)||1 (0.2)|| |
|Don't know||0 (0.0)||2 (0.7)||2 (0.4)|| |
|Inform HEW when newborn is bornc||170 (99.4)||274 (84.3)||444 (89.5)||<.001|
Qualitative analysis yielded 3 overarching themes in the objective-reflection-interpretation-decision discussions and focus group discussions data.
Mirror to the Community
Participants indicated that the mobile video show accurately portrayed their communities and homes and succeeded in transporting them into situations with which they could connect. One participant indicated that “the show helped us to judge our own practice at home.”
Participants affirmed that both types of husbands existed in their community, and they were familiar with the negative and positive outcomes portrayed in the 2 situations. Beyond that, however, they indicated they understood the importance of the good husband's actions. As one male stated:
This is evident in the video show. The one who ends up with a big sorrow of his wife's death wasn't willing enough to accept the advice from health extension workers and refused to take his wife to health centers for birth.
Participants acknowledged that communities are not generally aware of pregnancy-related problems or the availability and benefits of facility-based birth services and are not willing to accept medical advice from health extension workers (for example, that pregnant women should reduce their household workload). They affirmed that since, traditionally, male household heads control all decisions around pregnancy, it is difficult for women to seek antenatal care or postnatal care without his support. Participants pointed out that these mores are so strong that women often do not disclose their pregnancies to their husbands during the first trimester. Recognizing this, a participating husband admitted, “… [I]f I would have taken her to the health center soon when she started feeling pain, I would have saved my baby…,” and a female respondent shared, “I could have been spared from the harm and agony if my husband had taken me to a health center for medical checkup during my pregnancy.”
Responding to the mobile video show messages encouraging use of skilled providers instead of or in conjunction with TBAs, participants acknowledged the strength of the TBA tradition within the community. One male participant said that, “Our biggest problem is thinking of TBAs as angels who are sent to save the lives of mothers and their babies, ignoring the experienced birth attendants at health centers.” This belief leads most women to give birth at home with assistance only from TBAs or relatives. Confronting this belief, in light of the mobile video show message, one participant said, “TBAs are still misleading the society by saying that they can deliver their babies safely. Due to these problems, many farmers resist following the advice of health extension workers.”
Participants did indicate that change was taking place. They recognized that various community-level efforts such as house-to-house education visits by health extension workers and MaNHEP's CMNH family meetings and quality improvement efforts are beginning to be taken up by the community, resulting in improved care and outcomes. Focus group discussants reported approvingly that, recently, some husbands have allowed their wives to receive antenatal care and are assisting their wives in household chores. One participating husband proudly reported, “When she got pregnant with another baby, I took her to a health post, and she went through antenatal care as per the schedule, and we had our baby safely. I was so thrilled having a healthy baby with my wife in my arms.” Participants reported other positive behavior changes: husbands have started to save money for an emergency during the pregnancy, and mothers are covering their newborns with clean sheets directly after birth and waiting 24 hours to wash the newborn.
Call to Action
A powerful theme that emerged from the exercises and focus groups was that things have to change. A clear focal point of change is the attitude and behavior of husbands, who play such a critical decisional role in the lives of pregnant women. Reflecting on the value of mutual respect promoted in the mobile video show and the consequent need for appropriate antenatal, birth, and postnatal care, one male participant urged: “… [F]or whom are we going to care if not for our wife?” Another man, commenting on the mistreatment of pregnant wives (eg, being overwhelmed by household chores or being denied antenatal care), said: “…He [the husband] shouldn't enjoy the pleasure of being served by his wife at the expense of her welfare.” One man issued this call to action: “…[We] men who have watched this film must come to our senses and make ready ourselves for change.”
Viewers said that they had internalized the mobile video show messages and suggested ways in which they planned to enact them immediately in their own lives. Men and women indicated that they would have periodic medical check-ups, get timely maternal and newborn health education and antenatal care, avoid harmful traditional practices, give birth in health facilities with the help of skilled professionals, seek health care for their newborns from health centers, and consult with health extension workers and other health professionals on nutrition and postnatal care. One respondent summed up this personal responsibility: “We can only avert this problem if we … end all the harmful traditions we have in our society and listen to what health extension worker is telling and teaching us and put them into effect.” More pragmatically, participants saw the need to save money for emergencies during pregnancy and birth, and afterwards one participant emphasized: “… [T]o improve our saving culture, all individuals should be a member of the saving and credit association.”
Future-oriented reactions also extended to the responsibilities those who viewed the videos should assume to ensure the well-being of mothers and newborns. Participants felt that anyone who saw the mobile video show had an obligation to increase the awareness of the community at large about maternal and newborn health problems and care. As one viewer expressed it, “I wish I could have seen this film in the past so that we could have saved a lot of lives.”
Participants endorsed maternal and newborn health as a communal and societal responsibility, but they recognized its complexity. Many pointed to the need for a multifaceted effort with multisectoral and multilevel involvement, including government agencies but also kebele administration, health extension workers, religious leaders, social organizations, volunteers, school and youth groups, and the whole community. At the same time, reducing maternal and newborn deaths and eliminating harmful traditional practices are tasks that begin with individual commitment:
Like we work hard for our daily bread, I believe we should work hard emphasizing to save the lives of our mothers and children. We shouldn't leave this task to the government and health extension workers; rather, we should all participate to bring about any change.
As part of their overall enthusiasm for the mobile video show, participants made a number of suggestions for ways to improve the program or extend its reach. They suggested extending presentations of the mobile video show to kebeles other than those in MaNHEP's area and presenting the videos at regular intervals to draw in more families as they entered pregnancy. They also suggested inviting young people to enhance their knowledge of pregnancy-related problems. They suggested that the videos address problems related to early marriage, a prevalent and dangerous practice. Of note, respondents indicated that the films identified broader challenges to improving maternal and newborn health outcomes: there are few health extension workers, and these are stretched thin across many areas of health responsibility; the mobile video show only reached a portion of those who could benefit from them; and outside of special programs like MaNHEP, there is no vehicle for large-scale maternal and newborn health education.
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The evaluation did not allow us to measure the change in knowledge levels or attitudes before and after the show, but it is clear from the results of the endline survey as well as audience members’ reflections that those who attended retained the content and comprehended the intent of the show. Endline survey data identified significant differences (P < .001) in knowledge and beliefs about antenatal care, labor, and birth notification to health extension workers between those who were exposed to the mobile video show and those who were not. Similarly, mobile video show participants clearly indicated that the video provided resonant messages about maternal and newborn care. The show reinforced participants’ existing knowledge (taught by, for example, health extension workers) and presented messages in a convincing and memorable way for those who had not been previously exposed.
Post hoc, social cognitive theory provided a framework for examining the responses of focus group participants to the mobile video show. Social cognitive theory posits a structure in which self-efficacy beliefs operate in concert with goals, outcome expectations, and perceived environmental impediments and facilitators to regulate human motivation, action, health habits, and overall well-being. Application of this framework guided us in interpreting attendees’ responses and reactions in general categories of knowledge of appropriate health behaviors, benefits of appropriate action, self-efficacy, outcome expectations, and barriers and facilitators.
The social value of practicing appropriate behaviors was reinforced in the mobile video show and during the reflective exercises following the show. The mobile video show provided positive images of correct behavior and its social rewards. Seeing a healthy newborn in the hands of a smiling mother aimed to motivate husbands as well as all members of the family; the image embodied the rewards of a joyful family. Likewise, husbands who behaved responsibly toward their wives were recognized as well-respected members of the community.
Attendees articulated benefits of appropriate behavior in various ways. It was evident that the audience recognized the 2 scenarios presented in the show. The behavior of the 2 husbands was clearly represented in the show. In the discussions afterward, participants used the portrayals to share with others comparable examples from their own experience. These discussions typically led attendees to express their understanding of the roles that they can play as husbands and community members in preserving the health and well-being of women and newborns. The loss of the woman while giving birth had a deep impact; virtually all in attendance reflected on the importance of acting to prevent such outcomes and expressed taking action as a community good. Such behavioral intentions are a key focus of behavior change communication strategies.
One of the key components of the show was helping attendees to develop their confidence and influence self-efficacy and social and group efficacy. In keeping with the overall objectives of the mobile video show, participation stimulated reflection and commitment to action. Men from the community—particular targets of the mobile video show's message—as well as kebele and religious leaders invoked religious teachings and personal and government responsibility as motives for correct behavior.
The mobile video show portrayed many issues that can be considered barriers to and facilitators of appropriate behavior and provided a context and format for considering ways of overcoming and strengthening these, respectively. It recognized the problems posed by unavailable or uncoordinated services and weak infrastructure, resistance from elders, limited numbers of professionals in the community, poor saving culture, and low income levels of families. Conversely, the mobile video show positively portrayed the involvement of health extension workers in home-to-home visits, availability of trained TBAs, and availability of exemplary husbands in the community. The discussions and the messages in the show raised ways of strengthening the facilitators and minimizing the barriers.
The study has a number of strengths that contribute to the credibility of the findings and their potential application. The sample was large and drawn from 2 major ethnic groups, which have different cultures. The number of focus groups conducted and the excellent rate of participation among invited participants suggest that findings can represent the reality in the target community. The focus group discussions permitted interaction between participants that contributed to the richness of the data. Finally, the involvement of focus group experts in the design of questions, training of facilitators, and analysis of data improved the quality of focus group implementation and the process of data analysis.
There are several study limitations. Focus group research, as with other forms of qualitative research, is subjective. Participant responses are open to interpretation, and some comments may be given more weight than others by researchers. We attempted to limit subjectivity by conducting as many reflections as possible and by utilizing 2 researchers to independently code and interpret reflection and focus group transcripts. Moreover, participant responses are not independent—persons can reflect, amplify, or influence others or choose not to comment because of the tenor of the conversation or because others already have commented. However, the facilitators repeatedly encouraged people to raise their issues, regardless of other people's comments. In addition, the themes included in the article are those repeatedly mentioned by the participants; thus, smaller threads may have gone unreported. The study design limited our ability to track changes brought about by the behavior change communication that might have been seen in a more longitudinal design,[8, 22] but this was not feasible. The endline survey also has the same limitation of tracking the change of behavior because of the intervention; hence, only recollections of some key messages portrayed in the video were tracked.