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Supporting independent media through coalition building - the ultimate stress test

2022-01-04T10:53:26+00:00

You could be forgiven for thinking (as I did) that coalition-building is a field of media development where international organisations can play only a modest role.

However, the experiences of local stakeholders who have been involved in long-running advocacy initiatives suggest otherwise. The “Coalitions for Change” workshop held by the PRIMED (Protecting Independent Media for Effective Development) programme, led by �鶹Լ�� Media Action, in autumn 2021 offered a unique insight into the potential for balanced partnerships between international and local actors to bring about systemic change.

Success requires understanding and political savvy

The challenges are daunting. Coalition-building is a complex set of moving parts that is, to a large extent, hostage to the vagaries of the political, economic and social landscape – and multiple factors over which international organisations have limited influence or control. There are no shrink-wrapped solutions or off-the-shelf frameworks. Success relies on an in-depth understanding of the local operating environment, trust-based relationships with key stakeholders and plenty of political dexterity.

At first glance, it is difficult to see how international organisations can bring added value to what the French would call “an internal kitchen”. It could even be argued that external support is counter-productive since there is a danger that it will be perceived as interventionist or agenda-driven. Furthermore, top-down approaches can damage the sense of ownership and buy-in which are crucial to locally driven initiatives.

Yet the PRIMED workshop showcased several examples of successful coalitions which have been steered – and, in two cases, initiated – by international partners. The mutual benefits of these relationships were clearly articulated. First and foremost, such partners can provide unique access to experience and expertise from comparable environments. The value of these peer-to-peer exchanges is self-evident. Local stakeholders are given the chance to see how similar challenges have been addressed and overcome by their counterparts in other countries. This approach works well when it comes to developing new legislation, regulatory structures or ethical codes.

The PRIMED team in Bangladesh is mentoring journalists from a regional newspaper, Daily Gramer Kagoj, among other outlets, to produce accurate and engaging online content. Credit: �鶹Լ�� Media Action Bangladesh

International support can boost local confidence

These exchanges can be instrumental in building ownership for results, as local stakeholders are empowered to decide what works for them and choose appropriate solutions. These capacity-building efforts can be rolled out in different ways – through remote exchanges between peers, through on-site mentoring or, in the case of the International Federation of Journalists’ efforts to develop a 'Declaration on Media Freedom in the Arab World', through an extensive online consultation bringing together experts from across the region.

Second, international support can be highly effective in boosting the confidence of local actors. Media practitioners often experience a sense of isolation: they believe their problems to be unique and that, in any case, the outside world is largely indifferent to the challenges they face. External support helps to demonstrate that they are not alone, that they have loyal allies in what can be a gruelling battle of wills between civil society actors and political elites. As noted Jane Chirwa at the Media Institute of Southern Africa (MISA) in Zambia, these partnerships can also help promote international benchmarks, which serve to set the aspirations of industry players and government stakeholders alike.

The third area highlighted by PRIMED workshop participants was the role of international partners in unlocking funding streams and coordinating the efforts of the wider development community. The latter is, in my view, crucial for international support efforts worldwide and is sadly lacking in many regions. Frictions exist between implementing organisations competing for grants. There is also a spirit of competition between donor agencies which share an understandable desire to fund the most innovative projects and remain ahead of the curve. The result is widespread duplication and a limited appetite for pooling resources.

Asking for what is needed

But, for me, one of the most interesting takeaways from the PRIMED workshop was the observation that local partners should feel empowered to request the kind of support they need. Too often donors and international agencies base their programmes on assumptions and preconceptions. In extreme cases, the unwritten mantra seems to be: “Our experience in similar environments tells us that this is what you need.” Moreover, an insistence on quick-wins and time-bound results means that donors are often unwilling to invest in a slow burn, even if it has greater potential to deliver long-term impact.

Coalition-building is the ultimate stress test for effective partnerships between international partners and local beneficiaries. Coalitions require a joined up approach that takes full advantage of the unique qualities and assets that each stakeholder has to offer. They require an ability to adapt to changing circumstances and seize opportunities as and when they arise. Most of all, they depend on long-term support from international partners who are prepared to acknowledge that progress will be slow and the rewards may be very different from those which were initially envisaged.

Donors are not known for having limitless patience or sharing an appetite for risk. But if they do not invest in initiatives which can foster an enabling environment for independent media to operate, their efforts to build capacity in other areas are likely to have muted resonance.

Michael Randall has worked in the media development sector for more than 20 years, mostly for �鶹Լ�� Media Action where he led large-scale projects aimed at promoting public interest journalism in Eastern Europe and the Middle East. Michael currently works as an independent consultant, focusing on project design and development as well as monitoring, evaluation and learning.

PRIMED is a ground-breaking media support project in Bangladesh, Ethiopia and Sierra Leone, led by �鶹Լ�� Media Action with support from Free Press Unlimited, International Media Support, the Media Development Investment Fund, Global Forum for Media Development and The Communication Initiative, where a version of this blog first appeared. PRIMED is funded by the UK Foreign, Commonwealth and Development Office.

5 steps to enable health workers to better meet the needs of hard-to-reach communities

2019-04-05T14:05:00+00:00

As World Health Day approaches, and as we look towards the first-ever UN High-Level Meeting on Universal Health Coverage later this year, we’re sharing insights from �鶹Լ�� Media Action’s work to help health workers and communities work better together to build a healthier world.

In low-income countries in Africa and Asia, many health systems are staffed by community health workers. In Nepal they are known as Female Community Health Volunteers, in Ethiopia, Health Extension Workers, while in India and Bangladesh they are generally known as Frontline Health Workers.

Whilst the names may differ, most are women, most work in remote areas, and many are volunteers. They play a vital role connecting people to, and sometimes providing, basic primary care; referring patients to clinical services and motivating families to adopt heathier practices.

All are tasked with communicating about health, but often they lack sufficient training or engaging communication tools that would help them do this more effectively.

This is where �鶹Լ�� Media Action comes in. Over the last 10 years we’ve been supporting community health workers to better meet the needs of their communities. These are five important things we have learned in the process:

First, understand the world health workers live and work in

In Nepal, access to communities can be extremely challenging for Female Community Health Volunteers (FCHVs) due to large distances and difficult terrain between communities and health centres in rural areas. What’s more, FCHVs are often balancing their responsibilities with looking after family and, as many of them are volunteers, trying to earn an income.

Whilst access to mobile networks and internet is increasing, literacy rates remain low in rural areas and our research shows that some communities feel FCHVs should know more than they currently do. It became evident that updated training and tools that fit with the practicalities of FCHVs’ day-to-day lives and the changing community needs would help.

Most FCHVs have access to a basic mobile phone and mobile network, so we’re now working with our partners to explore how training and tools for basic mobile phones will help them to carry out their duties in remote areas. We’re also developing creative printed materials to support their interaction with people of all literacy levels in their communities.

In a similar project in Bangladesh, we discovered that health workers were using heavy, cumbersome flip charts to visit their clients in urban slums, so we developed a mobile app to help them undertake their roles more effectively.

“Now I’m getting all the topics by using one app which is not possible with other tools (flash cards, flip charts, leaflets). I can deliver all relevant information by the app which was difficult for me before” said one community health worker who frequently used the app.

Second, use human centred design and build partnerships

In rural India, the catalyst for the development of our highly successful Mobile Kunji and Mobile Academy projects was women’s lack of access to traditional mass media platforms. At the start of this work, our formative research showed that only a few women watched television or listened to the radio, however 82% had access to some form of basic mobile phone. So, rather than setting up a parallel system, �鶹Լ�� Media Action leveraged the one available.

Using human centred design, our India team created content that worked on basic mobile phones and suited how health workers used them – to make and receive calls only. We created Mobile Academy, a training course for health workers, which is delivered through mobile audio messages, whilst Mobile Kunji is a set of visual cards and accompanying mobile audio messages that health workers can use during visits with families. Using these services and tools, our research has shown that health workers are able to better reach, engage, and influence families to improve their health.

These projects have not only worked, but they’ve shown sustainability. By working in partnership with the state governments in Bihar, Odisha and Uttar Pradesh, we’ve trained 263,000 health workers so far on Mobile Kunji and about 260,000 people have completed the Mobile Academy course.

Mobile Academy is now active in 13 states and we recently transitioned responsibility for the service to the Indian Government to continue its vital work long into the future.

Third, create relatable and accurate content to help to build trust

In Bangladesh we learnt that community health workers were struggling to communicate effectively about sexual health to young women and men, which limited the impact of their advice.

So we developed a smartphone app. It shows Dr Natasha, a real doctor, talking about some of the key sexual, reproductive, and maternal and child health issues their clients were facing. By using appropriate language tailored to their audiences, we made sure the content was relatable, accessible, and engaging – which mattered especially in areas with low literacy levels.

Our research showed us that health workers felt more trusted by their clients and were more successful in persuading them to adopt healthier practices, such as attending antenatal care visits. As one of the health workers described, “Most of my clients were not interested in listening to my suggestions before using the job aid. But now they are convinced as they see there is symmetry between Dr Natasha’s information and my own”.

We found the app also helped to give them credibility to dispel myths around issues such as contraception and family planning.

Fourth, go beyond training on health topics and train on how to communicate

Community health workers cover a wide variety of health issues on their visits. Our research often reveals the benefits of refreshing or deepening their knowledge, but also of them gaining new skills on how to communicate within a family setting. We found in remote parts of Ethiopia, communicating with the men in the family is often overlooked because family health is still seen as a woman’s responsibility.

So we ran training for Health Extension Workers which focused on how to create safer feeding and playing spaces for children under three, during which participants learned how to communicate effectively with, and actively involve, both women and men in the families.

We found role play really helped during training because it encouraged Health Extension Workers to practise how to have compelling two-way conversations.

And finally, break down the barriers between communities and health workers

Mistrust and suspicion between communities and health workers is common in many of the places we work. Through our research, we often hear about these difficulties and then aim to create safe spaces for communities and health workers to come together, get to know each other, and discuss often sensitive issues.

In Nigeria we facilitate discussions around polio vaccinations and routine immunisation as part of our community drama radio recordings which are performed in front of a live audience. And, working with different partners, we accompany women during antenatal care check-ups to record what happens. By sharing real-life experiences in our radio programmes, it helps to build understanding and trust in health services amongst the public.

In Tanzania, we trained and worked with radio partners to facilitate lively community events that were recorded and broadcast in weekly radio shows to audiences across the country. The events were designed to build understanding about maternal and newborn health issues and encourage interaction with health workers. By facilitating conversations, we found people gained understanding and confidence to access health services. We also saw increased male engagement in maternal and newborn health care.

Looking forward

In summary, we’ve learnt to not only help build the skills and confidence of community health workers, but also to help improve engagement between them and members of their communities. Through creative communication and human centred design, it is possible to create more effective tools fit for the difficult environments health workers operate in. And in doing so, we’re able to help health workers and communities work better together.

Informed by our experience, �鶹Լ�� Media Action plans to continue this important work towards the UHC2030 global movement, to build stronger health systems for people around the world.

Emebet Wuhib-Mutungi and Genevieve Hutchinson
Senior Health Advisors for �鶹Լ�� Media Action
On Twitter: @ewuhib / @genevieveh77

The projects featured in this blog were carried out in conjunction with: national government ministries and departments of health, DFID, UNICEF, The Gates Foundation, UNFPA, Options, Abt Associates, Viamo, Care International, the Grameen Foundation and our media partners.

Look beyond numbers: we need to know why change happens

2017-09-13T15:28:59+00:00

Working in the development sector I am aware that, particularly over the last few years, donors and others expect project results to be quantifiable. Numbers talk.

This was apparent at the UN World Data Forum in Cape Town in January when we looked at how the SDGs will be measured, and it was discussed again at the Esomar World Research Congress in Amsterdam this week. Donors want statistics to demonstrate impact and show a project is value for money, but aren’t as confident using insights from qualitative research.

In my team we crunch a lot of numbers. In 2016, for example, we surveyed more than 20,000 people, which yielded strong results. For example, a statistical analysis of governance data across seven countries (which controlled for confounders such as people’s age, education levels and existing interests) shows that people who listened to or watched our programmes know more about politics and get more involved in civic life. In our health work, we used quantitative data to understand how change happens.

But we have increasingly come to appreciate the need for qualitative research to contextualise our data and explain why we are having an impact. We’re not alone.

At the Esomar conference I took part in a panel with colleagues from My Choices Foundation, StreetInvest, and Save the Children to showcase how qualitative research can provide greater value to the development sector. I summarised what we had learned from our recent projects.

Story behind the numbers

Qualitative research helps us to explain the story behind quantitative data.

Our radio health shows in Ethiopia, Jember (Maternal Light) and Biiftuu Jireenya (Dawn of Life) aim to help women have safer pregnancies and deliveries, and improve the health of newborn babies. Our surveys showed they were reaching a huge audience – around 21 million people across three states - more than a third of the adult population.

However, analysis of our data showed it was difficult to isolate the impact of our programmes. The health sector in Ethiopia was changing fast the government and donor investment leading to local health workers being trained across the country. This investment was reaping benefits; data from the Demographic and Health Survey showed the percentage of women going for antenatal care had jumped from 27 % to 62 % between 2011 and 2016. But what impact were we having?

To understand, we designed qualitative research, whereby we spoke to women and those they felt influenced their decisions (such as their local health extension worker, their husbands and close family members).

Women told us how health services and social norms had changed since they had given birth to their older children. Things that had been unthinkable, such as giving birth at a health facility, were now possible. They were also able to identify storylines and items in the shows that made them think differently about what was “normal” during pregnancy and birth. The shows were reinforcing the advice that health workers were giving – and health workers also felt women trusted them more because they were saying the same information that they had heard on the radio.

Reaching vulnerable people

A limitation of quantitative research is that it’s hard to reach vulnerable groups such as refugees or survivors of gender-based violence. They are less likely to agree to a face-to-face survey or might not have a fixed address. In this situation, it helps to use qualitative research techniques that put respondents at ease.

Last year, we spoke to Syrian refugees travelling from Greece to Germany to understand how humanitarian agencies could best communicate with them. We employed Arabic-speaking researchers and trained them to use a narrative approach, where they sat with a refugee for at least an hour, hearing about their journey and the part communication had played in it. Being listened to, rather than asked a series of fixed questions, helped the respondents feel comfortable and more likely to share information.

Qualitative research can also help us understand sensitive issues. In Syria, we assessed our radio drama Hay el Matar. To understand issues around the conflict we asked a trusted, local NGO to use projective techniques. This involved asking respondents to discuss the feelings of others – either people in their community or an “extremist” character in the drama. People felt more comfortable talking about how others view violence, or explaining the motives of a fictional character, than talking about themselves.

We discovered that Syrians interpreted people’s accents as a strong signal for which side of the conflict they were on. We relayed this to our radio producers who took greater care with the accents of the actors. We could not have grasped these nuances with quantitative data alone.

Insights on a budget

There’s another cold, hard fact to take into account. Conducting quantitative research, on the scale needed to measure media interventions, is expensive. Project budgets often don’t stretch to this so we need to gain qualitative insights in the absence of large-scale, representative surveys.

At the end of the panel discussion in Amsterdam this week, the Esomar Foundation’s Phyllis MacFarlane asked a crucial question: “What does the development sector need to do for qualitative research to be taken more seriously? Steve Kretschmer from Surgo Foundation summed it up nicely.Quantitative data needs to be used to explain the “what” he said, but when it comes to the “why”, well-designed qualitative research is invaluable. He added that the development sector could work with the commercial sector to adopt practices such as using video to capture emotions (rather than relying on what people say) to make the most of audience insight and – most importantly – to make a difference.

Health partnerships in the Global South: more than a marriage of convenience

2017-05-24T12:20:44+00:00

We use the word ‘partnership’ a lot in the development world. At a global level, we’re all ‘partners’ – a giant family of policymakers, donors, practitioners, academics and companies working together to advance a shared vision of a world free from poverty, hunger and violent conflict.

We come together for mutual benefit, bringing our different skills, experiences and resources to the table, to solve deeply rooted problems. But because we’re human, partnerships – as with any relationship – can be fraught with friction and misunderstanding.

At Media Action, we build partnerships so media and communication can make as positive a difference to people’s lives as possible. Our natural partners are, of course, other media organisations, often the local and national broadcasters in the countries where we work. We share a common interest in using media to provide a public service to enrich and enhance the lives of citizens.

But we have other, less obvious companions in our journey to make life better for people in the Global South. We also collaborate with governments and NGOs that don’t specialise in communication in order to improve the health and wellbeing of pregnant women and their children in Bangladesh, Ethiopia and India. Like us, they share the belief that, when rooted in evidence, media and communication have a key role to play in maternal and child health.

What’s everyone bringing to the table?

And what can a media organisation like us bring to these unions? Editorial acumen, technical know-how and tangible products. We provide high-quality media content that educates and entertains. Our programmes are custom-built to encourage social and behaviour change, creating demand for the maternal and child health services provided by our partners.

Of course, simply handing over a stack of DVDs does not a partnership make. So we also work with our partners to facilitate community discussions, which use our content to spark conversations about the kinds of issues addressed on TV and the radio. With some partners, this work goes further, with community health workers trained in how to communicate for change, skills they could then go on to use day in and day out.

Bringing their loyal audiences and in-depth knowledge of local people, our media partners are invaluable to us. They help us spread the benefits of media and communication further, to reach people left out 'in the dark', who often struggle to access media.

We in turn can offer programmes that draw audiences in, like dramas, to help pique the interest of those who aren’t normally interested in health matters but make decisions within families. There aren’t many people who reject entertainment after all. Dramas can sway ‘influencers’, who were previously somewhat ambivalent about maternal and child health, into pushing for their loved ones to take advantage of the services our partners offer.

What makes for a long and prosperous partnership?

Over the course of all this collaboration, we’ve learnt a few things about how to be a better partner and how to get the most out of working together. In many ways, it’s like a marriage or long-term relationship: if one side expects their meals to be cooked and the laundry to be done, but the other has no intention of doing that, there’s bound to be trouble! So it’s important to be upfront about each party’s expectations about the relationship from the start.

This last piece of guidance has been particularly helpful to us, as we’ve found that partners have high expectations of us because of the �鶹Լ�� brand. Clarity from the outset and a joint plan can help smooth out problems that may arise if those expectations are unrealistic.

We’ve also discovered that involving partners in content creation elevates projects into genuinely joint ventures that everyone has a stake in. Similarly, it’s worth providing ongoing support to partners so they can adapt to different scenarios and to ease the burden of carrying out outreach, which can be time-consuming and complex.

Ultimately, and at the risk of sounding obvious, it’s all about communication: listening and talking to each other…solving problems together…working for a common goal. That’s how sustainable change happens.

If you’d like to find out more about how �鶹Լ�� Media Action used media and communication to improve maternal, newborn and child health, go to our digital platform, Global Health Stories.

Sophia Wilkinson is �鶹Լ�� Media Action’s Acting Head of Health and Resilience; she was previously the organisation’s Senior Health Adviser. Sophia’s most recent publication is A bigger splash - partnering for impact, which reflects on �鶹Լ�� Media Action’s maternal and child health partnerships with governmental and NGOs in Bangladesh, India and Ethiopia. Sophia tweets as @SLPWilkinson.

Blog: Health communication changes lives by reaching millions

Film: Partnering for impact in Bangladesh and Ethiopia

The art of designing surveys about social norms: insights from Ethiopia

2017-05-17T14:16:48+00:00

How we view our role and relationships within our communities shapes how we behave – with important consequences for development. When widespread, these views constitute ‘social norms’, which people tend to follow because they believe that others do and because they think it’s expected of them. Media Action’s programmes aim to challenge social norms that can lead to people risking their health and reinforce those that support people to make healthier choices.

Donors increasingly want proof that we’re changing norms at scale. But it’s not easy either to define social norms or to identify exactly how media influences desired outcomes, such as children getting vaccinated or mothers going to antenatal check-ups.

These are some of the challenges we face as Media Action’s research team. How do we design research to measure social norms and track whether they’re changing? We came up against this question when evaluating whether our maternal health radio shows had changed social norms in Ethiopia.

We set out to understand whether our programmes had convinced families to prepare for a birth by, for example, saving money and planning how to travel to the hospital. In Ethiopia, preparing for a baby’s arrival typically means planning the important post-birth thanksgiving ceremonies. Women are judged negatively if they don’t put on a good spread but the costs of hosting this celebration mean that there’s less money to get a woman to a facility when the time comes.

We primarily used qualitative methods to understand social norms but we also undertook large-scale surveys to understand how we were shaping social norms at a population level.

To highlight challenges around researching social norms with surveys – and how they might be overcome – here are five common responses heard in the field in Ethiopia:

1. ‘How would I know what other people think?’

Though intuitive in English, it’s not always obvious in other languages that asking someone ‘what would your neighbour think?’ really means ‘what do you think your neighbour would think?’. Respondents sometimes take the question very literally and reply that they ‘didn’t know the minds of other people’.

Cognitive interviewing, where interviewees reflect on what they understand by a question, and careful piloting of questions can reveal when something isn’t interpreted as intended. To get the wording of a question right, it’s essential to take the time to test and refine translations into local languages and carefully train field interviewers.

2. ‘Which people?’

When asked about ‘other people in the community’, interviewees often weren’t sure who they were meant to be thinking about. We consequently explained what we meant to respondents, to help them move from an amorphous sense of ‘other people’ to something more meaningful. For example: ‘If you think of five women you know, how many of them would start going for check-ups in the first three months of pregnancy?’

3. ‘It’s none of my business!’

Our team found people in Amhara (a region in northern Ethiopia where the research took place) to be quite reserved. It’s an area where it seemed to be impolite to speculate on the lives of others, not least to an outsider with a clipboard.

Surveying was as much an art as a science, with interviewer rapport proving to be as important as good survey design.

When it comes to rapport the ordering of questions is important. First of all, you can turn people off a survey by leading with potentially sensitive questions. How willing would you be to tell someone what you earn or weigh when you just met them?

Second, it’s easier to get good answers to tricky questions (like those around social norms) if they’re asked some way into the survey after rapport has been built. But these questions can’t be left too late. People often find talking about things like community dynamics tiring, so you have to broach these topics while people still have enough energy to discuss them.

Finally, it’s important to brief interviewers well so they’re confident of the research aims. They’ll also be better at reassuring participants they’re not trying to probe into their private lives, but rather uncover the practices and perceptions of their community as a whole.

4. ’I don’t know’

Respondents are often stumped by questions – particularly by those that ask to what extent they agree with a given statement. However, presenting them with a range of simple and concrete options can help elicit answers.

For example, to determine whether respondents believe their community sees something as appropriate or expected, we presented them with options such as: ‘they would think it’s OK’, ‘they would think it’s not OK’ and ‘they wouldn’t care’.

To determine what respondents think people in the community are actually doing, we presented them with choices like ‘none or a few do it’ and ‘almost all do it’.

We found that listing these options helped increase understanding and made the surveys less demanding of participants, resulting in fewer ‘don’t knows’.

5. ‘Let me tell you what happened to me during my last pregnancy…’

When a respondent has to choose from a limited number of options, there’s no way of recording the rich detail someone might provide through sharing their experiences in a more narrative form. Within the context of a survey, personal stories become conundrums (how do I classify this?) rather than goldmines of information. This tension demonstrates why qualitative research remains invaluable.

Illustrating this, we recently used a personal narrative approach to allow mothers to tell us the journey of their pregnancy. Asking questions like ‘Would you say that your story of pregnancy is the same as most of the mothers in your community?’ helped us understand whether or not interviewees were conforming to norms.

We’re continually exploring ways to improve our surveys to pinpoint what social norms are and how they’re changing, always with the aim of truly reflecting people’s perceptions and helping them improve their health.

Hilina Assefa is a Senior Research Officer with �鶹Լ�� Media Action’s Ethiopia team; Lois Aspinall is a Research Manager with the UK office.

Blog: Design thinking and health communication: learning from failure

Blog: Health communication changes lives by reaching millions

Using social ties to make pregnancy safer: insights from Bangladesh and Ethiopia

2017-04-27T09:12:04+00:00

Following the launch of our Global Health Stories site, Emebet Wuhib-Mutungi explains how influencing mothers-in-law and husbands can help improve the health of mothers and their babies.

Over 800 women die every day because of complications caused by pregnancy or giving birth. Almost all of these women live in the Global South. And most could be saved through simple precautions, like going for regular antenatal check-ups.

But as we discovered through our work in Bangladesh and Ethiopia (watch the video below for more background), expectant mothers often don’t go for check-ups early enough. Our research into people’s beliefs suggests this is because Bangladeshis view pregnancy as a ‘natural process that doesn’t need special attention’, while in Ethiopia, going for a check-up is seen as inviting ‘bad luck’. We've seen similar views in India and South Sudan.

This external content is available at its source: https://youtu.be/cTE2GXW9OFQ

In Bangladesh and Ethiopia, mothers-to-be and their families don’t follow a number of other medical recommendations either. For example, ‘preparing for childbirth’ in Ethiopia generally doesn’t involve deciding on where to give birth, how to travel there and getting that all-important hospital ‘grab bag’ ready. Instead, the primary focus is on organising a big social event for family and friends to give thanks for the new life. Not doing so is frowned upon.

So… why is this?

Mother-in-law knows best?

Both Bangladeshis and Ethiopians believe that everything baby-related is the responsibility of women, with mothers-in-law – particularly in Bangladesh – serving as the ultimate arbiters of pregnancy.

Mothers-in-law are in turn likely to give their daughters-in-law advice based on their own experiences and what has always been done in their communities: give birth at home.

Expectant mothers are unlikely to defy both society and their mother-in-law to follow medical recommendations. This is because humans are social beings. When we choose whether or not to do something, we’re heavily influenced by social norms – what the people we love, respect and are surrounded by would normally do or strongly expect us to do.

Influencing the influencers

To encourage more women to seek medical help in pregnancy, it became clear that it was important to influence mother-in-laws.

Husbands – usually the household decision-makers – tend to not get involved in plans for childbirth. We saw this as an opportunity to engage men, who could then encourage their pregnant partners to adopt safer habits.

To reach and convince these family members to do things differently, we created TV and radio shows featuring husbands and mothers-in-law supporting the kind of practices we wanted to catch on. But modelling new behaviours isn’t enough to get them adopted. So to help audiences make informed choices, the shows also provided a space for discussion and explained why, for example, antenatal appointments were worth attending.

Inspiring change through fictional characters and real-life experiences

Of course, leveraging influencers, like mothers-in-law or men, to improve women and children’s health isn’t a new approach. What is less well-known is what works when trying to do so.

Speaking to audience members and project staff five years on, it was clear that husbands and mothers-in-law who tuned in to our shows saw themselves and their lives reflected in their fictional or ‘real life’ counterparts. This, they said, was critical.

As one husband told me, this was the first time he heard other men like him talk about accompanying their wives to the health clinic for her check-ups or saving money for a birth. While such anecdotes give us an idea of what inspired people to do things differently, they don’t give us – and the global health sector – the much-needed hard evidence of ‘what works’.

What we can say with confidence is that, after watching or listening to our programmes, husbands and mothers-in-law in both Bangladesh and Ethiopia are more likely to know the recommended guidance and to believe that it’s commonly followed in their community.

With improved knowledge and new perceptions of local social norms, influencers can offer better advice and support, helping secure a safer future for mothers and their babies. It’s just difficult to say exactly what it was about the programmes that set off this chain of events.

Future food for thought

Through influencing influencers, we’ve also begun to tackle gender stereotypes. For instance, we’ve shown that it’s OK for men and women to talk openly and freely together. In Ethiopia, our male and female radio presenters often share their own baby stories with each other in a light and friendly way.

We’ve also helped show that caring about babies is just as manly as keeping a job down and putting food on the table. Our TV drama in Bangladesh achieved this by weaving together storylines about male characters struggling with debt and ‘bad guys’, together with those about couples having a baby.

We’ve succeeded in getting men to watch and listen to our shows and get more involved in what’s considered a ‘woman’s issue'. We’ve done so without overtly challenging the status quo in which ‘men are the decision-makers.

Our next challenge is figuring out how we can help transform traditional gender roles, which could arguably have even longer-lasting impacts that also go beyond health.

If you want to find out more about how �鶹Լ�� Media Action used media and communication at scale to improve maternal, newborn and child health, go to our digital platform, Global Health Stories.

Emebet Wuhib-Mutungi is a Health Adviser with �鶹Լ�� Media Action. She tweets as @ewuhib.

Blog: Health communication changes lives by reaching millions

Health communication changes lives by reaching millions

2017-04-10T05:00:00+00:00

To mark the launch of our Global Health Stories site, Sophia Wilkinson explains how health communication can make a big difference at scale – for less than the cost of a can of coke per person.

“But what about the impact?”

This is the question I'm asked the most after I’ve told an audience that, quite literally, millions of people listen to our radio shows and watch our TV programmes about health. The other question I routinely get is:

“I don’t care how big your audience is! What I want to know is whether anything has changed?”

What people often don’t realise is that the more people you reach, the bigger the difference you can make. You don’t have to choose between the two.

Skilfully designed and well-executed media and communication projects can not only change behaviour and norms, they can do so at scale. Offering both quality and quantity, such interventions should be immensely attractive to those working to solve the world’s costliest and most widespread health challenges.

I’m going to brag. In Ethiopia alone, some 21 million people listened to our radio shows about different aspects of pregnancy, birth and newborn health over the course of just one year – and 14 million did so regularly. This means in the three states where we surveyed – Amhara, Oromia and SNNPR (Southern Nations, Nationalities, and Peoples' Region) – almost half of all adults listened to our shows.

But aside from professional pride, why does this box office success matter when you’re not looking to drive up profits from ticket sales?

It matters because of the scale of the challenges we’re trying to solve.

In Ethiopia, out of every 1,000 babies born, 29 will die before they’re even a month old and 48 won’t make it to their first birthday. And every year, 13,000 Ethiopian women die due to pregnancy-related complications.

Of course, we all know that the death of many of these mothers and newborns could be avoided. But it’s not just about providing good quality, accessible health services. It also requires lots of people to do things differently in their day-to-day lives. Millions. Not just hundreds.

The Ethiopian women who listened to our shows did just that. They were more likely to have: one, received antenatal care, two, made arrangements for having their baby in a health facility and, three, given birth in a facility or with a skilled attendant looking after them.

And this wasn’t due to wealth, or education, or proximity to services - our research controlled for these factors - and while it doesn’t provide causal data, this analysis helps us to be more confident in these results.

There are other reasons why reaching lots of people matters. As the World Development Report: Mind, Society, and Behavior highlighted back in 2015, human beings are very social animals. We don’t like being alone. We live and work in communities, big and small. We have friends. We spend time with our families.

Of course, one consequence of spending time together is that how we behave is deeply influenced by what those around us are doing, or what we think they’re doing and expect us to do. It follows that if more and more people start doing something, we can expect a snowball effect. Reaching more people will create a bigger splash.

Finally, reach matters when it comes to delivering value for money. Another accusation frequently bandied about is that media projects are expensive, especially if high-quality television dramas are part of the mix. Well, yes, if only a few hundred people watch that drama then it wouldn’t be very cost-effective to produce.

But it cost us just 23 pence per person to reach 93 million people in Bangladesh, Ethiopia, India and South Sudan with potentially life-saving information, using all manner of communication tools, from TV dramas to community discussions. Critics might dismiss our programmes as ‘all talk and no action’, but people are taking their newfound knowledge and doing things differently because of it.

Just take a look at what our research in Bangladesh is telling us:

Those who listen and watch our programmes have access to health information to help them make healthier choices…and for less than the cost of a can of coke. Sounds like a pretty good investment to me.

If you want to find out more about how �鶹Լ�� Media Action used media and communication at scale to improve maternal, newborn and child health, go to our digital platform, Global Health Stories.

Sophia Wilkinson is �鶹Լ�� Media Action’s Acting Head of Health and Resilience; she was previously the organisation’s Senior Health Adviser. Sophia’s most recent publication is A bigger splash - partnering for impact, which reflects on �鶹Լ�� Media Action’s maternal and child health partnerships with governmental and NGOs in Bangladesh, India and Ethiopia.