In this section we describe in detail the design and execution of the media intervention tested in the RCT in Burkina Faso, within the Saturation+ framework. We have also produced an open-access Saturation+ handbook (http://www.developmentmedia.net/saturation-handbook). This tool is designed for use by other organizations that are delivering mass media behavior change campaigns. While our mass media campaigns focus on child survival and the handbook was written with this subject in mind, the principles described are applicable to campaigns addressing other health and non-health subjects.
The broadcasting environment in Burkina Faso is unusual. Most people listen to local FM radio, rather than to the national station, because most output on the national station is in French (spoken by fewer than 1 in 5 rural Burkinabés) while the output of local FM stations is in the local languages. This environment makes it uniquely suitable for a randomized controlled trial.
Most people in Burkina Faso listen to local FM radio rather than to the national station, providing a uniquely suitable environment for an RCT.
Radio penetration in Burkina Faso is also high. The 2010 Demographic and Health Survey (DHS) reported that 68.3% of households owned a radio (65.7% in rural areas) while only 16.2% of households owned a television (5.8% in rural areas). In preparation for the trial, DMI and Centre Muraz conducted a media survey in 2011 to measure radio penetration in 19 rural areas and to identify the stations with the greatest number of female listeners. We found that 75% of women surveyed listened to the radio at least once a week. It was clear that radio is the only form of mass media currently capable of reaching our primary target audience (mothers of children under 5 years, pregnant women, and mothers-to-be) as well as the secondary audience (people who can directly influence the primary audience, in this case, the husbands and the mothers-in-law).
Saturation broadcasting can be achieved by paying the market-leading radio and television stations for airtime, but our experience is that it is much easier and cheaper to achieve saturation broadcasting if the broadcast industry is involved as a core partner. Unlike advertising agencies or governments, broadcasters have production capacity and airtime, the two vital ingredients of a media campaign. In the majority of our campaigns, we have negotiated free airtime in exchange for on-the-job training (working with each team to produce live evening programs) and for production expenses; the opportunity to secure better skills and advantage within a competitive media environment is usually enough incentive for broadcasters to partner with us. Our experience elsewhere has been that both private and public media organizations have been very willing partners. This was certainly the case in Burkina Faso.
The simplest way to achieve high intensity is to use short (e.g., 60-second) spots, as exemplified by the advertising industry. This format allows frequent daily broadcasts, across all peak listening times. It also allows us to produce precise health messages across a diversity of languages. The spots use emotion, humor, and dramatic techniques such as suspense to persuade our target audience to change behaviors. In our Burkina Faso campaign, we broadcast a new spot every week, played at least 10 times per day, over 35 months (from March 2012 to January 2015).
Short radio spots allow for frequent daily broadcasts across peak listening times.
Exposure through multiple channels is also associated with greater impact.5 In countries with sufficient television penetration and/or higher literacy levels, other communication channels would strengthen the impact of a campaign. Due to low television coverage in rural Burkina Faso, our campaign was broadcast on radio alone. However, we used multiple formats to deliver our messages on the radio.
To be effective, longer formats also need to reach audiences frequently. Throughout the campaign, we broadcast 2-hour interactive programs, 5 nights per week, on each of our 7 partner radio stations (one in each intervention zone), representing a total of 70 hours per week of live radio in 6 different languages. We therefore needed to devise a format that could deliver health messages, was cheap, could be broadcast daily, could be produced “live” (which costs a fraction of pre-produced radio) and yet could be controlled centrally. Producing a pre-recorded soap opera, for example, in 6 different languages would be expensive and logistically very difficult. So we created a system of self-contained drama “modules” that were written in French in the capital city, sent on USB keys through local transport companies to our partner radio stations, and improvised live by local actors on location in their own language within their 2-hour shows. These were followed by phone-ins to allow listeners to comment on the issues raised. The modules were around 10 minutes each, with the remainder of the 2-hour program taken up by news, music, and discussion. They were aired in the evening, which our research found to be the peak time for radio listening among our target audience. This program format works well in a fragmented media environment, which is becoming the norm in most developing countries. These longer dramas and interactive shows can add value by creating role models, demonstrating life skills, or allowing on-air dialogue with the public. They also help us to build relationships with partner stations and can thereby help to ensure that our spots are broadcast at the intensity required.
In Burkina Faso we used a system of broadcast monitoring to verify whether stations had played the spots as they had agreed, at the frequency required, and to allow swift remedial action if they had not (in our experience this was usually due to inefficiency or genuine technical problems). We hired two independent monitors or “trackers” in each radio station’s coverage area to record when our materials were broadcast, and we collected their results by telephone weekly. The radio stations were not aware of the identity of the monitors, nor were the two monitors aware of each other. Radio station compliance during the RCT was extremely high, with stations reliably broadcasting an average of at least 10 spots every day. Where feasible, radio programming software can also be used to monitor and verify spot broadcasting. Data on our broadcasting intensity, by health topic and by format, are presented in the companion midline results paper.3
Data and modelling should underpin the key aspects of campaign design. We use data in our campaigns in several ways. First, we use data to quantify the geographic coverage, audience size, and market share of different media channels in different parts of the country, at different times of day, and with different demographic groups. It is often difficult to obtain these data, but it is essential if resources are to be allocated correctly. In Burkina Faso, for example, we conducted a customized survey to estimate the market share and audience penetration of each radio station.
Data and modeling should underpin key aspects of campaign design.
We also use data to prioritize which messages can save the most lives per dollar spent. For this analysis, we use data on the mortality risk of different diseases, their susceptibility to behavior change, current levels of behavioral compliance, and the availability of key medical services. Our modeling work brings these data together,1 allowing us to predict the impact on mortality of each target behavior (using the Lives Saved Tool [LiST]17) and to weight campaign messages so that those predicted to save the most lives can be broadcast most frequently (Table).
For our campaign in Burkina Faso, where our primary aim was to reduce child mortality, we developed a message calendar based on the predicted impact of each behavioral message on under-5 lives saved. Our calendar also took into account seasonality, so that, for example, messages on seeking treatment for malaria were broadcast more frequently during the months when malaria transmission is typically highest. Each week of the year was assigned a message theme for spots; the theme of the longer modules changed daily but followed the same weighting as the spots (Figure 2).
The independent evaluation of our campaign included a baseline and a midline (as well as an endline) behavioral survey of 5,000 mothers of a child less than 5 years old, after 20 months of broadcasting. Using the midline results, we revised our message calendar to maximize the impact of the remaining months of the intervention. The revised message weightings were calculated by taking into account several factors, including the impact the campaign had already had on each behavior (from baseline to midline), the broadcast dose for each message (from baseline to midline), and the predicted impact of each behavior for the remainder of the campaign (from midline to endline, modeled using LiST). We suggest that impact data collected during a campaign (when available) should be used to adjust message weighting to optimize impact.
Message quality is also crucial, and qualitative research is a key element to ensuring this quality. Qualitative research includes formative research (to identify barriers to behavior change), pretesting of radio spots (to judge comprehension and appeal), and feedback research (to find out whether people have heard and understood the messages and what the remaining obstacles to behavior change are). The key, as argued below, is to link findings from such qualitative research as tightly as possible to the creative process.
We employed a team of in-house qualitative researchers, who conducted formative research at the start of our campaign. The research consisted of semi-structured individual interviews and focus group discussions with mothers and fathers of young children and influential members of their entourage (spouses, grandparents, co-wives), as well as individual interviews with key informants such as religious leaders, district medical chiefs, health center staff, midwives, and community health workers. For each health behavior, we synthesized this research into a 1-page message brief that presented the key behaviors to promote including:
Contextual information about the behavior, including Ministry of Health policy and guidelines, and information drawn from guidance from the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO)
Analysis of key decision makers within the target audience for the specified behavior
Context-specific barriers to behavior change
Context-specific factors facilitating behavior change
An example message brief is provided in Box 2. We have found that reducing formative research down to a 1-page message brief for each target behavior is a critically important step in our creative process as it makes the research more accessible to the script writing team and helps to bridge the gap between research and creativity.
BOX 2. Example of a One-Page Message Brief on Exclusive Breastfeeding From the Burkina Faso Radio Campaign
Breastfeed exclusively for the first six months of life
Behavior to promote
All mothers should breastfeed their babies exclusively for the first six months of life. The secret to having enough breast milk is to exclusively breastfeed. If you do not have enough milk for your baby, breastfeed more frequently and you will produce more milk. If you add other drinks/concoctions or food, including water, to your baby’s diet this will reduce your milk production.
Breast milk production is dependent upon frequent breastfeeding. Interrupting breastfeeding by giving other liquids to a baby will decrease production of breast milk. Breast milk is the best and only food and the best and only drink that an infant needs for the first six months of life, even in hot and dry climates. Through breast milk, the baby receives defenses against diseases such as diarrhea and respiratory infections. Adding other foods or liquids can affect the health of a baby during the first six months of life, because these liquids or foods can be contaminated, which may cause diarrhea.
Barriers to behavior change
Sometimes mothers who breastfeed their babies are concerned when the baby wants to nurse more often than usual. They can attach this behavior to a lack of breast milk. A baby may want to nurse more often for several reasons: perhaps a phase of intense growth is happening; the baby might just be more hungry/thirsty; during an episode of illness babies may nurse more often; babies also may nurse more often when teething; or the baby may be in need of more comfort. A mother may interpret the cries of a baby as signs of hunger, which is often the case, but a baby may also cry because he is tired, or because he wants to burp or pass wind.
Mothers should understand that they can produce enough milk by breastfeeding more frequently. If they believe that their baby needs other liquids or supplementary foods, and they give these to their baby, they may reduce their milk production because if the baby breastfeeds less frequently, the mother will produce less milk. Other liquids/brews or foods do not help the baby, nor the mother, because these will increase the baby’s risk of illness and the mother will then have to spend even more time taking care of a sick baby.
Many people think that exclusive breastfeeding is not possible because they believe that breast milk alone is not a sufficient source of nutrition or water for babies. Because of this they add other food supplements or water to the baby’s diet.Water is given because they fear that a baby will “dry up” in Burkina Faso’s extreme heat. People compare breast milk to solid foods that adults eat and believe that a baby will be more thirsty because of the fat content of breast milk. Breast milk is not considered a source of water for the baby.
Decision and influencers
Mothers-in-law or aunts accompany expectant mothers before and after delivery. They have a strong influence on exclusive breastfeeding as they will advise mothers to add water, herbal potions, or other foods during the first six months. Like many others they also believe that it is beneficial to give babies “welcome water” and/or other liquids that stimulate the newborn’s appetite. These practices exist in most of Burkina Faso’s ethnic groups. The mother’s entourage can help by not insisting on the mother giving additional liquids or foods to a crying baby, but by giving the mother time to nurse until the baby is satisfied. Also the entourage has a great responsibility to ensure that pregnant women and mothers are well nourished.
Factors contributing to behavior change
Women attach great importance to breastfeeding. Children under six months are usually in close physical proximity to their mother (on their back) and thus breastfeeding is readily accessible and available. So, mothers can feed their baby when they need to and until the baby is done.
Water is the main component of breast milk (88%); it is particularly hydrating and quenches thirst. The other components (12%) are: carbohydrates, lipids, proteins, and micronutrients. At the start of feeding, breast milk contains a lot of water and minerals to hydrate. In the middle of a feed, proteins and lipids increase in quantity. At the end of each feed, fat is more concentrated in the milk and gives the baby a feeling of satiety. This signals the end of feeding for the baby. That is why it is necessary to breastfeed the baby for long enough at each breast.
Infants younger than six months are usually in close proximity to their mother. The infants are carried on their mothers’ backs and thus breast milk is immediately accessible and available. Many mothers place great emphasis on breastfeeding and breastfeed their babies up to two years of age. Most children under three years of age are breastfed.
Our team of scriptwriters drew on these message briefs to create dozens of scripts. The best of these went through a validation process involving creative staff in both Burkina Faso and London before being produced. We pretested the spots (for clarity, popularity, and understanding) in multiple languages using focus groups before selecting the spots and distributing them for broadcast. Pretesting is essential for ensuring messages are well received by the target audience. For example, we pretested a spot in which a character impersonating a diarrhea germ had a discussion with a baby. Our target audience could not grasp the concept of bacteria/germs nor of young babies talking, so they did not understand this spot. Although they seemed to comprehend the health message within the spot well, it was rejected after the pretest because the confusion around the story would detract from the take-home behavior. In contrast, we pretested a spot that featured a beneficial “genie” telling a mother and grandmother who are about to press and discard the mother’s colostrum that this first milk is full of nutrition and protects the newborn against illness. This spot was accepted at pretesting, as it was a better fit to the Burkinabé context, in which people are very familiar with stories of genies.
Our qualitative researchers also conducted post-broadcast feedback research using focus groups to provide an understanding of audience reactions to our messages and to find out whether and why people who hear our messages have changed their behaviors (or not). After each trip, our researchers fed back their findings to the creative team, forming a continual feedback loop. We used the information gathered through pretesting and feedback research to continually refine our message briefs and to tailor our messages to target existing barriers to behavior change.
Our qualitative research team also helped us to monitor the availability of commodities to ensure we were generating demand that was met by sufficient supply. Throughout the RCT, we maintained strong links with the Ministry of Health, WHO, UNICEF, and other organizations working in Burkina Faso to help us track supply-side initiatives and to ensure that our messages were consistent with government policies. Our research team was able to provide insight into the availability and quality of services available on the ground through their visits to health centers and by liaising with district medical officers. This was particularly important for the effectiveness of our treatment-seeking messages, which were service-dependent. Although our program comprised a demand-side intervention only, had we found there were significant, frequent stock-outs of the essential medicines required to treat serious childhood illnesses, we might have needed to reconsider our approach to messages promoting service-dependent behaviors. Supply-side constraints will need to be taken into consideration when interpreting the generalizability of this RCT’s findings to other settings. We have taken supply-side availability into account in our scientific model, using the LiST tool to predict the impact of mass media campaigns on child morality in other settings.1
An independent economic evaluation of the trial (led by LSHTM) will estimate the cost-effectiveness of our intervention and will provide further insight into the costs of implementation, household costs from increased health service use, and health system costs associated with increased care seeking.
As mentioned previously, details of the independent evaluation of this intervention on child mortality will be published separately. In general, since randomization of media interventions is rarely possible, we advocate the use of time-series or other quasi-experimental study designs to evaluate media campaigns and enable attribution of impact. It is important when designing an evaluation to carefully consider which outcomes will be measured, using health outcomes where feasible, and measuring knowledge, attitudes, and behavioral outcomes as indicators along the causal pathway of behavioral change.
Stories have resonated with human beings for thousands of years. We are drawn to drama in ways in which we are not drawn to data or facts. Stories allow us to identify emotionally with characters, and emotions—such as fear, status, and guilt—are powerful determinants of behavior.18 But how do stories work?
We are drawn to drama and stories in ways in which we are not drawn to data or facts.
Creativity is often the “black box” in theoretical discussions: it is difficult to define or measure. Nevertheless it is possible to use systems to understand and then enhance the creative process. Understanding the structure of stories is important.
Virtually every Hollywood film conforms to a 3-act structure: Act I in which characters are given goals; Act II in which obstacles are thrown in front of the characters; and Act III in which the characters either change their goals or overcome the obstacles. This structure mimics life itself for most of us and also mimics the process of behavior change. The emotional turning point of most stories is at the end of Act II, the moment of decision for the main character when s/he must choose between competing emotions. Formative research, when conducted with this in mind, can therefore go further than simply identifying obstacles to behavior change (e.g., cost, inconvenience). It can identify the most important emotion (e.g., fear or guilt) that prevents people from complying and the most important emotion (e.g., love) that motivates people to comply. The conflict between those two emotions can then be made the centerpiece of a story’s dramatic climax at the end of Act II.
Choices about how we behave are often made in response to deep underlying human impulses to be accepted by others, to fit in with our peers, and to imitate people we respect. In Burkina Faso, both our spots and our longer-format programs were based on engaging stories and characters that reached out to the audience, helping them to feel empathy for the characters and their situations. Our stories aimed to move audiences to examine the health choices made in their own lives. Once people are thinking about making changes, the stories then provide concrete ideas about how to do that. Box 3 provides an example spot on the theme of exclusive breastfeeding.
BOX 3. An Example of a Short Spot About Exclusive Breastfeeding From the Burkina Faso Radio Campaign
«Saved by his Tears»
[sounds of baby crying each time his grandmother speaks, and laughing each time his mother speaks]
MOTHER-IN-LAW: [plaintive] Your baby is four months old now. His lips are dry. It’s hot. Let me give him some water. [The cries of the baby get louder.] You see he’s crying!
DAUGHTER-IN-LAW: Mother-in-law, I’m going to breastfeed him. There is enough water in my milk to quench his thirst; it also has all the nutrients he needs to grow strong until he’s six months. [baby’s laughter] Other liquids could harm his health; they could put germs in his belly.
MOTHER-IN-LAW: No decoctions or water until he’s six months old! Impossible! I’m going to give him some water. [louder crying from baby] But y it’s strange how he’s crying … !
DAUGHTER-IN-LAW: Mother-in-law, compare my baby to Fanta’s baby who is always sick. Fanta gives her baby other liquids and that makes him ill. Let my child drink my breast milk and you’ll see he’ll never be thirsty. [sounds of baby suckling followed by baby’s laughter]
MOTHER-IN-LAW: [embarrassed] You’re right because your baby is healthy and growing up strong. I’m going to suggest to Fanta she does the same as you. That’s what your baby is trying to tell me with his laughter. [more laughter from baby]
Stories for public health programming must be driven by research, requiring the creative and research teams to work in close harmony—often a formidable challenge given that creative writers typically rely on their own judgment and imagination to create stories. This practical challenge is a microcosm of the wider challenge of bringing science and mass media together. One practical tool to enable collaboration is to develop succinct, 1-page message briefs that summarize the formative research, forming the foundation for the scriptwriters’ work. Another method is to send scriptwriters to help lead focus groups in the field, while also involving qualitative researchers in the radio production process. In Burkina Faso, we found that field visits motivated scriptwriters, provided new inspiration and ideas, and gave them valuable insight into the realities of rural Burkinabé life.
To maximize creativity and for quality assurance, we use multilevel systems of editorial control whereby, for example, 30 ideas per month are reduced to 6 for pretesting and to 4 for production. It is important that after pretesting, as well as after broadcast, qualitative research is fed back to scriptwriters. This feedback loop ensures an evolving creative process that continually responds to the target audience.
Grassroots recruitment of local scriptwriters is essential to develop a creative team that understands the language, context, and cultures of the target audience. Rather than try to outbid other NGOs for the existing talent pool, in Burkina Faso we advertised in university campuses, bars, and public meeting places and asked applicants to write and submit a story. This approach resulted in 600+ applications and, in our experience, yielded higher caliber staff than working through the existing NGO or media industries. We reviewed more than 600 scripts, interviewed 80 people, and hired 13 as scriptwriters. The hired scriptwriters had a diverse range of previous employment experience, ranging from teachers to a security guard, and originated from 8 regions of the country. Once hired, the team initially received training from experienced creative producers, and skills development was then sustained through weekly creative workshops.
Recruiting local scriptwriters is essential to develop a creative team that understands the language, context, and culture of the target audience.