The Media or the Message? Experimental Evidence on Mass Media and Modern Contraception Uptake in Burkina Faso

"The structure of the campaign - with frequent messages over 2.5 years and the focus on engaging programming - was well adapted to influence behavior through this mechanism."

In 2014, only 16% of women of childbearing age in Burkina Faso used modern methods of contraception, and the average woman gave birth to six children over her lifetime. High fertility rates and short spacing between births are both associated with poor health outcomes for women, but social norms and lack of (or mis)information can discourage contraceptive use. Mass media campaigns have potential to provide information on the benefits and logistics of family planning and influence social norms at low cost. This two-level randomised controlled trial (RCT) assessed the effectiveness of a 2.5-year mass media campaign implemented by Development Media International (DMI) to increase modern contraceptive uptake in Burkina Faso. The Abdul Latif Jameel Poverty Action Lab (J-PAL) and Innovations for Poverty Action (IPA) were partners in evaluating the intervention, which was funded by the Global Innovation Fund (GIF), Development Innovation Ventures (DIV), and a private philanthropist.

The behavioural change campaign followed an approach developed by DMI called the "Saturation +" approach, which is based on the following principles (see Related Summaries, below, for additional details):

• Saturation: Broadcasting messages 10 times per day on market-leading radio stations, using 90-second spots in local languages, as well as regular interactive phone-in programmes.
• Science: Undertaking qualitative research: formative research, pre-testing, and feedback research, involving regular visits to rural villages in all areas reached by the programme, in order to understand the values and motivations of the intended audience.
• Stories: Designing messaging in the form of stories that feature an emotional climax of the story (the moment of decision, where protagonists must either overcome the obstacles or revise their goals) to address the crucial barrier to behaviour change, as identified by formative research.

DMI selected 16 areas in Burkina Faso, each with their own (community) radio station, and randomly assigned them into control and intervention groups. IPA surveyed 7,500 women of reproductive age in 252 villages before (and after) the campaign. They also conducted focus group discussions (FGDs) in rural Burkinabe communities to understand barriers and enablers to the uptake of modern contraceptives and family planning. They discovered that lack of information about modern contraception and fear of possible side effects such as infertility were common barriers to behaviour change. Deep-seated attitudes towards family size and lack of decision-making power for women also became apparent.

The researchers used these insights to develop key messages, which scriptwriters in Ouagadougou used to create (all in six languages):

• 59 motivational radio spots covering topics such as birth spacing and myths about side effects of contraception;
• 29 informational radio spots about different modern contraceptive methods and how they work; and
• 168 drama segments designed to address, in an entertaining way, the key barriers to contraception adoption through interactive two-hour, live, phone-in shows three nights per week, 52 weeks per year on each station. Audiences phoned in to discuss their fears, beliefs, and uncertainties with peers, and to receive accurate information and reassurance from health experts.

The radio campaign ran from June 2016 to December 2018 on eight radio stations across Burkina Faso, with eight radio stations as controls. To limit the incidence of power outages, the eight radio stations in the treatment group received new solar systems so they could broadcast with no interruption. Also, 1,557 women (in 1,397 households) who did not have a radio at baseline received a radio between March and June 2017. Thus, while the media campaign lasted 2.5 years, women in the additional radio intervention only had their new radio for 1.5 years.

The 16 stations reached an estimated 5.1 million people, or more than a quarter of the population of Burkina Faso. To measure the impact of the campaign, the researchers used two waves of survey data with 7,500 women (both those with and without radios at baseline) and 461 clinics, as well as monthly administrative data on the number of contraceptives distributed by all clinics located in the study areas.

The evaluation found that the campaign led to a 20% increase in modern contraceptive prevalence rate (mCPR) in intervention areas compared to controls. Modern contraceptive use rose 5.9 percentage points (p=0.046) in campaign areas and 5.8 percentage points (p=0.030) among those given radios in campaign areas. Assuming a constant trend, it would take 2.5 years for the control group to catch up with the treatment group. The intervention therefore approximately doubled the speed at which mCPR increased. Births fell 10%.

The campaign also shifted knowledge and attitudes about family planning. Women in intervention areas were 35% less likely to believe that modern contraceptives cause side effects such as illness or infertility compared to control areas. They were also 14% more likely to say that "women should control the number of children they have during their lifetime" and more likely to say that it is acceptable to discuss family planning in newspapers or during cultural events.

In contrast, women who received a radio in noncampaign areas not only reduced contraception use by 5.2 percentage points (p=0.039) but had more conservative gender attitudes (e.g., 3.6 percentage points (5%) more likely to agree with the statement that "a man is superior to a woman"). The researchers explain that, while radio distribution, by increasing listenership, increased the probability that women heard about family planning on the radio by 19 percentage points in noncampaign areas, this programming was not effective in increasing knowledge about contraception, suggesting the programming was not effective in changing women's beliefs. A potential mechanism is that access to media without the targeted DMI campaign had a negative impact on gender attitudes. (Qualitative interviews with local radio stations directors revealed that conservative gender attitudes are regularly expressed on the radio, either during debates or by callers (e.g., expressing negative attitudes towards women who use contraception). Radio directors reported that radio staff in control areas were not sufficiently trained on family planning to respond convincingly to such critics and concerns.) This finding "suggests that in this context, local radio stations (without the media campaign) do not promote progressive values on gender and modern contraception."

In addition, the researchers compared the rate of increase in modern contraceptive use from the campaign's RCT intervention areas to the average national increases in Kenya, Uganda, Democratic Republic of the Congo (DRC), Ethiopia, Côte d'Ivoire, Ghana, Nigeria, and Niger. The average national increase per year is 1.2 percentage points in these countries, ranging from -1.2 percentage points (pp) to 2.8 pp. By comparison, the average increase was much greater in our intervention zones, at 4.1 pp per year.

Modelling suggests a national Saturation+ radio campaign would lead to an additional 225,000 women using modern contraceptives in Burkina Faso at a cost of US$7.70 per woman. The Guttmacher Institute estimates that all other national family planning investments over the 2.5-year campaign period cost approximately US$45 million, whereas the DMI initiative cost US$3.4 million for 2.5 years at national scale. When the programme was scaled up nationally, the number of radio stations broadcasting the campaign increased from 8 to 39, meaning that approximately 83% of the population of Burkina Faso is reached by the campaign.

In addition to taking the initiative to national scale in Burkina Faso, DMI has provided technical assistance to the Sahel Women's Empowerment and Demographic Dividend (SWEDD) initiative, worked with the United Nations Population Fund (UNFPA) and governments to run family planning campaigns in Burkina Faso, Chad, Côte d'Ivoire, Mali, Mauritania, and Niger. They are also delivering family planning multimedia (radio, TV, and mobile video) campaigns in seven countries in East and Southern Africa through the Women's Integrated Sexual Health (WISH) programme. Next, DMI hopes to scale up family planning campaigns in Niger, Benin, and Guinea, where they believe a media campaign would have a significant impact.

In conclusion, this study "provide[s] causal evidence that access to mass media and varying the content of mass media can change a highly consequential behavior (fertility decisions) but that the impact depends critically on the quality of the message being delivered....[A] high-quality mass media public health campaign can effectively challenge misconceptions about contraception and increase the use of contraception when delivered at scale in highly realistic conditions." In addition, this study "demonstrate[s] that the challenge of studying mass media impact can be overcome (in some environments) with a multi layered randomization design which combines randomization at the radio station level with individual level randomization of access to radios."

Editor's note: Click here for information on an April 20 2021 online event, "Accelerating Progress in Family Planning: How Can We Double the Uptake of Modern Contraceptives by 2030?", which delves further into the RCT.