Impact Examples: Child Health Communication Programming

Ujan Ganger Naiya and Natoker Pore

BBC Media Action developed a television drama, Ujan Ganger Naiya (Sailing Against the Tide), and discussion show, Natoker Pore (After the Drama), to help change behaviour around and improve knowledge about the importance of regular antenatal care (ANC) check-ups, preparation for birth, and essential newborn care. They also sought to promote discussion, address the social norms that drive behaviours, and encourage pregnant women to: go for ANC check-ups with a skilled health worker, prepare for birth, and deliver with a skilled birth attendant.

For the evaluation, 900 women were randomly assigned to treatment or control groups: 300 women watched the drama and non-health discussion show, 300 watched the drama and complementary discussion show, and 300 watched a non-health drama and non-health discussion show. All women were surveyed immediately after exposure and, 2 weeks later, a sub-sample participated in focus group discussions.

Data published in March 2017 indicate:

Compared with the control, watching the health drama positively affected 4 of 5 knowledge areas (need to go for ANC in the first trimester, need to exclusively breast-feed in the first 3 days, need for 4 or more ANC check-ups, and need to always go for ANC), and watching the health drama and health discussion show positively affected 5 of 5 (also: need to start breast-feeding within an hour) knowledge areas. For example, women who watched the health drama only had an increase in knowledge of the need for 4 or more ANC check-ups of 15 percentage points compared with women in the control group; the number was 38 percentage points greater than the control group for those who watched both the health drama and health discussion show.

Compared with the control, watching the health drama positively affected 4 of 9 behavioural intentions, and watching the health drama and health discussion show positively affected 6 of 9 behavioural intentions. For example, women who watched the health drama only had an increase in the intent to go for 4 or more ANC check-ups of 10 percentage points compared with women in the control group; the number was 42 percentage points greater than the control group for those who watched both the health drama and health discussion show.

Using Behavior Change Approaches to Improve Complementary Feeding Practices

This paper applies an implementation framework, based on a behaviour change model, to compare 4 detailed case studies of complementary feeding programmes carried out in Bangladesh, Malawi, Peru, and Zambia. Approaches developed for reaching key audience segments in one or more of the programmes included: interpersonal counseling, community mobilisation, women's empowerment, mass communication, provision of handwashing stations, food production inputs, national and sub-national advocacy, coalition/alliance building to harmonise messages, and cross-sectoral coordination.

Selected findings from the study, published in 2017:

All 4 programmes documented improvements in dietary diversity attributable to their respective interventions. Selected findings:

• In Bangladesh, the greatest improvements took place in areas where coverage was above 90% for home visits combined with 60% for mass media. Changes were also documented in the timely introduction of specific foods, number of meals, and in reduced consumption of unhealthy snacks.
• In Malawi, a comparison of baseline and endline surveys showed that dietary diversity in children improved in the food production plus behaviour change communication intervention areas but not in food production areas with no behaviour change.
• In Peru, a significantly higher proportion of children in the intervention group received chicken liver, fish, or egg than did controls at both 6 months and 8 months of age. More children in intervention areas met their dietary requirements for energy, iron, and zinc than did controls. More mothers in the intervention area were able to name three important foods (i.e., chicken liver, eggs, and fish).
• In Zambia, a comparison of baseline indicators in 2011 and results of a process evaluation survey in 2014 found that dietary diversity rose from 25-30% at baseline to 75-80% in intervention areas; the control areas also improved to 50%. At endline, the knowledge of timely introduction of complementary foods was significantly higher in the areas where agriculture plus nutrition communication was implemented, compared to the control arm; this was most notable for animal source foods. The consumption of legumes/nuts was higher in both intervention arms (agriculture alone and agriculture plus nutrition communication) compared to control.

Impact Evaluation of the Marketing Innovation for Health Project in Bangladesh

Marketing Innovation for Health (MIH) is an integrated social marketing project funded by the United States Agency for International Development (USAID)/Bangladesh that is designed to provide comprehensive health and family planning education, products, and services in 19 priority districts of rural Bangladesh. Demand creation or awareness-raising was done through behaviour change communication (BCC) by deploying newly created and project-paid community mobilisers and through other media. Several BCC and information, education, and communication (IEC) materials were developed to improve knowledge and promote healthy behaviour in the community. These materials were used by the community mobilisation teams through interpersonal contact and group sessions like courtyard meetings.

The MIH evaluation was based on a prospective, quasi-experimental difference-in-differences design and data from representative household surveys conducted in BRAC and CPS intervention areas in 2013/2014 (baseline) and 2015/2016 (end line) in a panel of clusters.

Selected findings:

There was a significant increase in client-worker contacts and in women's knowledge and use of health products and services, as the project intended. The researchers found that all of the knowledge indicators increased over time in MIH intervention areas and that the MIH programme had strong and significant impacts on these outcomes. (An example would be % MWRA who could accurately report two specific risks/complications associated with pregnancies after age 35, which saw more than a 20 percentage point impact.) Health product and service utilisation also increased in MIH intervention areas over time, and the researchers found significant programme impacts on use of micronutrient powder (MNP) among young children, use of sanitary napkins, receipt of four or more antenatal care (ANC) visits, and use of safe delivery kits during home births.

Research Initiative: Test the Impact of a Radio Campaign Addressing Child Mortality

Development Media International (DMI) is conducting a 3-year randomised controlled trial to test the hypothesis that a radio campaign can reduce the large number of children dying before their fifth birthday in Burkina Faso. The research involves the broadcast, beginning in March 2012, of health messages using radio spots (60-second adverts) and radio phone-in programmes.

This independent survey is based on interviews with 5,000 mothers in the 7 intervention zones and 7 control zones halfway into the research intervention period (midline data, May 2014).

Findings with regard to practices in the areas of treatment-seeking, diarrhoea, pneumonia, malaria, sanitation and hygiene, nutrition, and health facility delivery are reported. For example:

Overall, the proportion of parents taking a sick child (with fever, cough, rapid breathing, or diarrhoea) to receive treatment at a health facility increased by 20.0 percentage points in intervention zones, compared to 11.1 in control zones (a "difference in difference" figure (based on cluster-level analysis) of 8.9). Adjusted for proximity to a health centre, the difference in difference is 12.9.

ReMiND Project

Using mobile phone-based health technology (mHealth) in Uttar Pradesh (UP), India, the Reducing Maternal and Newborn Deaths Project (ReMiND) aims to increase the adoption of key maternal newborn and child health practices by improving the presentation and content of health information provided by Accredited Social Health Activists (ASHAs), as well as strengthening support and supervision structures for the ASHAs.

The ReMiND project completed a baseline study in January 2013 that included a qualitative study and a quantitative knowledge, practice, and coverage (KPC) survey covering 1,100 households. The midterm evaluation in August 2014 employed the same methodology with 2,200 households.

Key findings:

• The project reduced the number of low-coverage ASHAs to less than 20% of the total, down from more than 60% at baseline. Only 44% of women received an ASHA visit with a counseling component prior to the intervention, but 72% received a counseling visit from their ASHA at the time of the midterm evaluation survey. Most of the improvement came from an increase in counseling on nutrition and rest during pregnancy, for which there was a module in CommCare.
• Recall of nutrition messages increased from 17.8% to 55% of women, while recall of counseling danger signs increased from 3.8 % to 14% of women.
• The average woman accessed 41% more antenatal care (ANC) sessions at midterm than baseline, with 58% more women receiving the recommended number of three or more checkups (from 18.9% of women to 30.2%). The effects were concentrated among households with lower socioeconomic status.

Alive & Thrive (A&T) in Ethiopia

In order to reduce death, illness, and malnutrition caused by poor breastfeeding and complementary feeding practices, A&T had to address widespread and limited recognition of the long-term consequences of stunting and find ways to reach mothers and their families in a large and diverse country with multiple languages, overextended health workers, and limited media reach. Community-based and mass media activities were concentrated in the 4 most populous regions: Tigray, Amhara, Oromia, and Southern Nations, Nationalities, and Peoples (SNNP).

A baseline and an endline survey were conducted in 2010 and 2014, respectively.

Findings related to practices:

• Rates of exclusive breastfeeding increased from 72% at baseline to 80% at endline in project areas.
• The proportion of children who met minimum dietary diversity and minimum adequate diet, while still extremely low, doubled in the programme evaluation areas (from 6% to 15% and from 5% to 12%, respectively) between 2010 and 2014. In addition, minimum meal frequency increased by more than 20 percentage points (from 46% to 70%). These gains were achieved despite high levels of food insecurity in A&T's intervention areas.
• Nearly 30% of the women surveyed in a sentinel site surveillance in December 2012 had participated in a food demonstration of an enriched porridge in the past 6 months, and of these women, nearly three-fourths reported trying at home what had been demonstrated.

In a March 2012 sentinel survey, about two-thirds of mothers reported that their husbands were involved to some extent in infant and young child feeding (IYCF). By November 2013, the rate had increased to 76%, and almost 80% of mothers reported discussing child feeding with their husbands.

Alive & Thrive (A&T) in Bangladesh

A&T used advocacy, interpersonal communication and community mobilisation, mass media, and strategic data to improve breastfeeding and complementary feeding practices and to reduce stunting and anaemia in young children.

A baseline and an endline survey were conducted in 2010 and 2014 respectively in 50 upazilas (subdistricts) where A&T was implemented.

Rapid improvements in breastfeeding and complementary feeding practices included:

• Increased timely initiation of breastfeeding from 64% to 94%
• Increased exclusive breastfeeding from 48% to 88%
• Increased timely introduction of solid and semi-solid foods from 46% to 99%
• Increased dietary diversity from 32% to 64%
• Increased minimum meal frequency from 42% to 75%
• Increased minimum acceptable diet from 16% to 50%
• The percentage of mothers washing hands before feeding young children improved from 23% to 31%.

Noting the inadequacy of complementary feeding (CF) in Bangladesh, the A&T initiative used intensified interpersonal counseling (IPC), mass media (MM), and community mobilisation (CM) in an effort to foster optimal child growth and development. The intensive group received all 3 interventions; the nonintensive group received standard IPC and less-intensive MM and CM. A cluster-randomised, nonblinded impact evaluation design was used to compare the impact of the 2 A&T intervention packages. A cross-sectional household survey was conducted at baseline (2010) and exactly 4 years later (2014) in the same communities.

Selected findings:

CF improvements were significantly greater in the intensive than in the nonintensive group [difference-in-difference (DDE): 16.3, 14.7, 22.0, and 24.6 percentage points (pp) for 4 CF practices: minimum dietary diversity, minimum meal frequency, minimum acceptable diet, and consumption of iron-rich foods, respectively]. In the intensive group, CF practices were high: 50.4% for minimum acceptable diet, 63.8% for minimum diet diversity, 75.1% for minimum meal frequency, and 78.5% for consumption of iron-rich foods. Timely introduction of foods improved. Significant, nondifferential stunting declines occurred in intensive (6.2 pp) and nonintensive (5.2 pp) groups in children 24-47.9 months.

Exposure to the greatest number of intervention platforms, i.e., to IPC + MM + CM, was associated with increased odds of improved CF practices ranging from 2.8-5.9-fold greater odds for different CF practices compared with no exposure. There was no similar discernible pattern of exposure to combinations of programme interventions with stunting or height-for-age z score (HAZ), although exposure to MM or IPC alone was associated with lower odds of stunting.

In Vietnam, A&T, through Save the Children, worked with the government to establish a total of 781 social franchises within government health facilities in 15 of 63 provinces at the province, district, and commune levels, using social franchising principles to deliver facility-based individual and group IYCF counseling under the brand name Mặt Trời Bé Thơ, or MTBT ("The Little Sun" in English). Referrals, CM, promotional print materials, and television advertising were used to generate demand for preventive IYCF counseling services. The MM component consisted of a national broadcast campaign that used television and digital media. In intensive areas, the MM campaign also included additional out-of-home advertising on optimal IYCF practices through billboards and broadcasts on village loud-speakers. In intensive areas, CM was operated by village health workers who visited households of women with children younger than 24 months to deliver invitation cards, encourage mothers to attend MTBT counseling services, and provide women with basic IYCF messages.

After 4 years, at endline (2014):

In the modified per-protocol analyses (MPAs), greater improvements in the intensive than in the nonintensive group were seen for minimum dietary diversity [DDE: 6.4 percentage points (pps); P 0.05] and minimum acceptable diet (8.0 pps; P 0.05). Significant stunting declines occurred in both intensive (7.1 pps) and nonintensive (5.4 pps) groups among children aged 24-59.9 months, with no differential decline.

Strategic Design of Mass Media: Promoting Breastfeeding in Viet Nam

This is the story of how A&T integrated a national mass media campaign into its comprehensive programme to improve IYCF in Viet Nam. The campaign used the following types of media:

1. Broadcast: TV spots on national and regional TV stations, as well as audio messages delivered over outdoor loudspeakers.
2. Out-of-home: print ads on the outside of buses, billboards, and posters in health centres.
3. Online: a website, dedicated to IYCF, with information and TV spots; interactive online counseling; interactive mothers' forum; TV spots placed on Vietnamese websites that are most popular with women; a Facebook fan page; and a mobile app to connect young mothers and allow them to track baby's milestones, share photos, and access feeding recommendations.

Evaluation data published in 2014 show:

• One year into the mass media campaign, the behaviour of exclusive breastfeeding up to 6 months of age had risen from 26% to 48%.
• Women who reported exposure to the campaign were more likely than their unexposed counterparts to have breastfed exclusively up to 6 months (the difference between exposed and unexposed ranges from 9 percentage points to 18).
• Exposure to mass media was associated with mothers' beliefs that exclusive breastfeeding for 6 months was the norm. Organisers asked mothers whether they agreed that people whose opinions they cared about thought that they should give breastmilk only - no water, no infant formula, no semi-solid food - for the baby's first 6 months: 68% of those exposed to the TV spots agreed, compared to 46% of mothers not exposed to the spots. Results were similar when mothers were asked if they believed that other mothers were giving only breastmilk: 66% of mothers who had seen the spots agreed, and 47% of those who had not been exposed agreed.
• Eighteen months into the mass media campaign, 85% of mothers exposed to the campaign were confident that their breastmilk alone offered all the nutrients baby needs for 6 months, compared with 72% of mothers not exposed to the campaign.

WHO Communication-for-Behavioural-Impact (COMBI) in the Field: An Example of Evaluation and Research Challenges

Developed by the World Health Organization (WHO), COMBI (Communication for Behavioural Impact) is a process that blends strategically a variety of communication interventions intended to engage individuals and families in considering recommended healthy behaviours and to encourage the adoption and maintenance of those behaviours. In brief, the process involves multiple channels at multiple levels to connect schools, communities, health service providers, local authorities, and agencies in pursuit of a behavioural objective around these communication action areas: mobilising decision-makers and communities, conducting interpersonal communication, creating and distributing promotional materials and advertising, and organising point-of-service promotion.

Amongst the impact data shared in this presentation are a set of data emerging from an effort in Moldova to promote positive mother and child health/antenatal care behaviours as part of a United Nations Children's Fund (UNICEF)/Ministry of Health and Social Protection campaign.

Selected findings from Moldova:

• Seeing a doctor in the first 12 weeks of pregnancy: before COMBI campaign (69%); after COMBI campaign (81%).
• Taking folic acid in the first 12 weeks of pregnancy: before COMBI campaign (32%); after COMBI campaign (76%).
• Taking iron tablets for at least 2 months during pregnancy: before COMBI campaign (62%); after COMBI campaign (88%).
• Knowledge of danger signs: before COMBI campaign (59%); after COMBI campaign (91%).

In February 2010, Sesame Workshop in India launched a healthy habits campaign as part of Galli Galli Sim Sim (GGSS). The campaign included a press launch and three components: on-air (13 weeks of GGSS), online (a dedicated health page on the GGSS website), and on-ground (a mobile community viewing (MCV) programme).

205 households (99 in the treatment group and 105 in the control group), consisting of one child per household between the age group of 5-6 years and their caregivers, participated in the research. Two groups were measured before and after one of the groups was exposed to the intervention.

Results showed:

Exposure to MCV had a positive and significant effect on the usage of soap prior to eating, the presence of soap in the house, and identification of vegetables at p=0.1, 0.06, and 0.03, respectively. The average gains were in the range of 16% for populations exposed to the intervention, which was almost twice that of the control group. Results also showed higher improvements for the exposed group for presence of soap in households, with an average improvement of 10% amongst the exposed group when compared to a 4% improvement in populations unexposed. The percentage gains made: 6%.

The researchers conducted a cluster, randomised controlled trial in 14 preschool facilities in Usaquén (Bogotá, Colombia) between May and November 2009. Based on social cognitive theory and the transtheoretical model in health promotion, the intervention sought to teach preschool children key messages on the importance of healthy eating and living an active lifestyle in 3 integrated areas: body and heart, nutrition, and physical activity.

Results from structured survey, used at baseline, at the end of the study, and 12 months later:

Children in the intervention group showed a 10.9% increase in tests of knowledge, behaviours, and attitudes around healthy eating and living (compared to a 5.3% increase in the control group). With regard to parents, the results paralleled those of children - with gains in the intervention group of 8.9% versus only 3.1% in the control group. Among teachers, the results were 9.4% and 2.5%, respectively. One year after the intervention, children in the intervention group still showed a significant increase in weighted score.

Endline Study for Community Led Initiatives for Child Survival (CLICS)

The CLICS programme was implemented by the Department of Community Medicine (DCM) and the Aga Khan Foundation (AKF) India, with support from the United States Agency of International Development (USAID). Over a period of 5 years, starting from the year 2003, the programme had 32,962 direct beneficiaries comprising children under the age of 3, women in the reproductive age group, and adolescent girls in 67 villages. The programme aimed at building the capacity of the community to develop, manage, and achieve ownership of the village-based child survival and health services. To achieve this goal, a mix of social mobilising, social franchising, community ownership, and cross-cutting, issue-based strategies was implemented in the project area.

Sample findings:

• The proportion of children aged 0-23 months who were born at least 24 months after the previous surviving child was 64.4% in the baseline survey; it increased marginally to 68.0% in the midterm and then significantly to 76.1% in the endline survey. This clearly indicates that there has been an increase in adoption of birth spacing methods in the project area.
• The proportion of children aged 0-23 months whose birth was attended by trained providers (including TBAs [traditional birth attendants]) was 82.2% in the baseline survey. This proportion increased significantly to 97.0% in the midterm survey and was similar in the endline survey.
• The proportion of children aged 6-9 months who were given breast milk and complimentary foods in the last 24 hours was 72.0% in the baseline; it increased significantly to 97.98% in the endline survey.
• The proportion of children aged 12-23 months who were fully vaccinated was observed to be 62.4% in the baseline, 69.8% in the midterm survey, and 95.8% in the endline survey.
• .The proportion of mothers who reported washing hands before preparing food increased from 9.1% in the baseline to 36.0% in the midterm and 46.1% in the endline survey.

Will Rahima's Firstborn Survive Overwhelming Odds? Positive Deviance for Maternal and Newborn Care in Pakistan

This case study explores the use of the Positive Deviance (PD) approach to strive for better maternal and newborn health outcomes in 8 villages of Haripur District in Pakistan's North West Frontier Province (NWFP) from January 2001 to October 2004. PD is based on the observation that in every community there are certain individuals or groups whose uncommon behaviours and strategies enable them to find better solutions to problems than their peers, while having access to the same resources and facing similar or worse challenges. Initiated by Save the Children as part of their Saving Newborn Lives (SNL) Initiative in Pakistan, the project was carried out in 2 phases.

A pre-post, interventional control research design pointed to significant gains in maternal and newborn care indicators. In comparison to control villages, where the gains were insignificant, in the intervention villages:

• The percentage of mothers giving homemade pre-lactal feeds in the first 3 days decreased from 70% to 25%.
• The percentage of pregnant mothers visiting antenatal clinics increased from 45% to 63%.
• The percentage of newborns whose cords did not receive unhygenic homemade remedies increased from 7% to 19%.
• The percentage of fathers who saved money and arranged for transport to tackle pregnancy emergencies increased from 45% to 62%.
• The percentage of families that used a new blade to cut the baby's cord increased from 19% to 33%.
• The percentage of families that delayed bathing the newborn for the first 24 hours increased from 18% to 32%.

Sisimpur Community Outreach Project - Bangladesh

Sisimpur is an educational television programme designed for Bangladeshi children between the ages of 3 and 7 years old. Sisimpur's messages are also featured in community outreach materials designed for use in a variety of settings, including early childcare centres, pre-schools, kindergartens, and homes. The kits, which contain books, games, flash cards, and growth charts, are distributed to caregivers from low-income households through a series of 3 workshops conducted by specialised trainers from 12 non-governmental organisations (NGOs).

2006 evaluation showed:

All findings are significant at p < .05:

Compared with non-participants, caregivers who participated in the outreach programme were:

• 8.4 times more likely to own a toothbrush at home
• 5.3 times more likely to own toothpaste at home
• 4.0 times more likely to use a toothpaste to clean teeth
• 3.8 times more likely to use toothbrush to clean teeth
• 2.1 times more likely to have soap in the home
• 2.1 times more likely to have a clean towel in the home
• 4.4 times more likely to wash their hands with soap before having a meal
• 2.1 times more likely to bathe 7 times or more a week
• 3.0 times more likely to bathe with soap 4 times or more a week

Compared with non-participants, children of caregivers who participated were:

• 8.6 times more likely to use a toothbrush to clean teeth
• 5.0 times more likely to use toothpaste to clean teeth
• 7.8 times more likely to clean teeth more than once a day
• 2.8 times more likely to clean teeth after a meal
• 10.9 times more likely to clean teeth at night
• 8.0 times more likely to use soap to wash hands before a meal
• 4.6 times more likely to use soap to wash hands after defaecation
• 3.0 times more likely to comb hair more than once a day
• 3.0 times more likely to eat eggs daily
• 3.0 times more likely to drink milk at least once a week

Cambodia Mass Media Campaign

This was a multifaceted mass media campaign in 2003 that was an effort to help stop the spread of HIV and AIDS, improve care and support for people living with HIV, and improve the health of Cambodia's mothers and children. The coordinated campaign consisted of a television soap opera, 3 radio phone-in and discussion programmes, television and radio public service announcements (PSAs), and a print magazine.

• 100 episodes of a soap opera ('Taste of Life') were broadcast.
• 666,000 copies of a photo-strip magazine were produced each month and distributed to the public.
  A youth radio phone-in programme ('Really?') was broadcast weekly.
• A radio discussion programme ('Real Men') was broadcast weekly.
• 99 shows of the maternal and child health radio phone-in programme 'First Steps' were broadcast.
• 23 television and 22 radio public service announcements (PSAs) about child and maternal health. In the space of a year, the radio PSAs were broadcast more than 35,000 times across 11 radio stations.

2006 evaluation showed:

• Knowledge of the benefits of breastfeeding immediately after birth rose from 38% to 67%; and parents' awareness of acute respiratory illnesses in children rose from 20% to 80% during the campaign.
• The number of people who said they washed their hands to avoid diarrhoea increased from 10% to 25%.
• The number of children who were taken to health centres with signs of acute respiratory illness rose from 51% to 70%.
• The prevalence of those reporting a child in their care with diarrhoea in the last month decreased from 17% to 13%.

Tanzania Essential Health Interventions Project (TEHIP)

TEHIP was established to test innovations in planning, priority setting, and resource allocation at the district level, in the context of the reform and decentralisation of Tanzania's health care system. The project's goal is to determine the feasibility of an "evidence-based" approach to health planning - an approach whereby decisions on how to allocate scarce health care resources are made based on information obtained locally - and measure its impact. TEHIP uses participatory research and implementation strategies to give local people a say in the causes of child and adult mortality, drawing on personal contact, radio, and computers as tools to strengthen health systems' capacity to improve health.

2005 evaluation showed:

• Average clinic visits per child increased from 2.8 to 5.8 a year. More children were treated for malaria, more early cases of worms were spotted, more eye infections were caught, more AIDS messages were shared, and more mothers had exposure to family planning information.
• Child mortality fell in the 2 districts by more than 40% over the 5 years of implementation. Adult mortality dropped by about 20%, even as AIDS was beginning to spread. During this period, districts not using the TEHIP plan experienced virtually no change in their death rates.
• In accomplishing the above, the districts were able to use just 30 cents out of TEHIP's promised US$2 increase the first year. (The figure increased to 89 cents in the second year, and US$1.37 in the third.)

Talk to Me - South Africa

Talk to Me is a nationwide television and radio campaign to support parents and caregivers in talking to children about HIV/AIDS. It uses South Africa's "best-known five year old orphan muppet living with HIV/AIDS, Kami from Takalani Sesame." Newspapers and educational supplements support the campaign.

2005 evaluation results:

Communication between the caregiver and any child living in the household was significantly positively associated with the intervention.

• Overall, 54% of the control group and 75% of the intervention group reported having spoken to any child in their household about HIV in the previous two weeks at follow-up.
• After adjusting for communication at baseline, caregivers in the intervention group were twice as likely as those in the control group to report that they communicated with a child in their household about HIV in the previous 2 weeks ([odds ratio] OR=2.08; 95%CI [confidence interval] 1.08, 4.02).
• This association was statistically significant and remained so, even after adjusting for other potential confounders and effect modifiers (OR=2.46; 95%CI 1.14; 5.32).

Third Annual/Midterm Evaluation Report: The Salvation Army/Zambia Chikankata Child Survival Project

This report shares the results of a midterm evaluation (MTE) of Zambia's Chikankata Child Survival Project (CCSP), which was launched October 1 2005. The central strategy being used is the Care Group model, according to which every household with women of reproductive age is cared for and visited every month by community health volunteers, called Care Group Volunteers.

The main accomplishments of the project, according to the MTE, are as follows:

• CCSP contributed to an increase in childhood immunisation coverage from 33% to 84%.
• 85% of mothers interviewed identified fever as a sign of malaria, and 91% of these women stated that they would seek care for an episode of child fever that same day. This is a substantial increase from the baseline, where 11% stated they would seek care within 24 hours.
• 86% of mothers of children under 5 years reported that their children slept under an insecticide-treated net (ITN). This is an increase from 22% at the baseline.
• 90% of mothers of children under 5 reported that they had their child's growth monitoring card on hand, and over 80% of the cards were up-to-date in recording immunisations, growth monitoring attendance, and weight measurement.
• 98% of the pregnant women had their antenatal cards in their possession, and 100% of them had at least one prenatal visit recorded on the card.
• 58% of home births in the month of May (2008) were done by Trained Traditional Birth Attendants (TTBA). This is an increase from 13% at the baseline.
• 81% of pregnant women ate iron-rich food the day before the evaluation.

Behavior Change Interventions for Safe Motherhood

Jhpiego's Maternal and Neonatal Health (MNH) Program included behaviour change interventions (BCI) - behaviour change communication (BCC) activities, community and social mobilisation, advocacy, and alliance building - that were evaluated through population-based surveys in Burkina Faso, Guatemala, Indonesia, and Nepal.

In the 4 countries, knowledge of birth preparedness, danger signs, and ANC attendance all increased after an integrated campaign. Highlights include:

• In the Koupéla district of Burkina Faso, skilled attendance at birth increased from 39% at baseline (2001) to 58% at follow-up (2004). In Guatemala, more than half (55%) of the exposed women in the follow-up survey gave birth at a facility, compared to 31% at baseline and 31% of those women who were not exposed to the Program (adjusted for sociodemographic characteristics). In Nepal, skilled attendance increased from 15% at baseline to 37% at follow-up.
• An increase in ANC attendance in all 4 countries: In Burkina Faso, for example, the number of first-time users of ANC rose from 66% in 2000 to 85% in 2003 in the MNH Program area.
• Increased awareness of severe bleeding as a danger sign during the postpartum period among women in all 4 countries: Women exposed to BCI activities in all 4 countries showed higher levels of knowledge than did women who were not exposed.
• An increase in the proportion of women who made arrangements for transportation to a healthcare facility in case of an obstetric emergency in all 4 countries: Women exposed to BCI activities showed higher levels of action - by making arrangements for emergency transport - than those who were not exposed.

Participatory Intervention with Women's Groups

A team from Mother and Infant Research Activities (MIRA) in Kathmandu, Nepal, undertook a low-cost, community-based participatory intervention with women's groups to test the impact of interpersonal communication on birth outcomes in an economically poor rural population.

2004 evaluation showed:

Women in intervention clusters were more likely than those in the control clusters to have had antenatal care, to have taken haematinic supplements, to have given birth in a health facility, with a trained attendant or a government health worker, to have used a clean home delivery kit or a boiled blade to cut the umbilical cord, and to have been cared for by a birth attendant who washed her hands. Rates of maternal morbidity were similar, but women in intervention clusters were more likely than those in control clusters to have visited a health facility in the event of illness. Likewise, infant illness was more likely to have led to a visit to a health facility.

Alam Simsim Outreach Program - Egypt

Alam Simsim is a multiple episode, half-hour television series developed by Egyptian educators, child development experts, scriptwriters, and film makers. To help extend the messages of the TV series, an outreach initiative was launched in December 2002 that sought to provide parents and caregivers with information and materials to improve their children's health, hygiene, and nutrition, as well as to promote the use of media as an educational tool in improving children's readiness for school. Working closely with local community development associations (CDAs), the outreach team developed a 2-month training component, as well as educational materials for parents and children (such as booklets, flash cards, and a healthy habits calendar).

2004 evaluation showed:

Awareness of important health behaviours increased after participation in the programme. For example, 32% more parents and caregivers with the experimental group (those exposed to the outreach programme) demonstrated knowledge of the Diptheria, Pertussis (Whopping Cough), and Tetanus (DPT1) vaccine; knowledge levels of DPT1 remained relatively unchanged within the control group.

Health - "In the post-exposure survey, 29 percent of the parents in the experimental group stated that they now take their children to the doctor for regular checkups, compared to only 10 percent of the parents in the control group. Although this variable is not directly comparable with any variable in the baseline survey, this proportion is consistent with the proportion of parents in the experimental group who stated that having regular checkups was a health behavior that changed as a result of the training (27%)."

Hygiene - The outreach programme had a measurable impact on the hygiene of parents/caregivers and the children. For example, exposure to the outreach programme was related to reported increases in the frequency of making sure that children washed their hands before eating (a gain of 5% over the control group); washing face with soap and water (a gain of 15% over the control group); using an individual towel rather than a shared one for drying (a gain of 24% over the control group); brushing teeth (a gain of 26% over the control group); and covering one’s nose or turning away when sneezing (a gain of 34% over the control group).

Nutrition - When parents in the experimental group were asked what they do differently now after they finished the training, the issue mentioned most frequently by parents who had attended the training was the knowledge of different components of balanced, healthy meals. These included the addition of vegetables, making sure that there was a source of protein included in the meal, adding items that have iron such as spinach, diversifying food for meals, etc. The impact of these changes could not be measured directly from the data on specific meal items, but this knowledge can be an important and valued component in driving behavioural changes. This knowledge of good nutritional practice was also passed on to their children, who were more likely to report changes in their nutritional habits (such as drinking milk and eating more fruits and vegetables) compared with children in the control group.

Eyi Megh Eyi Roudro - Bangladesh

The aim of this television series was to encourage Bangladeshi people to take advantage of available health services like the Essential Services Package (ESP) that are provided by these clinics as well as to instill the habit of visiting health services clinics.

2003 evaluation showed:

• More viewers than non-viewers are aware that newborn babies should be given colostrum right after birth. They are also more aware of pre-delivery preparations, and pre- and post-delivery complications. In addition, viewers are more aware that delivery should be performed either by trained birth attendants or doctors. Viewers are more aware about the sources of information regarding different diseases and problems among children, and are more aware of the symptoms of pneumonia and polio. 43% of viewers stated that they had learned something from the quiz sessions, such as how to take care of pregnant mothers (28%), health-related information (26%), child immunisation (26%), proper care of children (16%), family planning (15%), and Smiling Sun clinics (6%).
• 77% of the viewers of the drama said that children who have pneumonia should be taken to doctors, as compared to 74% of non-viewers.
• 93% of viewers and 86% of the non-viewers had given the polio vaccine to their children. 70% of viewers had received antenatal care (ANC) services during their last pregnancy, as compared to 48% of non-viewers. 58% of non-viewers, versus 41% of viewers, said they had taken "no preparations" in advance of their last pregnancy.

Blue Star Campaign - Nicaragua

In the aftermath of the hurricane that struck Central America in October 1998 (Hurricane Mitch), the Blue Star Water and Sanitation Campaign used mass media, community mobilisation, advocacy, and educational training to increase the prevalence of appropriate hygiene and water management practices, such as handwashing and the maintenance of a clean latrine. The goal of the campaign was to decrease the incidence of diarrhoea among Nicaragua's children, aged 5 years and younger.

Campaign components included:

• TV and radio public service announcements (PSAs).
• A TV documentary, mini-series, and informational programme.
• An educational bus toured the country, with training opportunities and promotional materials.
• Educational materials were supplied to schools, and teachers were trained to introduce them.
  

2001 evaluation showed:

In May 2001, evaluators visited 476 homes in two municipalities in each of the regions prioritised due to Hurricane Mitch, as well as two municipalities in Managua. Among those exposed to Blue Star messages, the best recalled message was that of handwashing (90% or more).

As part of another component of this evaluation process, before and after each presentation of the Blue Bus (see above), 13 people were randomly chosen and asked 8 questions to assess level of recall for Blue Bus messages. Of 1,268 people interviewed:

• the percentage who knew that diarrhoea is avoided by using a potty seat increased from 5% to 11%
• the percentage who knew that one should not touch dirty water with one's hands increased from 17% to 29%
• the percentage who knew that diarrhoea is avoided by washing hands increased from 79% to 82%
• the percentage who knew that one should wash hands before preparing food increased from 45% to 62%

185 of those interviewed had no access to TV or radio. Among this group:

• the percentage who knew that diarrhoea is avoided by using a potty seat increased from 3% to 15%
• the percentage who knew that one should not touch dirty water with one's hands increased from 13% to 21%
• the percentage who knew that diarrhoea is avoided by washing hands increased from 64% to 75%
• the percentage who knew that one should wash hands before preparing food increased from 32% to 49%
  

National WIC Breastfeeding Promotion Project - United States

This Special Supplemental Nutritional Program for Women, Infants, and Children (WIC) sought to reframe the traditional health benefits of breastfeeding to emphasise a new benefit: the development of a special relationship with an infant from birth. Programme materials included three bilingual (English and Spanish) television commercials, three bilingual radio commercials, outdoor billboards, nine bilingual posters, nine bilingual educational pamphlets, and several information and resource guides and WIC staff kits. Carrying the slogan "Loving Support Makes Breastfeeding Work," programme materials explained the supportive role family members and friends can play in encouraging a new mother to breastfeed.

2001 evaluation showed:

• Prior to the start of the programme, breastfeeding rates for mothers in the state of Iowa while in the hospital had been 57.8%. Six months after the campaign's start, rates in Iowa increased to 64.4%; one year after the start they increased to 65.1%.
• The rates for women still nursing six months after birth also increased. Before the start of the campaign, the percentage of women still breastfeeding at six months was 20.4. Six months after the start of the campaign, rates increased to 29.3%, and to 32.2% a year later.

Back to Sleep Campaign - Canada

A targeted mass media messaging campaign to teach parents and other primary infant caregivers across Canada how to avoid the risk factors associated with Sudden Infant Death Syndrome (SIDS). The campaign primarily addressed mothers, expectant/new mothers, partners and peers aged 20 to 34, grandparents, and other caregivers. Certain campaign components also addressed people directly involved in the provision of infant health care and the dissemination of infant health care information (i.e., public health units, hospitals, physicians, and pre- and post-natal educators).

2001 evaluation results:

• In 1999, 61% of health professionals claimed to have given advice to place child on its side to sleep; 21% advised the placing of the child on its back. In contrast, in 2001, 21% claimed to have advised a side position, while 67% of advised a back position for the baby to sleep.
• Among all respondents, 66% of those surveyed in 2001 said that a back position reduces SIDS risk (as compared to 45% in 1999).
• Among caregivers or parents that have taken action to reduce the risk of SIDS, 69% said that they lay their babies on their backs to sleep, up from 41% in 1999.
• In 1999, 84% of respondents said they were aware that secondhand smoke or smoking in the household increases risks of SIDS; 82% said smoking during pregnancy increases risk. In 2001, 89% said second hand smoking in the household increases risk of SIDS and 81% said smoking during pregnancy increases risk.

Better Parenting Project - Jordan

This project sought to address the needs of parents of very young children for basic information and for support in their tasks of childrearing, particularly in the areas of health, nutrition, and social-emotional development. The campaign included: 4 video presentations, 4 accompanying parent booklets, and 3 facilitator guides to the use of these materials.

2000 evaluation showed:

For the 112 mothers who attended every one of the 8 sessions (out of the 214 who attended some), "the findings demonstrated that the program had a statistically significant effect on creating differences in the performance of mothers, as measured against the pre- and post-participation evaluation tools. Improvement was observed in the level of the mothers' knowledge in the areas of child growth and development....The program also contributed towards improving the mothers' patterns of parenting. No differences were found in the performance of literate or illiterate mothers. The results also demonstrated that the program was both effective and suitable, that it led to raising the level of mothers' awareness in the area of early childhood upbringing..."

Immunization Promotion Activities: Are They Effective in Encouraging Mothers to Immunize Their Children?

This study was conducted to evaluate the effectiveness of the Mexican National Vaccination Council's (CONAVA) communication activities for the Second National Health Week (SNHW) in Mexico City. The study sought to determine whether the messages communicated were effective in providing information to mothers and in motivating them to have their children vaccinated.

Key findings (1999):

Overall, 83% were aware of the campaign and 63% were impacted by its messages. The net increase in immunisation between the "aware" and "unaware" groups was 14.8%, though it must be recognised that a relatively large proportion of the "unaware" mothers also took their children for vaccinations, a feature the authors attribute to long-term momentum gained by successive vaccination campaigns.

Let's Work Together to Beat Measles - Australia

In 1998, the Commonwealth of Australia launched a 4-month public health initiative in an effort to eliminate measles in primary schools. Information and advocacy messages were designed to inform parents, teachers, and school principals of the benefits and risks of vaccination - involving them in the process of developing informational materials and seeking their consent. The campaign also worked to bolster the knowledge of physicians regarding vaccination, and then relied on them to talk with parents about the safety and efficacy of the vaccine.

1998 evaluation showed:

Evaluators claim that the campaign "resulted in a significant increase in levels of protection against measles among preschool and primary school age children, and averted an estimated 17,500 cases of measles (NCIRS 1999)". 1.7 million primary school aged children (96% of children this age) were vaccinated during the campaign. More than 1.3 million of these children were vaccinated in the school programme, in almost 8,800 schools in all States and Territories. A serosurvey conducted after the campaign showed that 94% of children aged 6-12 years were immune to measles, an increase from 84% before the campaign. It was estimated that 97.5% of those aged 12-42 months had received their first dose of MMR vaccine, and serology showed that 89% of children aged 2-5 years were protected, a rise from 82% before the campaign. Approximately 18,000 children who were due or overdue for the first dose of MMR vaccine at the beginning of the campaign were vaccinated. The post-campaign serosurvey also showed that the level of seropositivity in young people aged 12-18 years who were not directly addressed by the campaign remained static at 91% before and after the campaign.

2 Smart 2 Smoke Theatre Programme for Children - United States

The intervention consisted of two 30-minute plays that were presented at 160 schools in Minnesota in an effort to communicate the anti-smoking message to elementary schoolchildren. Classroom activities and take-home materials for parents were used as supplementary tools to increase the impact of the play's messages.

1998 evaluation showed:

• Of the grade 4-6 respondents, the mean of those in the post-test group that knew that "smoking costs lots of money" was 85.8% vs. 62.8% in the pre-test group; the mean that believed that "nicotine is more addictive than heroin" was 54.5% vs. 23.3% in the pre-test group. There were also significant differences in the reasons given not to smoke (grades 4-6): "That there are other ways to have fun" was 88% for the post-test vs. 81.7% for the pre-test; that "I might get addicted" was 71.7% in the post-test vs. 65.3% in the pre-test; and that it "costs too much money" was 64.5% in the post-test vs. 46.8% in the pre-test.
• Students in grades 4-6 also had significantly more negative attitudes and expected outcomes of smoking, and more reasons not to smoke as a result of the production. Of the grade 4-6 respondents, the mean of those in the post-test group who thought "smoking is dumb" was 92.4% vs. 89.3% in the pre-test group; the mean of those who thought "billboards get you to try smoking" was 77.2% vs. 70.6% in the pre-test group.
• Among the students in grades 4-6, 76% reported that they learned about alternatives to smoking and 56% practised ways to say "no" to cigarette offers.

1995 National Immunisation Days (NIDs) - Bangladesh

Bangladesh launched its first two National Immunisation Days (NIDs) in 1995 - on March 16 and April 16. The goal was to administer two doses of the oral polio vaccine (OPV) to all children under the age of 5 years, irrespective of their previous immunisation status. Among the vehicles used to spread the word about the campaign were radio, television, mobile loudspeakers, printed materials (newspapers, posters, and leaflets), community meetings, and house-to-house contact (female field workers and volunteers promoted the NIDs during visits to women's houses).

1997 evaluation showed:

• After the second NID, 81% of all women interviewed spontaneously mentioned that polio is a vaccine-preventable disease, increasing from 63% before the first NID. The increase was more pronounced among slum dwellers, where the awareness rose to 74% (having been 52% before the first NID).
• 88% of children under 5 years received at least one dose of OPV during the NIDs; 67% received 2 stipulated doses, with no significant differences between slum (65%) and non-slum (69%) groups.
• 68% of the children contacted during the NIDs were given vitamin A supplementation.
• The nutritional surveillance reports indicate a dramatic improvement in vitamin A coverage from 42% to 87% of the children living in the rural areas serving as sentinel sites (NID efforts were combined with other services - a strategy that was found to be very effective).

Immunisation Communication - Burkina Faso

This campaign used interpersonal communication, radio programmes, songs, print materials, flipcharts, stickers, and posters to improve the number of children with full immunisation (a series of five immunisation contacts) before age 1. The local population was mobilised to actively participate in the programme through discussions and provision of information about immunisation.

1994 evaluation showed:

• Over 70% of the mothers mentioned vaccination when describing what the interactive sticker and form had taught them. Mothers mentioned numerous benefits when asked how these materials helped them, including: remembering to get vaccinations, understanding and protecting children, acquiring good health, and dealing with side effects.
• More of the exposed mothers (87-96%, depending on type of exposure) knew that 5 visits were required to complete the immunisation compared to those who had not been exposed (71-80%). Similarly, more exposed mothers (60-75%) than unexposed (38-48%) knew that a child should be vaccinated against measles at 9 months. An increase in the number of materials that the mothers were exposed to correlated to an increase in the knowledge of the mothers with respect to the questions asked.

Measles Communication Programme - Philippines

A national multimedia mass communication project to increase knowledge and participation in measles vaccinations.

1990 evaluation showed:

• Some of the shifts noted in the bivariate analysis included: "Some people get measles and others do not. Is there any way to protect a child from getting measles? If yes, what can one do to prevent measles?", to which correct answers increased from 53.2% in 1989 to 73.2% in 1990. Furthermore, the number of respondents who correctly identified that the best time to get children vaccinated was between 38-52 weeks jumped from 45% to 66%. Increase in the mean vaccination knowledge score between 1989 and 1990 was 0.67 (on a 4-point scale).
• The proportion of fully vaccinated children of ages 12-23 months increased from 54% to 65%. The proportion of children whose vaccinations were started on time increased from 43.3% to 55.6% and the number that finished on time jumped from 32.2% to 56.2%. The average number of vaccinations that a child under 2 years received increased from 4.32 to 5.10. Coverage increased between 1989 and 1990 by 0.77. The amount of this increase that was attributed to the media was 0.54. 64% of mothers who knew of the campaign had their children immunised; 42% of mothers who did not have the knowledge of the campaign had their children immunised.

Participatory Intervention with Women's Groups

The programme began by providing 900 health care workers with four to eight hours of Oral Rehydration Therapy (ORT) training. A supportive media campaign was developed based on print materials and radio advertisements to issue basic messages related to ORT and the associated training programme.

1981 evaluation showed:

• 93% of the mothers surveyed in rural Honduras knew that the programme's radio campaign was promoting Litrosol, the brand name of the locally packaged oral rehydration salts (ORS) used to treat diarrhoea.
• Of the mothers sampled in the study, 42% knew that the use of Litrosol prevented dehydration.
• 49% of the mothers surveyed had used the ORS Litrosol. Of these women, 94% accurately described the correct mixing volume and 96% knew that the entire package of ORS was to be used in treatment.
• 16 months after the programme's start, 39% of all of the cases of diarrhoea within the prior two weeks among the sampled families had been treated using Litrosol.
• Between 1981 and 1982 mortality rates for children under five years of age had decreased from 47.5% to 25%.