DMI Presentation Moz

DMI

© Development Media International | www.developmentmedia.net | [email protected]

Can mass media save lives?

António CabralCountry Representative, MozambiqueDevelopment Media International

DMI


India impact data (1999-2001)

Number of people treated for leprosy in India following a campaign: 200,000

Percentage of respondents who would be unwilling to sit beside a leprosy patient:

47%

33%

27%

0%

5%

10%

15%

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25%

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35%

40%

45%

50%

Baseline (November 1999) Phase one (March 2000) Phase two (September 2000)

Evidence: before and after data

DMI


Evidence: time-series analysis

Calls to Telehansen during Brazil Leprosy Media Campaign, 29 January - 27 February 2003

(10,501 calls recorded during campaign, average 477 calls/day)

0

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7-11

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prior to campaign -weekly average - 22-27

Jan preparing for launch

week 1 - launch 29 Jan week 2 week 3 week 4 week 5 - broadcasts end 27Feb, Rio civil unrest-

Telehansen closed early,Carnival 28 Feb-5 March

Week of Campaign

Nu

mb

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of

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ls p

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Media

Campaign

Begins

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Evidence: observed behaviours

Ethiopia impact data (2002-2005)*

0%

10%

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80%

Children observed with dirty hands Trachoma prevalence in areas receiving no antibiotics

Baseline

Endline

* Edwards et al, Ophthalmology. 2006 Apr;113(4):548-55, and Tropical Medicine and International Health, Vol.13, no.4 pp556-565. Sample size 2008. P-values calculated, ranging from p<0.001 to p=0.17

DMI


Evidence: dose-response analysis

Cambodia impact data (2004-2006)

10,0%

21,7%25,2%

28,4%

49,2%

63,9%67,1%

74,5%

0%

10%

20%

30%

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Baseline (2004) Low exposure (2006) Medium exposure (2006) High exposure (2006)

Washing hands Ante-natal check-ups

DMI


Can we reduce child mortality?

Modelling impact of mass media on child mortality

• Never previously measured or modelled

• Collaboration with LSHTM (Prof Simon Cousens, Prof Anne Mills, Dr Jo Borghi)

• Multi-disease approach

• Mathematical model based on:

• Lancet data on impact of interventions on child mortality (Child Survival Series 2003 and 2005)Now replaced by the Lives Saved Tool (LiST)

• DMI evidence of previous behaviour change campaigns

DMI


The model’s predictions

CountryUnder-five deaths per year

Predicted under-five lives saved

As % of all deaths

Media penetration

Cost per DALY

Cameroon 74,000 8,917 12.1% 69% $7.15

Chad 82,000 10,809 13.2% 45% $6.66

Côte d'Ivoire 75,000 9,562 12.7% 74% $7.55

DR Congo 391,000 14,384 3.7% 44% $6.41

Ethiopia 205,000 10,052 4.9% 33% $7.48

Ghana 56,000 7,166 12.8% 92% $11.87

Guinea 41,000 6,010 14.7% 64% $10.42

Kenya 108,000 20,316 18.8% 86% $6.36

Malawi 43,000 5,501 12.8% 70% $14.45

Mali 83,000 16,379 19.7% 81% $4.40

Mozambique 84,000 14,592 17.4% 88% $7.12

Niger 91,000 12,392 13.6% 64% $5.17

Sierra Leone 39,000 4,801 12.3% 57% $14.31

Tanzania 98,000 18,040 18.4% 70% $4.59

Uganda 103,000 14,967 14.5% 83% $6.23

Zambia 50,000 11,182 22.4% 72% $8.24

DMI


How much will it cost?

$673 - $1,494 $82 - $409 $1 - $16 $2 - $15

$0

$200

$400

$600

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$1.000

$1.200

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Anti-retrovirals Primary care Immunisation Saturation media

DMI


Testing the model through an RCT

DMI


Our study measures mortality in seven intervention zones and seven control zones (50,000 sampled at baseline, 100,000 at endline). We are also conducting surveys of behaviour: 5,000 mothers sampled at baseline, midline and endline.

These results are the preliminary midline behavioural results.

Fieldwork took place after 20 months of broadcasting (59% of a 34-month campaign) and was supervised and analysed by Simon Cousens and Sophie Sarrassat at LSHTM.

Midline results

DMI


Midline results | Changes in behaviours

8,6

1,5

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8,7

12,6

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-2,5

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11,5

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-5 0 5 10 15 20 25 30

Sought treatment for diarrhoea at a clinic

Received ORT or increased liquids for diarrhoea

Received antibiotics for pneumonia

Sought treatment for fever at a clinic

Women sleeping under bed net during pregnancy

Household ownership of latrines

Early initiation of breastfeeding (2 hours of birth)

Exclusive breastfeeding aged 0 to 5 months

Gave birth in health facility/with skilled attendant

Saved money for an emergency during pregnancy

Control Intervention (adjusted)

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Midline results | Dose-response analysis

-5

0

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Dif

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Number of weeks of spots broadcast at midline

Correlation co-efficient = 0.57

1 | SATURATION

Broadcast spots 8-12 times per

day (radio), or 3 times (TV), and

daily longer formats

Broadcast 365 days of the year

for at least one year (preferably

for three years or more)

Broadcast in languages which at

least 75% of the target

population can understand well

Broadcast on stations viewed or

heard at least weekly by at least

75% of the target population

2 | SCIENCE

Use mathematical modelling to

estimate the number of lives

saved by each message / issue

Create multi-issue campaigns to

tackle all major RMNCH issues

Allocate airtime to each issue

based on the number of lives

saved (and e.g. seasonality)

Measure and attribute impacts

using time series or other quasi-

experimental evaluations

3 | STORIES

Integrate formative research

findings into the creative

process

Test all materials before and

after broadcast for audience

reaction, clarity and impact

Recruit and train scriptwriters

who are familiar with the

culture of all audience groups

Ensure emotional climax of

dramas reflects key barriers to

behaviour change

Spots are often broadcast once

or twice per day, and other

formats are often weekly

Many campaigns are broadcast

for limited periods, sometimes

as little as one week

Many campaigns use the lingua

franca, which many understand

only imperfectly

Many campaigns reach large

urban audiences but much

smaller rural audiences

No current media campaigns are

able to estimate the number of

lives saved

Many campaigns focus on

vertical issues and so lose

economies of scale

No current media campaigns are

able to prioritise messages

based on lives saved

Many campaigns measure

impact using pre-post designs,

with little attribution

Most campaigns have formative

research but it is not always

used effectively

Most campaigns pre-test

materials but few collect post-

broadcast feedback

Most campaigns produce

content locally, but many

scriptwriters are urban-focused

Most campaigns use drama

rather than simply giving

information but not all do it well

CURRENT

PRACTICE

BEST

PRACTICE

CURRENT

PRACTICE

BEST

PRACTICE

CURRENT

PRACTICE

BEST

PRACTICE

DMIAchieving impact (lessons learned from other countries ): Saturation+

DMI


DEVELOPMENT MEDIA INTERNATIONAL

www.intensaude.org

Project proposal for a nationwide Saturation+ radio and TV campaign to promote reproductive, maternal, newborn and child health in Mozambique

MAPUTO | António Cabral | Country Representative+258 82 974 3254 | [email protected]

LONDON | Will Snell | Director of Strategy & Development+44 20 3058 1631 | [email protected]

Mozambique RMNCH mass media campaign

http://www.intensaude.org/

DMI


BackgroundWhy this project?

DMI’s randomised controlled trial in Burkina Faso has proved that a mass media campaign alone can reduce under-five mortality by changing behaviours

Our Media Million Lives initiative aims to raise sufficient funds (c. $185m) to scale up nationwide maternal and child health campaigns to 10 African countries by 2024, saving one million lives

We have already received some funding from donors (bilateral and multilateral agencies, NGOs and foundations) to conduct limited scaling up of child health media campaigns in Burkina and DRC

We are now seeking funding for long-term, nationwide campaigns to meet our objective of saving a million lives, starting in Mozambique

We plan to run a nationwide campaign in Mozambique, based on at least three years of ‘saturation’ broadcasting, and incorporating a rigorous time-series evaluation design to continue to generate robust evidence of impact at scale

Why Mozambique?

Strong government support

Our plans for a reproductive, maternal, newborn and child health campaign are directly aligned with the Ministry of Health’s strategy

Poor health indicators

High maternal, newborn and child mortality and low coverage of target health behaviours

Conducive media landscape

High levels of radio and TV consumption; national radio broadcasts in 19 local languages and has good audience share; two television networks dominate

Leverages seed funding and established presence

$200k from Mulago Foundation has enabled us to hire a Country Representative since March 2015

Good funding base for continued support

Raised 56% of costs of first two years ($2.5m) from a US foundation, and need to raise remaining 44% ($2m) by end of 2015

DMI


Reproductive, maternal, newborn and child health is a key thematic priority of the Ministry of Health in Mozambique. Health promotion (i.e. behaviour change and demand creation) is one of the priority interventions for improving RMNCH outcomes, based on the MoH strategic plan (see slide 10).

There is good health promotion work underway in Mozambique, but there is also plenty of room to do more. In particular, there is an agreed need to develop and implement media campaigns that:

• Cover all priority RMNCH health behaviours• Change behaviours, not just increase knowledge• Reach the majority of the population of Mozambique

(including in remote rural areas)• Use all the major local languages, and not just Portuguese

and Makhuwa• Reach people at high frequency (several times per day, every

day) for a sustained period• Co-ordinate with and reinforce other RMNCH health

initiatives in Mozambique, on both the supply-side and demand-side (including APEs)

• Are evidence-based, well evaluated, and provide demonstrable value for money

The chart below shows our view of the extent to which current mass media campaigns meet some of these objectives (in blue), compared to our planned Saturation+ media campaign (in red).

Reaching thewhole

population(including inrural areas)

Broadcasting inall major local

languages

Broadcasting athigh frequencyfor a sustained

period

Covering a fullrange of

RMNCH healthbehaviours

Co-ordinatingwith

community-level BCCinitiatives

Co-ordinatingwith supply-side RMNCHinterventions

Current INTENSAÚDE

Rationale

DMI


Project overviewTarget behaviours

• Prevention and treatment of malaria• Prevention and treatment of diarrhoea• Prevention and treatment of pneumonia• Hygiene and sanitation• Breastfeeding and nutrition• Antenatal care, giving birth in a health centre• Family planning (contraceptives, birth spacing)• Increasing the age of first pregnancy• Preventing mother-to-child transmission of HIV• Encouraging parents to talk to young babies

Media formats and languages

• One-minute radio spots (10 times per day)• 30-second TV spots (3 times per day)• Weekly radio phone-in programmes

Radio spots in Portuguese and 19 local languages

TV spots and radio phone-in programmes in Portuguese and five local languages

Media channels and audience reach

Radio Moçambique: 12.5m peopleCommunity radio stations (3): 3.5m peopleTV Moçambique: 4.0m peopleSoico TV: 3.3m people

Net estimated audience: 19.6m people

Percentage of population reached: 75%

Expected outcomes

• Increases in compliance across the full range of RMNCH behaviours (for example, increasing malaria treatment-seeking from 30% to 53%)

• 36,098 lives saved over three years (reducing under-five mortality in Mozambique by 18% and maternal mortality by 5%)

• Cost per disability-adjusted life year (DALY) of $8.90 (as cheap as childhood immunisation)

DMI


Year 2016 2017

Month J F M A M J J A S O N D J F M A M J J A S O N D

Planning and setup

Staff training

Formative research

Radio production

Radio broadcasting

TV production

TV broadcasting

Broadcast monitoring

Evaluation

Year 2018 2019

Month J F M A M J J A S O N D J F M A M J J A S O N D

Radio production

Radio broadcasting

TV broadcasting

Broadcast monitoring

Evaluation

Project timeline

DMI


Predicted impact and cost effectivenessLIVES SAVED AND COST-EFFECTIVENESS ESTIMATES

People reached 20m

Under-five lives saved 35,604

Of which neonatal 8,499

Of which post-neonatal 27,105

Maternal lives saved 494

Cost per DALY $8.90

BREAKDOWN OF LIVES SAVED BY DISEASE TYPE

Pneumonia

Malaria

Diarrhoea

Neonatal

HIV/AIDS

Meningitis

Other

ANALYSIS BY TARGET BEHAVIOUR: PROJECTED INCREASES IN INTERVENTION COVERAGE AND LIVES SAVED BY THIS CAMPAIGN*

TARGET BEHAVIOUR CURRENT COVERAGE EXPECTED COVERAGE LIVES SAVED

Provide oral rehydration salts for diarrhoea 55% 70% 4,283

Seek treatment if child has danger signs of pneumonia 12% 19% 1,256

Recognise malaria symptoms and seek treatment 30% 53% 10,188

Give birth in a health facility / with assistance of a skilled attendant 55% 60% 2,698

Breastfeed exclusively for six months after birth 43% 60% 4,548

Use insecticide-treated bednets for malaria 51% 57% 1,764

Get your child vaccinated to prevent pneumonia 0% 31% 3,311

Wash hands with soap 17% 47% 2,881

Hygienic disposal of children’s stools 78% 82% 195

Use latrines/toilets 20% 31% 995

DMI


Maternal and child health indicators are

poor across much of the country (see

heat map below for under-five mortality).

We can achieve large economies of scale

by broadcasting a wide range of maternal

and child health messages to the whole

country, rather than to particular regions.

We therefore plan to run a nationwide

campaign.

NATIONWIDE CAMPAIGN COMPREHENSIVE RADIO COVERAGE

Radio Moçambique covers most of the

country (and has an estimated regular

audience of 12.5m people) with a network of

10 medium wave transmitters (blue circles

below). We will cover gaps in Radio

Moçambique’s signal by working with a small

number of community radio stations (red

circles below), ensuring that no well-

populated areas are unreached by the

campaign.

TARGETED TELEVISION COVERAGE

Television has a similar audience to radio

among men and women in the south of

Mozambique. Here, the TV network with the

largest audience is STV, the leading

commercial network.

We are also working with Televisao de

Mocambique, which has the largest network

of TV transmitters and relay transmitters (see

map) and has a presence in 10 provinces,

broadcasting in several local languages.

FULL RANGE OF LANGUAGES

Campaign design

The top six local languages in Mozambique

(Makhuwa, Tsonga, Ndau, Lomwe, Sena and

Tswa) account for 62 % of the population.

However, they are not spoken in areas with

the worst health indicators (much of Niassa,

Zambezia, Tete and Manica provinces). For

full national coverage we need to broadcast in

19 local languages (see map).

DMI


MEASURING IMPACT ATTRIBUTING IMPACT QUALITATIVE RESEARCH

We will conduct regular surveys to measure

knowledge, attitudes and behaviours before,

during and after the campaign.

We will measure a set of key behavioural

outcomes linked to our target health

messages.

We will also capture data on potential

confounders known to be associated with

healthy behaviours, such as socio-economic

status, level of education and access to

health services, so that these can be

controlled for in analyses.

We will enter the behaviour change

outcomes into the Lives Saved Tool to

estimate the impact of the campaign on

reducing under-five mortality.

We will survey knowledge, attitudes and

behaviours at regular points before, during

and after the campaign to conduct a time-

series analysis. This quasi-experimental

evaluation design allows us to attribute

impact to our intervention.

If possible, we will sample in two areas

where our campaign is being broadcast, and

in two comparable control areas where it is

not being broadcast. We do not believe that

it will be feasible to use a randomised

evaluation design at the same time as

running a nationwide campaign on the

national broadcast network of Mozambique.

We will use dose-response analyses to

examine the correlation between campaign

exposure and impact.

We will employ an in-house qualitative

research team, with three core functions:

• Formative research (building on

existing knowledge and behaviour

surveys, government policies and

UNICEF/WHO guidance to produce a

message brief for each target

behaviour)

• Pre-testing of spots (using focus

groups from our target audience to

investigate understanding, clarity and

appeal)

• Feedback research (to help us to

understand audience reactions to our

broadcasts and to refine our

messages)

Monitoring & evaluation

DMI


Province Language↓ 05.00 06.00 07.00 08.00 09.00 10.00 11.00 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 20.00 21.00 22.00 23.00XichanganaXirhongaPortuguêsXichanganaCicopiPortuguêsGuitongaCitswa + CindauCicopiPortuguêsCibalkeCimanyikaCiuteeCindauPortuguêsCisenaCindauPortuguêsCinyanjaCinyungueCisenaPortuguêsEmakhuwaPortuguêsEchuwaboElomweCisenaPortuguêsCiyaoCinyanjaEmakhuwaPortuguêsEmakhuwaShimakondeKimwanySwahiliPortuguês

Time →

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C. Delgado

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RM provincial programming

DMI


Thank you !

António CabralCountry Representative, MozambiqueDevelopment Media International

Documents

DMI Presentation Moz