Download - DMI Presentation Moz
DMI
© Development Media International | www.developmentmedia.net | [email protected]
Can mass media save lives?
António CabralCountry Representative, MozambiqueDevelopment Media International
DMI
© Development Media International | www.developmentmedia.net | [email protected]
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%
20%
25%
30%
35%
40%
45%
50%
Baseline (November 1999) Phase one (March 2000) Phase two (September 2000)
Evidence: before and after data
DMI
© Development Media International | www.developmentmedia.net | [email protected]
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
100
200
300
400
500
600
700
1-4
Jan
7-11
Jan
14-1
8 Ja
n
21-2
5 J
an
3764
8
3764
9
3765
0
3765
1
31.0
1
376
55
376
56
376
57
376
58
376
59
376
62
376
63
376
64
376
65
376
66
376
69
376
70
376
71
3767
2
3767
3
376
76
376
77
376
78
376
79
376
80
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
er
of
Cal
ls p
er
Day
Media
Campaign
Begins
Media
Campaign
Ends
DMI
© Development Media International | www.developmentmedia.net | [email protected]
Evidence: observed behaviours
Ethiopia impact data (2002-2005)*
0%
10%
20%
30%
40%
50%
60%
70%
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
© Development Media International | www.developmentmedia.net | [email protected]
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%
40%
50%
60%
70%
80%
90%
100%
Baseline (2004) Low exposure (2006) Medium exposure (2006) High exposure (2006)
Washing hands Ante-natal check-ups
DMI
© Development Media International | www.developmentmedia.net | [email protected]
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
© Development Media International | www.developmentmedia.net | [email protected]
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
© Development Media International | www.developmentmedia.net | [email protected]
How much will it cost?
$673 - $1,494 $82 - $409 $1 - $16 $2 - $15
$0
$200
$400
$600
$800
$1.000
$1.200
$1.400
$1.600
Anti-retrovirals Primary care Immunisation Saturation media
DMI
© Development Media International | www.developmentmedia.net | [email protected]
Testing the model through an RCT
DMI
© Development Media International | www.developmentmedia.net | [email protected]
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
© Development Media International | www.developmentmedia.net | [email protected]
Midline results | Changes in behaviours
8,6
1,5
10,5
8,7
12,6
9,6
-2,5
14,1
11,5
5,6
24,6
24,8
25,3
17,8
16
11,9
8,2
12,3
11,7
14,1
-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)
DMI
© Development Media International | www.developmentmedia.net | [email protected]
Midline results | Dose-response analysis
-5
0
5
10
15
20
25
0 2 4 6 8 10 12
Dif
fere
nce
in d
iffe
ren
ce
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.developmentmedia.net | [email protected]
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
DMI
© Development Media International | www.developmentmedia.net | [email protected]
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
© Development Media International | www.developmentmedia.net | [email protected]
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
© Development Media International | www.developmentmedia.net | [email protected]
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
© Development Media International | www.developmentmedia.net | [email protected]
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
© Development Media International | www.developmentmedia.net | [email protected]
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
© Development Media International | www.developmentmedia.net | [email protected]
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
© Development Media International | www.developmentmedia.net | [email protected]
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
© Development Media International | www.developmentmedia.net | [email protected]
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 →
Nampula
Zambézia
Niassa
C. Delgado
Maputo
Gaza
Inhambane
Manica
Sofala
Tete
Jorn
al d
a M
anhã
. Sim
ulta
neou
s with
Ante
na N
acio
nal f
rom
Mon
day
to F
riday
.
Jorn
al d
a Ta
rde.
Sim
ulta
neou
s with
Ant
ena
Nac
iona
l fro
m M
onda
y to
Frid
ay.
Jorn
al d
a N
oite
. Sim
ulta
neou
s with
Ant
ena
Nac
iona
l fro
m M
onda
y to
Frid
ay.
Últim
o Jo
rnal
. Si
mul
tane
ous w
ith A
nten
a N
acio
nal f
rom
Mon
day t
o Fr
iday
.
Gra
nde
Entr
evis
ta o
u G
rand
e Re
port
agem
. Sim
ulta
neou
s w
ith A
nten
a N
acio
nal f
rom
Mon
day
to T
hurs
day.
RM provincial programming
DMI
© Development Media International | www.developmentmedia.net | [email protected]
Thank you !
António CabralCountry Representative, MozambiqueDevelopment Media International