Making waves: can radio reduce child mortality?
Authors: Tim Colbourn, Audrey Prost
Journal: The Lancet Global Health (2018)

In The Lancet Global Health, Sophie Sarrassat and colleagues1Sarrassat S Meda N Badolo H et al.Evaluation of the effect of a mass radio campaign on family behaviours and child survival in Burkina Faso: a repeated cross-sectional, cluster-randomised trial.Lancet Glob Health. 2018; 6: 330-341Summary Full Text Full Text PDF PubMed Scopus (25) Google Scholar report on the first cluster randomised controlled trial of a radio intervention to reduce child mortality. The study is exceptional in its design and ambition: a systematic review of 111 mass media interventions to improve child survival found that only 32 used moderate to strong evaluation designs and only one measured an actual health outcome.2Naugle DA Hornik RC Systematic review of the effectiveness of mass media interventions for child survival in low- and midlle-income countries.J Health Commun. 2014; 19: 190-215Crossref PubMed Scopus (76) Google Scholar This elegant Burkinabé trial bucks all trends. Unfortunately, the study found no effect of the radio campaign on child mortality, or on any of 17 self-reported protective behaviours, except perhaps one. Using time series analyses of routinely collected health facility data, the authors reported a 7·7% increase in antenatal care attendance, a 7·3% increase in facility deliveries, and a 23·7% increase in all-cause consultations for children over 3 years of intervention. The researchers conclude that the radio campaign did not reduce child mortality but improved health service use. The fact that increases in service use from facility data are not echoed in self-reported data is puzzling, but the smaller self-report surveys might have been underpowered. Intervention areas had much lower levels of use at baseline, so it might have been easier for them to improve by a larger amount, and adjustments via confounder scores could have been insufficient to temper residual confounding in view of the substantial differences between groups at baseline. Is the lack of effect on child mortality surprising? Perhaps not. This study wrestled with three familiar problems. First, it assumed that giving information would be sufficient for caregivers to practice behaviours that protect children: "virtually all mothers are highly motivated to protect their child with the proper knowledge of how to do so".3Murray J Remes P Ilboudo R Belem M Salouka S Snell W et al.The Saturation+ Approach to Behavior Change: Case Study of a Child Survival Radio Campaign in Burkina Faso.Glob Health Sci Pract. 2015; 3: 544-556Crossref PubMed Scopus (19) Google Scholar This statement underestimates other social, financial, and geographic constraints on behaviour. People need capabilities and opportunities to change behaviour in addition to the knowledge and motivation that radio messages might provide.4Michie S van Stralen MM West R The behaviour change wheel: a new method for characterising and designing behaviour change interventions.Implementation science. 2011; 6: 42Crossref PubMed Scopus (4702) Google Scholar Other community-focused interventions, such as participatory women's groups and home visits, go beyond providing information: ideally, they build women's, families', and communities' capacities to problem-solve in order to overcome social and financial barriers.5Prost A Colbourn T Seward N et al.Women's groups practising participatory learning and action to improve maternal and newborn health in resource-limited settings: systematic review and meta-analysis.Lancet. 2013; 381: 1736-1746Summary Full Text Full Text PDF PubMed Scopus (374) Google Scholar, 6Bhutta ZA Das JK Bahl R et al.Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost?.Lancet. 2014; 384: 347-370Summary Full Text Full Text PDF PubMed Scopus (762) Google Scholar However, even this approach may not be sufficient to reduce mortality, especially when access to care is key. As Sarrassat and colleagues point out, other studies identified challenges with perceived and actual quality of care in facilities in the trial areas. Interventions that generate demand must be coupled with efforts to make quality services accessible to those in need in order to achieve mortality reductions.7Victora CG Requejo JH Barros AJ et al.Countdown to 2015: a decade of tracking progress for maternal, newborn, and child survival.Lancet. 2016; 387: 2049-2059Summary Full Text Full Text PDF PubMed Scopus (238) Google Scholar The Integrated Management of Neonatal and Childhood Illness approach8Costello A Dalglish S Colbourn T et al.Towards a grand convergence for child survival and health: a strategic review of options for the future building on lessons learnt from IMNCI.http://apps.who.int/iris/bitstream/10665/251855/1/WHO-MCA-16.04-eng.pdf?ua=1Google Scholar recognises this by highlighting the indivisibility of community, outpatient, and inpatient health facility efforts for child survival. Finally, given widespread decreases in under-5 mortality, a challenge for any trial testing a new intervention is to reduce mortality over and above ongoing efforts. The trial was designed to detect a 20% reduction in post-neonatal child mortality over 3 years, but it is possible that reductions caused by ongoing national policy changes outpaced the intervention. Is there a role for mass media in promoting child survival in low and middle-income countries? Undoubtedly. Campaigns focusing on fewer behaviours linked to child survival (eg, vaccination uptake) have recorded positive effects.2Naugle DA Hornik RC Systematic review of the effectiveness of mass media interventions for child survival in low- and midlle-income countries.J Health Commun. 2014; 19: 190-215Crossref PubMed Scopus (76) Google Scholar Future initiatives need to carefully consider equity and evaluation designs. Sarrassat and colleagues found that the intervention increased care-seeking for childhood illness among those who lived less than 2·5 km away from a facility, but not those who lived further away. Do mass media campaigns reduce or worsen inequalities in knowledge, practices, access to services, and ultimately survival? Trials incorporating a realist approach might help us understand who benefits and why.9Bonell C Fletcher A Morton M et al.Realist randomised controlled trials: a new approach to evaluating complex public health interventions.Soc Sci Med. 2012; 75: 2299-2306Crossref PubMed Scopus (330) Google Scholar Few mass media campaigns are done only via local radios—many use national media and a combination of television, radio, digital, and print media. Most are also done in combination with community engagement and activities to strengthen health services. This is what makes isolating the contribution of mass media challenging. It also provides an opportunity for evaluative innovation. The Alive and Thrive initiative studied large-scale programmes to improve infant and young child feeding in Bangladesh, Ethiopia, and Vietnam. In all countries, mass media was used in varying degrees of intensity, with or without community mobilisation and interpersonal counselling. Variations in intensity and coupling allowed evaluators to explore which aspects led to the best outcomes. The results suggest that mass media campaigns alone are usually insufficient for substantial change, and that effects on practices are more likely when campaigns are strengthened by community mobilisation and interpersonal counselling.10Nguyen PH Kim SS Nguyen TT et al.Exposure to mass media and interpersonal counseling has additive effects on exclusive breastfeeding and its psychosocial determinants among Vietnamese mothers.Matern Child Nutr. 2016; 12: 713-725Crossref PubMed Scopus (44) Google Scholar Trials testing varying levels of media exposure, times series, and propensity-score-matching studies could provide less clean but fairer approaches to assessing the contribution of mass media to child survival in the real world. Could a standalone radio campaign reduce child mortality in low-income and middle-income countries? Probably not. The Burkina Faso radio trial may have provided an elegant answer to the wrong question. We declare no competing interests. Effect of a mass radio campaign on family behaviours and child survival in Burkina Faso: a repeated cross-sectional, cluster-randomised trialA comprehensive radio campaign had no detectable effect on child mortality. Substantial decreases in child mortality were observed in both groups over the intervention period, reducing our ability to detect an effect. This, nevertheless, represents the first randomised controlled trial to show that mass media alone can change health-seeking behaviours. Full-Text PDF Open Access