Communicating Safe Motherhood: Strategic Messaging in a Globalized World Santosh Vijaykumar

ABSTRACT. The practice of education as a tool of persuasive communication has been used in family planning and reproductive health for at least 50 years. However, the past three decades have seen a phenomenal evolution of communication as a social science; as a result there has been an increasingly systematic research-based application of mass media—particularly television, radio, newspapers, and internet— for enhancing the impact of health messaging. In this article I examine the theoretical underpinnings of behavior change communication in the context of the aforementioned mediating factors that influence the design and content of family planning and reproductive health programs. I look at three main types of behavior change communication strategies, entertainment education, social marketing, and advocacy, and describe how these three strategies have been applied to effect social change using a case study to describe and assist in reviewing the impact they have had on targeted behaviors. The descriptions of different programs and their impact have been taken from detailed reports procured from either organizational personnel who conducted those programs or from organizational websites. This chapter culminates with a discussion of key technical, administrative, and political Santosh Vijaykumar is a doctoral student at the Saint Louis University School of Public Health, St. Louis, MO. Address correspondence to Santosh Vijaykumar, Health Communication Research Laboratory, Saint Louis University School of Public Health, 3545 Lafayette Ave, St. Louis, MO 63104. E-mail: [email protected] Marriage & Family Review, Vol. 44(2/3) 2008 Available online at http://www.haworthpress.com # 2008 by The Haworth Press. All rights reserved. doi: 10.1080/01494920802177378

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challenges that affect the creation and implementation of such international collaborative programs, with insights from field experts. KEYWORDS. Family reproductive health

planning,

health

communication,

India,

INTRODUCTION In all countries and among all groups, information, education, and communication activities concerning population and development issues must be strengthened. This includes the establishment of gender and culturally sensitive information, education, and communication plans and strategies related to population and development. At the national level, more adequate and appropriate information enables planners and policy makers to make more appropriate plans in relation to population and sustainable development. At the most basic level, more adequate and appropriate information is conducive to informed, responsible decision-making concerning health, sexual and reproductive behavior, family life, and patterns of production and consumption (Chapter XI, Population, Information, and Communication Section B11.23–ICPD on IEC; United Nations Population Information Network, 1994). The practice of education as a tool of persuasive communication has been used in family planning and reproductive health for at least 50 years. India, the first country to create a family program in 1952 and integrate a mass education media (MEM) division in the Department of Family Welfare (Ministry of Health and Family Welfare [MOHFW], Government of India, n.d.), employed family planning workers to make house-to-house visits to motivate couples to accept family planning methods during the second phase of their program (International Institute of Population Sciences, 2006). However, the past three decades have seen a phenomenal evolution of communication as a social science, resulting in an increasingly systematic research-based application of mass media—particularly television, radio, newspapers, and internet—for enhancing the impact of health messaging. This phenomenon was also paralleled by a realization that although information, education, and communication (IEC)

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initiatives were creating knowledge and awareness among the targeted audiences, they had to be supported by mediating mechanisms that would translate the knowledge into action to effect the necessary change in behavior (Johns Hopkins Bloomberg School of Public Health, 2003). IEC has now evolved into behavior change communication (BCC) and attempts to bridge this gap by shaping the enabling environments surrounding the targeted behavior. The difference between IEC and BCC is enumerated in a document by the Reproductive Health Response Consortium (RHRC [2004]). While IEC aims to develop communication strategies that encourage positive behaviors among people appropriate to their settings, BCC (in addition to IEC) also aims to provide a supportive environment that might enable people to initiate and sustain these positive behaviors. The ‘‘supportive environment’’ is especially critical in the context of family planning and reproductive health issues that evolve out of many sociocultural and psychosocial dynamics that operate at different levels. For example, contraceptive use can depend on a combination of attitudinal and cultural factors such as gender-engineered power dynamics (Blanc, 2001) and structural factors like community-level family planning conditions, labor market conditions, and infrastructure development (Degraff et al., 1997). Reproductive health services utilization depends on individual, household, service, and community-level factors, though the intensity differs between different types of services used (Stephenson & Tsui, 2002). Demographic and social determinants of reproductive health service use are mediated by cultural influences that characterize the nature of an individual’s perceptions about his or her own behavior (Basu, 1990; Bhatia & Cleland, 1995; Goodburn & Chowdhury, 1995). Severe discrimination against the female child is one of the banes of existence in Uttar Pradesh, India, where this predominant attitude is reflected in the state’s poor performance on most reproductive health and socioeconomic indicators (Social Action Forum for Manav Adhikar, [SAFMA], n.d.). In many South Asian cultures the concept of routine prenatal care is an alien concept because such services are perceived to exist solely for curative purposes. Similarly, fear of and misconceptions about medical institutions have retained women’s reliance on traditional home delivery in India (Stephenson & Tsui, 2002).

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These factors are especially important because they affect program design in light of the International Conference on Population and Development (ICPD) 1994 conference that ‘‘redefined family planning as one element of comprehensive reproductive health care services, viewed health within a broader social context, and acknowledged the importance of equity and empowerment for women’’ (PATH, 2004). The ICPD paradigm is adopted by major international development agencies like the U.S. Agency for International Development (USAID) and the U.K. Department for International Development (DFID), who have now integrated IEC=BCC as a core element of their family planning=reproductive health program strategies (USAID, 2006; DFID, 2005). International politics and a global exchange of social scientific expertise are thus inextricably woven into modern-day BCC program planning, thereby creating its own set of opportunities and challenges. Although BCC program planning on a global scale involves the promising prospect of increased knowledge sharing and technical expertise among academic and professional organizations between countries, the challenges that stem from geopolitical considerations and cultural idiosyncrasies are daunting and cannot be overlooked. It is ironic that often the staunchest test for communication programs is the communication gap itself—between donor agencies and implementing agencies; between technical and programmatic personnel working on the same project from different countries, brought up on different cultures of communication; or political and administrative issues between donor countries and host countries. In this chapter I examine the theoretical underpinnings of BCC in the context of the aforementioned mediating factors that influence the design and content of family planning and reproductive health programs. I then look at three main types of BCC strategies: entertainment education, social marketing, and advocacy (Clift, 1998; U.S. Department of Health and Human Services, National Institutes of Health, & National Cancer Institute, 2004). After briefly explaining the reproductive health indicators and issues in Bihar and Uttar Pradesh in India, I describe how these three strategies have been applied in these states to effect social change, using a case study for each strategy, and review the impact that they have had on targeted behaviors. The descriptions of different programs and their impact have been taken from detailed reports procured from either organizational personnel who conducted those programs or from

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organizational websites. Finally, this chapter culminates with a discussion of key technical, administrative, and political challenges that affect the creation and implementation of such international collaborative programs, with insights from field experts.

BEHAVIOR CHANGE COMMUNICATION THEORY BCC Theories and Models Traditionally, health communication campaigns have centered on cognitively based theories that guide health communication practitioners in establishing the link between messages and behavior. The major theories=models that inform BCC programs are as follows: 1. The Health Belief Model (HBM) (Rosenstock, 1974; Rosenstock, Strecher, & Becker, 1994). In trying to predict human behavior, the HBM argues that people are ready to act if they believe that (1) they are susceptible to the condition (perceived susceptibility), (2) the condition has serious consequences (perceived severity), (3) taking action will reduce their susceptibility (perceived benefits), (4) the costs of taking action are outweighed by the benefits (perceived barriers), (5) they are exposed to factors that prompt action (cues to action), and (6) they are confident of their ability to perform the behavior (self-efficacy) (National Cancer Institute, 2005). At the risk of oversimplification, BCC program planners can, for example, evaluate how members in a population perceive the risk and severity of contracting a sexually transmitted disease (STD) and accordingly disseminate information via mass media, making them aware of the benefits of using contraceptives and guide them on overcoming barriers to contraceptive use. 2. Theory of Reasoned Action (TRA) (Fishbein and Ajzen, 1975; Fishbein, Middlestadt, & Hitchcock, 1991). This theory explains volitional human behavior by proposing that an individual’s intention to perform the said behavior is the most critical determinant of human behavior. BCC campaigns that use this theory try to understand the factors (or determinants) that influence the ‘‘intention’’ and design messages that shape those determinants. 3. The Extended Parallel Process Model (EPPM) (Witte, 1992; Witte & Allen, 2000; Witte, Cameron, Lapinski, & Nzyuko, 1998). This

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theory suggests that evaluating the perceived threat and perceived efficacy surrounding the communication intervention determines the behavioral pathway taken by the audience upon exposure to the message. Thus the EPPM suggests that BCC campaign messages should incorporate (1) a ‘‘threat’’ component that makes the audiences perceive susceptibility to the severe threat and (2) an ‘‘efficacy’’ component that convinces the individual of his or her ability to perform the recommended response that will avert the threat. 4. Social Cognitive Theory (SCT) (Bandura, 1994, 1997; Baranowski, Perry, & Parcel, 2002). The SCT explains human behavior as a dynamic, reciprocal triad where behavior, personal factors, and environmental influences all interact. The personal factors primarily comprise an individual’s ability to symbolize behavior, anticipate its outcomes, learn from observing others, have the confidence to perform the behavior, and then reflect and analyze on what has been performed. In the BCC context, health educators have creatively used this model to develop interventions, techniques, and procedures that influence these intuitive processes, leading to an increased likelihood of performing the targeted behavior. 5. Transtheoretical=Stages of Change Model of Behavior Change (Prochaska & DiClemente, 1992; Prochaska, Redding, Harlow, Rossi, & Velicer, 1994). This model is primarily a decision-based model and is centered on different stages of an individual performing the behavior: from precontemplation to maintenance. The model includes cognitive processes that effect the transition from one stage to another and has been used to inform communication campaigns in a range of health behavior change domains including smoking, alcoholism, and HIV=AIDS. Recent scholarship has noted criticisms of existing theories and models based on four aspects: individualistic bias (where the focus of campaigns is on individual behavior), structural context (where the structural environment, for example in resource deprived countries, is ignored by only focusing on perceptions and beliefs), measurement and message context (where the measurement techniques used by these models are unable to capture the actual context of behavior performance), and cognitive bias (by proposing that behavior follows as a result of cognitive and rational processes, these theories=models ignore habitual behavioral choices or behavioral decisions that are made in the spur of the moment) (Dutta-Bergman, 2005).

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In the context of this criticism, it is important to mention the model that brings together theoretical perspectives from all the above approaches. This model is known as the Integrative Model of Behavior Change (Fishbein, 2000; Fishbein & Cappella, 2006). According to this model ‘‘any given behavior is most likely to occur if one has a strong intention to perform the behavior, has the necessary skills and abilities required to perform the behavior, and there are no environmental or other constraints preventing behavioral performance’’ (Fishbein & Cappella, 2006, p. S2).

Does BCC Really Work? The evidence of the impact of theory-based health communication interventions on behavior change among various constituents related to reproductive health issues is well documented. The Radio Communication Project in Nepal, a theory-based multimedia reproductive health campaign, improved the quality of client–provider interactions, increased self-efficacy in dealing with health workers, and improved the adoption of family planning methods and services (Storey, Boulay, Karki, Heckert, & Karmacha, 1999). In Tanzania, complementary messages stemming from multiple media sources of information helped to create an environment where practice of contraceptive methods is considered a social norm (Rogers et al., 1999). Awareness of contraceptives and discussions about reproductive health issues with parents, teachers, and siblings increased after a mass media intervention in Zimbabwe (Kim, Kols, Nyakauru, Marangwanda, & Chibatamoto, 2001). A reproductive health communication campaign in Bolivia indicated that mass media may substitute for personal networks and speed the process of social change by accelerating the behavior change process (Valente, 1998). BCC interventions have historically had an equally strong impact among Indian populations. A comparison of 12 different communication media through which people are exposed to family planning messages suggested that mass media helped in alleviating fear and misconceptions surrounding family planning issues (Saksena & Rastogi, 1988). Data analyzed from the National Family Health Survey (NFHS-II) revealed that exposure to family planning messages on radio, television, and newspapers was found to have a significant, positive impact on current and intended use of contraception (Retherford & Mishra, 1997). A later study supported this finding

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by suggesting that women who were exposed to mass media messages were not only more likely to know more about a modern contraceptive method than women who were not, but also that they were more likely to discuss family planning issues with their husbands than women who were not exposed to television or print media (Olenick, 2000). In translating behavioral knowledge and attitudes to practice, a most recent data analysis of data from NFHS-I (1992–1993) and NFHS-II (1998–1999) revealed that women who were exposed to mass media were more likely to use contraception compared with women who were not exposed (Dwivedi & Ram, 2006).

BEHAVIOR CHANGE COMMUNICATION STRATEGIES: ENTERTAINMENT EDUCATION, SOCIAL MARKETING, AND ADVOCACY In health communication practice, there are different strategies that can shape the psychosocial and contextual environments of a particular health issues at different levels, increasing the likelihood of behavior change. The common thread that binds these strategies is the programmatic process of developing a BCC campaign that involves the following steps: analyzing the situation, designing the strategy, pretesting communication strategy and materials, continuous monitoring and implementation, and final impact evaluation. I now detail three main kinds of BCC strategies, entertainment education, social marketing, and advocacy, by describing their application in the two Indian states of Bihar and Uttar Pradesh. I do so by first explaining the strategies, reviewing the context in which the program took place, describing the content of the program, and assessing the impact it had on the intended behavior.

Entertainment Education Entertainment education (E-E), also known as enter-educate or edutainment, leverages the educational potential of entertainment media by weaving social messages into entertainment programs. The E-E strategy involves incorporating an educational message into popular entertainment content to raise awareness, increase knowledge, create favorable attitudes, and ultimately motivate people to take socially responsible action in their own lives (Singhal & Rogers, 1999).

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The various forms of E-E, such as soap operas, radio serial dramas, cartoons, interactive talk shows, and folk media, are characterized by the premise of creating a central character who demonstrates the positive or negative consequences of his or her actions. The gradual process of awareness creation leading to behavior change takes place in an unobtrusive manner as the audience identifies with the character and at times even wants to emulate the characters’ behavior, in the process making decisions without being preached (United Nations Population Fund [UNFPA], 2002). The E-E strategy was accidentally discovered in Peru in 1969 when the sales of Singer sewing machines soared after Maria, a character in the telenovela (television novel), Simplemente Maria (Quiroz & Cano, 1988), overcame a tragic life to climb the socioeconomic ladder by dint of her hard work, motivation, and skills with Singer machines. Since then, this strategy has been adapted for promoting family planning practices and creating awareness about reproductive health issues in a number of other settings, most notably Twende na Wakati (Let’s go with the times) in Tanzania; Tushauriane (Let’s discuss) and Ushikwapo Shikimana (When given advice, take it) in Kenya; and Hum Log (We people), Hum Raahi (co-travelers), Tinka Tinka Sukh (Happiness lies in small things), and, most recently, Taru (the name given to a fictional female character) (2002–2003) in India (Singhal & Rogers, 1999). The rapid diffusion of this innovative health communication strategy has been facilitated by creative and technical experts from a number of academic and professional realms, including public health and communication research, scriptwriting, and the performing arts. Organizations like Population Communications International (PCI) and JHUCCP have continuously created impacting E-E programs while spearheading the increasing use of this strategy in countries around the world. The following is a review of the Taru initiative implemented in Bihar, India in 1996–1997, in the context of the target audience, social context, the story line, and an analysis of its impact.

Case Study: The Taru Initiative Program Context Bihar, an eastern state that was once regarded as the center of education in ancient India, is home to nearly 83 million people. The state suffers from the lowest literacy rate (47.0%) and the highest number

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of people living below the poverty line (40%) in India (Census of India, 2001a; World Bank, 2005). Bihar’s total fertility rate (TFR) of four children per woman of reproductive age is the highest in the country and at least 49% higher than the national TFR of 2.68 children per woman. Bihar’s reproductive health indicators reflect a disturbing trend as compared with national figures, especially the percentages of currently married women using any contraceptives (34.1% vs. 56.3%) and unmet need for family planning (23.1% vs. 13.2%) (NFHS, 2006). The low literacy levels, poverty, and an unstable political structure are mired in a sociological environment where caste and gender discrimination and orthodox cultural beliefs are rampant. Additionally, Bihar’s health care structure is crippled with a serious shortfall of health subcenters and primary health clinics, even as existing clinics and equipment are poorly maintained. The Bihari woman’s strong preference for using private providers for prenatal care (more than half) compared with government providers (one-fifth) compounds with other aforementioned problems to pose serious challenges for developmental health programs in this state (World Bank, 2005).

Program Strategy Against this backdrop, the Population Communication International (PCI), an international nonprofit organization, collaborated with Janani, a local nongovernmental agency (NGO) providing reproductive health care in the states of Bihar and Madhya Pradesh, All India Radio (AIR), and researchers from Ohio University, United States to research and create a radio serial drama called Taru. Based on the life of a fictional woman named Taru, the project was ultimately intended to motivate listeners to take charge of their own health, seek health services, and better their living (Communication Initiative Network, 2002). This E-E broadcast feature was combined with on-the-ground reproductive health service delivery provided by Janani (Duff, Singhal, & Witte, 2005). The radio program incorporated messages related to family planning, reproductive health, and HIV=AIDS; value of the female child; literacy; and other social issues. The 52-episode soap opera was broadcast once a week over the period of 1 year and was addressed to rural men and women living in Bihar and also to three other states, Jharkand, Madhya Pradesh, and Chattisgarh, which together constitute a population

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of 190 million. The launch of the Taru serial drama was preceded by folk media performances in the Abirpur, Kamtaul, Madhopur, and Chandrahatti villages that dramatized the Taru story line and primed audiences to listen to the serial drama when it aired (Singhal, Sharma, Papa, & Witte, 2004). An excerpt from a research paper authored by researchers from Ohio University who conducted program evaluations for this project details the story line of Taru and reflects how social messages are incorporated in the radio serial drama format (Singhal et al., 2006) (see Appendix 1).

Program Impact Quantitative impact evaluation studies were conducted to study the effect of the Taru radio serial drama on the intended health outcomes, mainly attitude, awareness, knowledge, intention, and behavior related to family planning (Singhal, Witte, Muthuswamy, & Duff, 2003). There were two rounds of quantitative studies conducted: a baseline sentinel site survey before Taru was aired (sample size, 1,500 households) and an end-line sentinel site survey to evaluate Taru’s impact (sample size, 1,500 households). The findings from the end-line impact evaluation follow. At the individual level, . Respondents held significantly stronger gender equality beliefs

after Taru was aired. . Awareness of various family planning issues increased among sur-

vey respondents, as did approval from friends on adopting family planning issues. . Perceived self-efficacy of respondents to use contraceptives to prevent unwanted births increased significantly after the serial drama was broadcast. . The use of modern family planning methods (with the exception of vasectomy) increased after the Taru broadcast. At the community level, . Pre–post studies showed that perceived collective empowerment

increased significantly among respondents who were exposed to Taru.

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. Post-Taru respondents expressed that their communities displayed

greater degrees of social capital as compared with pre-Taru respondents. At the service-delivery level, . Perceived quality of family planning services and knowledge about

how to access those services increased significantly during postTaru as compared with pre-Taru. . Sales of condoms, contraceptives, and pregnancy dipsticks increased exponentially in the villages of Abirpur, Kamtaul, Madhopur, and Chandrahatti. In learning from the Taru initiative, it can be said that the E-E strategy mediates behavior change by shaping attitudes and increasing knowledge and awareness. This strategy also builds an enabling environment for the performance of the intended behavior by influencing the social norms regarding related behavioral issues. The result of influencing attitudes and building an enabling environment is that it facilitates a smoother transition from awareness to knowledge to intention to behavior.

Social Marketing Social marketing, traditionally defined as ‘‘the design, implementation and control of programs calculated to influence the acceptability of social ideas and involving considerations of product planning, pricing, communication, distribution and marketing research’’ (Kotler & Zaltman, 1971), involves the use of marketing principles, viz. product, price, promotion and place, to influence human behavior for improving health or benefiting society (Population Services International [PSI], 2007; Turning Point, n.d.). In the context of family planning and reproductive health, social marketing has been extensively used in involving the private sector to facilitate access to reproductive health services and provide affordable prices for contraceptive products, especially condoms. A wellknown strategy used to engage the private sector under the social marketing approach is to use commercial channels, techniques, and communication approaches to market networks of service providers (also known as franchises) or products with a public health benefit (Peters, Mirchandani, & Hansen, 2004).

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Communication, being a key factor of this approach, along with the adoption of appropriate health practices, products, and services, is addressed by the use of brand-specific and educational advertising campaigns implemented by a mix of mass media and interpersonal communication strategies. DKT International, PSI, and the Futures Group are examples of some international organizations that use strategic BCC theories and strategies to implement their social marketing programs in more than 60 countries around the world by collaborating with in-country partners. Social marketing programs have been effectively implemented for selling prepackaged treatment kits for men with urethral discharge through an over-the-counter program in private pharmacies, clinics, and drug shops in Uganda (Jacobs et al., 2003); improving adolescent health in Cameroon (Van Rossem & Meekers, 2000); and promoting condom use in nonregular sexual partnerships in Mozambique (Agha, Karlyn, & Meekers, 2001). In the above interventions it was found that this approach not only contributed effectively to treatment compliance and increased self-efficacy for condom use, but also proved to be a costeffective method for increasing contraceptive prevalence. Given that India was one of the first countries to initiate a social marketing effort through a campaign for ‘‘Nirodh’’ condoms as early as the 1960s (the Government of India was then the largest social marketing entity in the world) (PSI, 2007), I review a 3-year social marketing initiative in India’s largest and most populated state of Uttar Pradesh.

Case Study: PSI’s Social Marketing Initiative in Uttar Pradesh Program Context The northern Indian state of Uttar Pradesh is home to about 166 million people (Census of India, 2001b), almost one-sixth of India’s billion-plus population. The state has a young age structure with almost 41% of the household population below 15 years of age, but all the same, underage marriages happen frequently: 13% of women aged 15 to 49 were married by the age of 13 and 35% by the age of 15. The total fertility rate in Uttar Pradesh has shown only a slight decline over the years from 6.6 in 1971 to 4.4 in 2003 and 3.82 in 2005–2006 (NFHS, 2006; Population Reference Bureau, 2006).

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Against this backdrop, it is interesting to see that though knowledge of modern family planning methods is universal, only 35% of married women are currently using some method of contraception to prevent or delay childbirth, whereas 44% of urban and 21% of rural women have used a modern birth control method for spacing births. This apparent chasm between knowledge and behavior can partially be explained by the fact that only 53% of the demand for contraceptives among married women is presently met, in a scenario where most demand for products and services is from the private sector, according to the Reproductive Health Indicator Survey (RHIS) (Futures Group, 2005). Full coverage of prenatal services is said to be ‘‘abysmally low’’ in this state, where only 2 of 10 deliveries are said to be institutional deliveries and barely a quarter of the deliveries are assisted by health personnel. However, nearly 33% of women have heard or seen family planning messages on radio or television, though the urban–rural divide in this aspect is quite severe (67 to 26) according to the RHIS (Futures Group, 2005).

Program Strategy In this context, PSI (2005a) launched the Social Marketing Strategies for Maternal and Child Health in Uttar Pradesh and neighboring states of Uttaranchal (now Uttarakhand) and Jharkand with the main goal to reduce infant and child mortality and morbidity in the three states. The project, whose overarching strategy was to test the application of social marketing approaches for maternal and child health and use lessons learned for scaling up future operations, comprised two main components: 1. Component One mainly comprised social marketing of PSI’s Maternal and Child Health (MCH) products and testing methods to increase consumer uptake of condoms, oral contraceptive pills, iron–folic acid tablets, oral rehydration packets, and clean delivery kits. 2. Component Two was focused on developing the Saadhan network of health providers in selected low income slum areas of Uttaranchal. The main purpose behind this activity was to test whether a community-based social marketing approach would be successful in increasing the knowledge and use of the MCH

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products and services in low-income communities. To implement this component, PSI facilitated the creation of the Saadhan network by training private health providers, retailers, and female community workers to provide detailed information about MCH issues and also promote PSI’s products. The network included 130 female workers (recruited from the local urban development agencies) who were trained on interpersonal communication and MCH issues and covered around 260 households every month. PSI tested four interventions related to this network: birth spacing, maternal and newborn care, control of diarrheal diseases, and child nutrition and immunization.

Program Impact Component One. At the end of the program period, the final evaluation study recorded that while the sales of condoms and oral contraceptive pills had met expectations, the sales of diarrheal treatment sachets, iron–folic acid pills, clean delivery kits, and water disinfectants exceeded expectations by 184%, 228%, 148%, and 188% respectively. Further, the targeted populations received increased access to MCH products that were now available at 45,522 new outlets, whereas they also stood to benefit from an increased public–private–NGO collaboration with the establishment of 15 community depots to promote safe water systems in slums (PSI, 2005b). Component Two. Most of the indicators of increase in health practices related to maternal and child health showed a marked increase, except for the increased use of clean delivery kits during home deliveries, and a decrease in the number of parents who gave less fluid during their child’s previous diarrheal episode (which in fact showed a reverse trend). The Saadhan network improved access to basic MCH-related information that was reflected in the number of communication activities promoting MCH under the Saadhan banner and also those promoting the Saadhan network of providers. Most importantly, the pilot test succeeded in improving access to essential MCH products as was reflected in the increase in sales of condoms and also the number of outlets with social marketing MCH products in the network areas.

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The success of the social marketing approach in combining sophisticated marketing and BCC principles to enhance MCH-related health practices and mobilize the community for effecting the social change in the form of increasing access to MCH products and services are thus demonstrated.

Political and Media Advocacy Reproductive health practices and access to reproductive health products and services are influenced not only by individual psychosocial or community-level contextual factors but also by macro-level political concerns where policymakers work with international funding agencies, international cooperative agencies providing technical support, in-country partners, and grassroots level organizations to tailor family planning=reproductive health (FP=RH) policies for their populations. In a globalized world where the political environment is increasingly hostile, funding is reduced and restructured, and there are shifts in the development paradigm, one cannot guarantee that sexual and reproductive health issues are foremost in, or even on, national or international agendas (International Planned Parenthood Foundation, 2001). In such a scenario, advocacy helps to draw the policymakers’ attention to critical issues, guides them in setting program priorities, and works with them to ensure policies are implemented smoothly. Advocacy, also called lobbying or campaigning, is thus ‘‘used to promote an issue to influence policymakers and encourage social change. Advocacy in public health plays a role in educating the public, swaying public opinion, or influencing policymakers (American Public Health Association, 2000). Media advocacy recognizes the news media as a prime arena for contesting public policies. It encompasses all the skills and strategies used by public health advocates to use the media to build support for policy initiatives (World Health Organization [WHO], 2004). BCC strategies are intensively applied in the creation and implementation of advocacy programs (Family Health International, 1994). The following is an examination of one of the largest advocacy initiatives undertaken by the White Ribbon Alliance for Safe Motherhood in India, a collaboration of 64 organizations including local NGOs, United Nations agencies, donor agencies, and individuals and was established with a view to increasing awareness on the need for safe pregnancy and child birth.

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CASE STUDY: WHITE RIBBON ALLIANCE FOR SAFE MOTHERHOOD INDIA (WRAI) MATERNAL & CHILD HEALTH ADVOCACY Program Context The maternal mortality rate in India is a definitive reflection of the reduced social, cultural, and economic status of Indian women, which in turn inhibits them from adequate access to health facilities. As of 2005, India recorded nearly 450 maternal deaths per 100,000 live births (WHO et al., 2007). Furthermore, although 65.4% of women deliver at home, 52% do not have the authority to make their own health decisions. Barely 7% of those who deliver at home receive postpartum care in the next 7 days. The maternal mortality ratio in India has only increased since the NFHS-I study in 1992–1993 from 424 (per 100,000) to 450 in 2005, as both government and programmatic initiatives have failed to bring the maternal mortality ratio to acceptable levels (WHO, 2007; WHO et al., 2007).

Program Strategy The WRAI launched its advocacy initiative in 1999. According to Dr. Bulbul Sood, the WRAI’s mission was directed by three main goals: raise awareness among citizens, international and national NGOs, and the government of the need to ensure safe pregnancy and childbirth; build alliances through intersectored partnerships with nontraditional groups like teachers and religious organizations; and act as a catalyst for action to address the tragedy of maternal death (Dr. Bulbul Sood, WRAI, personal e-mail correspondence, January 3, 2007). To achieve these goals, the WRAI conducted specific activities that would synergistically help in grabbing the attention among key stakeholders and help conduct a meaningful dialogue: . A public rally called ‘‘Save the Mothers’’ that was attended by

around 2,500 students, nurses, doctors, NGO workers, social workers, activists, and safe motherhood experts. In this rally, well-known political and film personalities spoke about grave concerns related to maternal health in India, thereby engineering public discourse to create awareness and raise the issue.

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. A ‘‘launch function’’ along with the MOHFW to announce the

Janani Suraksha Yojana (Maternity Benefit Scheme). This event was attended by nearly 600 government representatives, donor agencies, NGO workers, students, safe motherhood experts, and advocates. . Compiled the ‘‘Best Practices in Safe Motherhood’’ supported by ‘‘how to’’ guidelines, presented ‘‘A Delhi Call for Action’’ to the MOHFW, and announced the Safe Motherhood Champion Awards. . Nationwide integrated media campaigns called ‘‘Know your birth rights’’ and ‘‘No mother should die giving life’’ that included a series of print advertisements, placement of 40 news stories in newspapers, facilitating the production of two television spots run by Doordarshan (India’s national television), radio drama on safe motherhood broadcast by AIR and CBS in 21 languages, and a postcard campaign that comprised printing and disseminating a series of five postcards on the Women’s Rights Aspect of Safe Motherhood. . In collaboration with the MOHFW and Indian Association of Parliamentarians on Population and Development (IAPPD) advocated for establishing the National Safe Motherhood Day with an objective to engage parliamentarians in advocacy for safe motherhood policies and programs at the state and national levels.

Program Impact As a result of the above advocacy activities: . In 2004 the WRAI was invited by the MOHFW to develop

evidence-based guidelines and protocols for their essential package of MCH services. . Responding to this request, WRAI formed a core committee and a technical group with clinical experts, representatives of national and international NGOs, UN agencies, and multilateral and bilateral organizations. . Three guideline documents were prepared for prenatal care and skilled attendance at birth by auxiliary nurse midwives and lady health visitors, pregnancy and management of common obstetric

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complications by medical officers, and operationalizing a primary health center for providing 24-hour delivery and newborn care. These efforts were directed toward developing, in collaboration with the MOHFW, a formal cadre of skilled birth attendants. It was proposed that role and skills of a skilled birth attendant in birth and management of obstetric emergencies in rural areas be consensually defined and skills training mechanisms provided. . As a result, auxiliary nurse midwives and lady health visitors are now legally empowered to work as skilled birth attendants and permitted to administer life-saving drugs and perform life-saving interventions under clearly specified situations.

CHALLENGES FOR BCC PROGRAMS AND CONCLUDING REMARKS Beneath the aforementioned case studies that detail the successful application of three BCC strategies in India lie innumerable collaborations between cooperative agencies across countries (in this case, the United States and India) and their in-country partners, grassroots level organizations, the Ministry of Finance, the Ministry of Health and Family Welfare, quasi-governmental agencies like the State Innovations in Family Planning Services Agency (SIFPSA) in Uttar Pradesh, and other private sector organizations ranging from advertising agencies to corporate bodies. In such a scenario of global exchange of scientific and artistic expertise and mammoth financial proportions, it is only natural that international and local politics, cultural and geographic differences, and professional and power dynamics affect the performance of global health communication programs. Some of the biggest challenges that confront the efficient conduct of global health communication programs stem from severe political and administrative hurdles. For example, the U.S.’s Global Gag Rule policy prohibits USAID funding to organizations or projects that ‘‘perform or actively promote abortion as a method of family planning in USAID-recipient countries or provide financial support to any other foreign nongovernmental organization that conducts such activities’’ (Center for Reproductive Rights, 2000). Similarly, USAID=India does not have a mechanism to provide direct support to NGOs but must route its funds only through the government-to-government

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mechanism. This stipulation provides for conditions of bureaucracy, inefficiency, centralized planning, corruption, political interference, low responsibility, and lack of accountability (Dr. Arvind Singhal, e-mail correspondence, December 17, 2006), thereby causing inordinate delays in campaign planning and implementation. Structurally, constant changes in the leadership of key in-country implementing agencies like SIFPSA disrupt the smooth functioning and implementation of BCC campaigns. Communication experts point to several weaknesses that need to be addressed. One, campaigns suffer from minimal planning and the lack of cohesive strategic design that provide direction for achieving specific aims. As a result, there is limited pretesting of messages with intended audiences to measure their effectiveness before launching the main campaign. Consequently, messages are characterized by a ‘‘one-size-fits-all’’ formula, when they need to be adequately tailored and customized to different audiences. From a holistic perspective, the failure of communication campaigns in integrating their messages with service-delivery programs has been caused by an assumption that awareness leads to behavior change. Other main issues of concern include sparse application of behavior change theories and lack of robust indicators and evaluation tools to measure the impact of communication campaigns. To address these concerns, it is important for implementing organizations to recognize, and believe in, communication as a powerful tool to influence behavior change. The wealth of scientific evidence, some of it cited in this chapter, provides ample support on this account. Campaigns must be informed and guided by research data pertaining to audience segments and behavior determinants most likely to influence behavior change. Similarly, implementing agencies must make evidence-based decisions on campaign design and content. It is also necessary for campaigns to be constantly assessed through process evaluations. Communication programs must be implemented on a continuous rather than one-off or ad-hoc basis if they are to have maximum impact. Most importantly, although recent campaigns by NGOs and the commercial sector alike have increasingly projected women as ‘‘empowered’’ and those who makes family and reproductive health decisions, they have yet to effectively communicate the benefit proposition of the behavior and give communities a reason to practice it. (Dr. G. Narayana, e-mail correspondence, January 19, 2007; Ms. Preeti Tiwari, e-mail correspondence, January 23, 2007).

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Finally, the cases described in this chapter allude to the basic precepts of designing and implementing a successful BCC campaign. An in-depth insight of the situation=issue, an understanding of the target audience, audience segmentation, theory-based approaches to message construction, pretesting messages, decentralized implementation, consistent process evaluation, and impact evaluations are all basic steps in the process that will provide the required scientific and programmatic rigor to organizations conducting theory-based, strategically designed BCC interventions on the way to achieving their goals of impacting healthier reproductive health behavior.

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APPENDIX The Story of Taru The story of the radio serial revolves around Taru, a young, idealistic, and educated woman who works in Suhagpur village’s Sheetal Centre, an organization that provides reproductive health care services, carries out village self-help activities, and fights social injustices by mobilizing community action. Taru is a close friend of Shashikant, her coworker at the Sheetal Centre. Although there is an undercurrent of romance between the two, they have not yet explicitly expressed it, given that Shashikant is mindful of his lower caste status. (Taru belongs to an upper-caste family.) Their relationship, including its romantic interludes, represents a call to caste and communal harmony. Taru’s mother, Yashoda, is highly supportive of her daughter, whom she sees as an embodiment of her own unaccomplished dreams. On the other hand, Mangla, Taru’s rogue brother, derides Taru’s social work and ridicules her friendship with the lower caste Shashikant. With the help of Aloni Baba (a village saint) and Guruji (a teacher), Taru and Shashikant fight multiple social evils in a series of intersecting story lines, including preventing a child marriage, stopping the killing of a newborn female child, encouraging girls to be treated at par with boys, and fostering compassion for those afflicted with AIDS. A subplot involves Naresh, his wife Nirmala, his mother Ramdulari, and his four daughters. Ramdulari insists on a fifth child, arguing for the importance of having a grandson. Nirmala uses contraception to avoid an unwanted pregnancy, and as the story evolves, Ramdulari undergoes a change of heart and starts valuing her granddaughters. Taru and Shashikant work with this family to celebrate

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the birthday of one of the granddaughters. Another subplot involves Neha, a close friend of Taru’s, newly married to Kapileshwar, the son of the local zamindar (landlord). Kapileshwar starts out as a controlling husband, restricting Neha’s mobility outside the home. But Neha wants to lead a meaningful life and begin a school for dalit (low-caste) children. Kapileshwar undergoes a change of heart and becomes highly supportive of Neha’s activities, despite criticism from his parents. Importantly, the story line of Taru clearly shows that this is a program about building social capital in communities. In each episode there are examples of deepening friendships and relationships across gender and caste lines, sparking volunteerism and civic engagement (Singhal, 2004).