Behavior change after 20 months of a radio campaign addressing key lifesaving family behaviors for child survival: Midline results from a cluster randomized trial in rural Burkina Faso

Background: In Burkina Faso, a comprehensive 35-month radio campaign addressed key, multiple family behaviors for improving under-5 child survival and was evaluated using a repeated cross-sectional, cluster randomized design. The primary outcome of the trial was postneonatal under-5 child mortality. This paper reports on behavior change achieved at midline. Method: Fourteen community radio stations in 14 geographic areas were selected based on their high listenership. Seven areas were randomly allocated to receive the intervention while the other 7 areas served as controls. The campaign was launched in March 2012. Cross-sectional surveys of about 5,000 mothers of under-5 children, living in villages close to the radio stations, were conducted at baseline (from December 2011 to February 2012) and at midline (in November 2013), after 20 months of campaigning. Statistical analyses were based on cluster-level summaries using a difference-in-difference (DiD) approach and adjusted for imbalances between arms at baseline. In addition, routine health facility data were analyzed for evidence of changes in health facility utilization. Results: At midline, 75% of women in the intervention arm reported recognizing radio spots from the campaign. There was some evidence of the campaign having positive effects on care seeking for diarrhea (adjusted DiD, 17.5 percentage points; 95% confidence interval [CI], 2.5 to 32.5; P = .03), antibiotic treatment for fast/difficult breathing (adjusted DiD, 29.6 percentage points; 95% CI, 3.5 to 55.7; P = .03), and saving money during pregnancy (adjusted DiD, 12.8 percentage points; 95% CI, 1.4 to 24.2; P = .03). For other target behaviors, there was little or no evidence of an impact of the campaign after adjustment for baseline imbalances and confounding factors. There was weak evidence of a positive correlation between the intensity of broadcasting of messages and reported changes in target behaviors. Routine health facility data were consistent with a greater increase in the intervention arm than in the control arm in allcause under-5 consultations (33% versus 17%, respectively), but the difference was not statistically significant (P = .40). Conclusion: The radio campaign reached a high proportion of the primary target population, but the evidence for an impact on key child survival-related behaviors at midline was mixed. The population of Burkina Faso was estimated at 15.7 million people in 2010, of whom 77% lived in rural areas.13 Since 1990, the under-5 mortality rate has declined from an estimated 202 deaths per 1,000 live births to 186 deaths per 1,000 live births in 2000 and to 98 deaths per 1,000 live births in 2013.1 In 2013, malaria, pneumonia, and diarrhea accounted for an estimated 23%, 15%, and 10% of under-5 child deaths, respectively.14 The government is the main health service provider, and the country is organized into 70 health districts, each with 1 district hospital and 10 or more primary health facilities (Centre de Santé et de Promotion Sociale, or CSPS). The Integrated Management of Childhood Illness (IMCI) strategy was introduced in 2003.15 Since 2002, free antenatal care (ANC) has been offered in public health facilities, and in 2006 subsidies were introduced for child birth and emergency obstetric care.16 In 2005, artemisinin-based combination therapy (ACT) replaced chloroquine as the recommended treatment for uncomplicated malaria, and in 2010 ACT was introduced at the community level.17 In early 2011, we identified 19 distinct geographical areas using digital terrain maps and an engineer’s modeling together with on-the-ground mapping of radio signal strength. Each geographical area contained one or more community FM radio stations, with little or no overlap of radio signal between areas. We then performed a cross-sectional survey in each geographic area to assess women’s radio listenership. Fourteen areas with high levels of reported listenership (above 60% of women listening to the radio in the past week) were selected for inclusion in the trial, and, within each area, the radio station with the highest listenership was chosen as a potential partner to implement the campaign. High radio listenership was a key factor for the power of the trial given our assumption that the effect of the campaign would be directly proportional to the number of women listening to the radio. Seven areas were then randomly allocated to receive the intervention and 7 other areas to serve as controls using pair-matched randomization based on geography and radio penetration rate (Figure 1). Specifically, we defined 3 radio listenership strata (from 61% to 70%, from 71% to 80%, and above 80%), and within each stratum, we paired the areas geographically closest to each other, one of which was randomly assigned to receive the intervention. Randomization was performed by SS and SC (both with the London School of Hygiene and Tropical Medicine), independently of DMI. Due to time constraints with implementing the campaign, randomization was performed before the baseline survey (see below) and therefore could not make use of behavioral and mortality data from the baseline survey. After randomization, DMI began formative qualitative research and capacity building with radio stations in the intervention clusters while the baseline survey took place. Broadcasting started at the end of the baseline survey. Pair-Matched Randomization of Clusters Based on Geography and Radio Penetration Rate Adapted from Wikipedia. For the purpose of the evaluation, the trial population in each area was restricted to the communities with limited access to television, who would consequently be more likely to listen to the radio. We therefore excluded the population living in the electricity grid, i.e., those living in the towns where the selected control and intervention community radio stations were located, as well as those living in villages within 5 km of the town, in villages with electricity, or in villages with a population above 5,000 inhabitants (and likely to be a priority for the national electrification program). Villages with poor radio signal strength were also excluded. Using the last national census, we then identified sufficient eligible villages to provide a total population of about 40,000 inhabitants per trial cluster. The average number of villages per cluster was 34 and 29 in the control and intervention arms, respectively. With the exception of Kantchari intervention cluster (toward the East), the town with the community radio station was also the location of the regional or district hospital. The trial population also had access to primary health facilities in villages across each area. The trial was designed to detect, with a statistical power of 80%, a 20% reduction in all-cause, postneonatal under-5 child mortality. DMI’s radio campaign launched in March 2012 and ended in January 2015. Women of reproductive age and caregivers of children less than 5 years old were the primary target of the campaign, which covered a wide range of behaviors along the continuum of care (Table 1). A full description of the theory of change—the Saturation+ methodology —used to design the campaign and its implementation is provided elsewhere.11,12 Briefly, short spots of 1-minute duration were broadcast in the predominant local language approximately 10 times per day, and interactive long-format programs of 2-hours’ duration were broadcast 5 days per week. The spots were designed to be entertaining and informative and were developed and pretested based on qualitative formative research. Behaviors covered by spots changed weekly, while the long-format program changed daily, covering 2 behaviors a day. The radio campaign in Burkina Faso broadcast both short spots and longer dramas. At the time of the midline survey, no radio campaigns of comparable intensity were being broadcast in any of the clusters included in the trial. Various nutrition and sanitation programs were operating in similar numbers of clusters per arm, and community case management for malaria, pneumonia, and diarrhea was supported by the United Nations Children’s Fund (UNICEF) in one of the intervention clusters and one of the control clusters (Table 2). Cross-sectional surveys were performed in all clusters at 3 time points: at baseline, from December 2011 to February 2012, before the launch of the campaign; at midline, in November 2013, after 20 months of campaigning; and at endline, between November 2014 and April 2015, at the end of the campaign. (Endline results will be reported separately.) At baseline, the behavioral survey was part of a larger survey conducted to estimate under-5 child mortality during the 2 years prior to the intervention. Due to cost constraints, the baseline survey was conducted in a simple random sample of half the villages included in each cluster. The average number of villages sampled per cluster were 17 and 15 in the control and intervention arms, respectively, with average populations per village of 1,359 inhabitants (range: 55 to 4,730) and 1,430 inhabitants (range: 83 to 4,702), respectively. In the sampled villages, a census was performed of all compounds to identify all women aged 15 to 49 years old and to collect pregnancy history data. The behavioral questionnaire was then addressed to a random subsample of about 5,000 mothers with at least one under-5 child living with them. At midline, about 5,000 mothers were selected using a 2-stage sampling procedure. In each cluster, 9 villages were first drawn with probability proportional to size from villages surveyed at baseline. In each village, 100 women were then selected by simple random sampling using the census data collected at baseline, and the first 40 eligible and available women were interviewed. The sample size of 5,000 mothers at each survey was calculated assuming a design effect of 2 with a view to providing an absolute precision of ±3% or better for behaviors relating to all children. The expected precision for behaviors related to childhood illness was ±6% for fever or diarrhea and ±10% for fast or difficult breathing. At baseline, a short interview with the household head addressed socioeconomic status and radio ownership. Interviews with women addressed their basic demographic characteristics, radio listenership, and family behaviors of relevance to child survival. Questions regarding maternal health referred to the last pregnancy of more than 6 months’ duration, and those regarding newborn health referred to the last live birth. Questions regarding nutrition, health care seeking for childhood illnesses, bed net use, and sanitation applied to the youngest child less than 5 years old. Illnesses were recorded using a recall period of 2 weeks preceding the interview. At midline, socioeconomic status was not reassessed, and interviews with women used the same baseline questionnaire but with additional questions on radio ownership and recognition of the campaign. Spots broadcast in the last 2 weeks of October were played at the end of the interview, and women were asked whether they had listened to the long-format program by referring to its title. In the control clusters, the same method of recall was used with spots, and the title of the long-format program broadcast in the closest intervention cluster with the same language was mentioned. Interviews were performed using Trimble Juno SB Personal Digital Assistants (PDA). Quality of data collection was monitored regularly, and repeat interviews were requested in cases of missing and/or inconsistent responses. Routine health facility data were obtained to complement self-reported data on service-dependent behaviors. The “Direction Générale des Etudes et des Statistiques Sanitaires” (DGESS) of the Ministry of Health of Burkina Faso provided monthly absolute numbers of pregnant women attending ANC, health facility deliveries, and all-cause under-5 child consultations in primary health facilities located in the trial clusters for 2011 and 2013. Analyses were performed on cluster-level summaries using a difference-in-difference (DiD) approach.18-20 With fewer than about 15 clusters per arm, cluster-level analyses are preferable to methods based on individual-level data.19 While generalized estimating equations (GEE) and random effects models have good asymptotic properties, they may not be robust when the number of clusters is small. The GEE approach tends to result in inflated type I errors in such situations,18,20 while the distributional assumptions of random effects models are difficult to verify without a large number of clusters.18 For each target behavior (Table 1), in each cluster, the reported prevalence was estimated at baseline and midline, and the difference in prevalence between surveys calculated. The campaign began broadcasting in March 2012, so analyses of maternal and newborn-related behaviors at midline were restricted to pregnancies ending after June 2012 (thus allowing for at least 3 months’ exposure to the campaign). Linear regression was used to regress cluster-level differences in prevalence between surveys on the cluster-level baseline prevalence and the intervention status of clusters (intervention/control). The coefficient of the intervention variable thus provided an estimate of the DiD. Two-sided t tests were performed to test the null hypothesis of no intervention effect. Adjustment for cluster-level baseline prevalence was used to account for the phenomenon of regression to the mean.19 In the absence of accurate estimates of the intraclass correlation coefficient ρ, weighted analyses may be less efficient than unweighted analyses.19,21 All clusters were therefore given equal weight in the analysis, although the effective sample size in each cluster varied for behaviors applying to a subsample of women and their children (e.g., health care seeking and treatment). The matching procedure used for randomization was ignored as recommended for trials with fewer than 10 clusters per arm.22 At midline, a third of women in the Gayeri control cluster (North-East) reported listening to the campaign’s radio station partner in the Bogande intervention cluster (Figure 1). All analyses were performed both on an intention-to-treat and per-protocol basis, the latter excluding all women interviewed in villages where contamination occurred. At baseline, the mean postneonatal under-5 mortality risk during the 2 years preceding the intervention was estimated at 113.1 per 1,000 children in the intervention arm versus 84.1 per 1,000 children in the control arm, a risk difference of 29.0 deaths per 1,000 children between arms. To control for imbalance between arms, a confounder score was developed and used to obtain adjusted DiD estimates. Three covariates, particularly imbalanced between arms at baseline and expected to predict mortality, were combined using principal components analysis to produce a single cluster-level summary confounder score. These 3 covariates were the mean distance to the capital, as a proxy for general level of development (158 km versus 232 km in the control and intervention arms, respectively); the median distance to the closest health facility (2.5 km versus 6.3 km, respectively); and the baseline health facility delivery prevalence (81.8% versus 56.0%, respectively). After controlling for the confounder score, the mortality risk difference between arms at baseline was reduced from 29.0 to 4.1 per 1,000 children. Regular listeners were defined at baseline and at midline as women who reported listening to the radio in the past 7 days. A sensitivity analysis, restricted to these women, was performed using the methods described above. Three categories of radio ownership were defined to look for evidence of effect modification: no radio in the compound, radio in the compound, and radio in the household. In each cluster, the change in reported behavior prevalence from baseline was calculated by radio ownership category. A DiD analysis was performed including an interaction term between intervention status and radio ownership category. Cluster-specific random effects were included to account for the expected correlation in the change from baseline estimated for each radio ownership category in the same cluster. To examine the relationship between broadcasting intensity and reported behavior change, DiDs for all target behaviors were plotted against broadcasting intensity. Intensity was measured as the number of weeks during which spots were broadcast from March 2012 to October 2013 and as the number of long-format modules during the same period. DiDs were then regressed on broadcasting intensity. The assumption that behaviors are independent of each other may not be true, and, therefore, no formal statistical tests were performed. The 95% confidence intervals (CIs) for the regression coefficients should be interpreted with caution as they may be too narrow. For each target service (ANC, deliveries, and all-cause under-5 child consultations), the absolute number of consultations at primary health facilities located in the trial clusters was calculated by year and by cluster. For each cluster, the ratio of the absolute number of consultations in 2013 over the absolute number in 2011 was then calculated, and a 2-sided t test was used to compare the mean ratio by arm. The study was approved by the ethical committees of the Ministry of Health of Burkina Faso and the London School of Hygiene and Tropical Medicine. The nature of the intervention precluded formal blinding of respondents and interviewers. Each interviewed woman recorded into the PDA her written consent to participate in the survey, which they were told was about their children’s health, without any mention of the radio campaign. The trial is registered at ClinicalTrials.gov (Identifier: {“type”:”clinical-trial”,”attrs”:{“text”:”NCT01517230″,”term_id”:”NCT01517230″}}NCT01517230).