Systematic Review of the Effectiveness of Mass Media Interventions for Child Survival in Low- and Middle-Income Countries

"The potential advantages of mass media (e.g., radio, television, newspapers) include their reach and frequency, control over message content and delivery, consistency, ease of translation into multiple languages, and relatively low cost per person exposed. Potential disadvantages include the difficulty of capturing audience attention in an increasingly cluttered media environment, the oft-criticized one-way flow of information, and the inability to individually tailor messages."

Through a systematic review of the literature, this article summarises and evaluates evidence for the effectiveness of mass media interventions for child survival in low- and middle-income countries (LMIC). It attempts to address what has been done, what has been successful, and what knowledge gaps remain.  It was written by an evidence review team (ERT) to address the goals of the Evidence Summit on Enhancing Child Survival and Development in Lower- and Middle-Income Countries by Achieving Population-Level Behavior Change, which was held in Washington, DC, United States (US), June 3-4 2013. It was hosted by the United States Agency for International Development (USAID), in collaboration with the United Nations Children's Fund (UNICEF) and the National Institute of Mental Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, the Centers for Disease Control and Prevention, The Communication Initiative, and the American Psychological Association. The summary below is part of a special issue of the Journal of Health Communication that is a product of the Evidence Summit.

"The article expands on the work of previous reviews by capturing a broader range of child survival health topics over a longer period and with more rigorous inclusion criteria. To be included, studies had to (1) describe a mass media intervention using the radio, television, or newspapers; (2) address a child survival health topic including diarrheal diseases, immunization, malaria, nutrition, PMTCT, reproductive health, or respiratory infections; (3) present quantitative data from a low- or middle-income country (a country designated by the World Bank as a low-income, lower-middle income, or upper-middle income economy); (4) use an evaluation design that compared outcomes using (a) preintervention and postintervention data, (b) treatment versus comparison groups, or (c) postintervention data across levels of exposure; and (5)measure and report a behavioral or health outcome." Authors attempted to code the included campaigns on "a number of features that the literature suggests may be relevant to the success of mass media campaigns. These include use of (a) formative research, (b) theory, (c) audience segmentation, (d) targeted messages, (e) message pretesting, (f) number of channels, and (g) duration and frequency of the campaign messages...", finding that not all campaign evaluators used these criteria equally.

Evaluations were ranked as weak to strong based upon methodology. threats to methodological integrity included; self-reports of individual respondents - self-selection and causal order challenges in post intervention survey design; simple comparison and the possibility of non-equivalent samples in a pre-/post-intervention survey design; non-comparable baselines and differential natural rates of change over time in addition to history at sites in designs comparing treatment versus control geographic areas; and biased sampling not generaliasable in the target population.

Conclusions include observations from failed and from successful campaigns, as well as from weak evaluations, including:

• "[E]xposure to campaign messages must be high enough to reasonably expect an effect; low exposure to immunization and diarrheal disease campaigns may have been responsible for the failure of mass media." campaigns in Democratic Republic of the Congo, Indonesia, and Lesotho *"If the evaluation does not respect the model of effect for a given behavior in a given context, the campaign will be deemed ineffective even though it might have eventually produced a positive result. Conducted only two months after the campaign launch, the evaluation of an intervention to promote exclusive breastfeeding in Uganda did not take into account the time-frame required to influence a complex behavior and found no effects on exclusive breastfeeding."
• "[I]nterventions with mass media campaigns can positively impact a wide range of child survival health behaviors in low- and middle-income countries around the world. These include one-off behaviors such as tuberculosis testing or vasectomy, episodic behaviors such as vaccinations, use of oral rehydration therapy, and early initiation of breastfeeding, and habitual behaviors such as nightly bed net use, handwashing, consumption of iron and foods rich in vitamin A, and use of modern contraceptives. In addition, evaluations show effects across theoretical frameworks, channels, target audiences, message types and styles, and evaluation designs."
• "In the future, evaluators should address threats to inference of mass media effects by using unbiased samples, multiple comparison groups across time, levels of exposure, and treatment and control sites, statistical controls and advanced statistical methods, and data triangulation. The written report should reflect the measures taken to mitigate threats to inference. Published evaluations of mass media campaigns should provide detailed information about the campaign, exposure, and the evaluation to permit meta-analyses as the literature base grows."