The Saturation+ Approach to Behavior Change: Case Study of a Child Survival Radio Campaign in Burkina Faso

"Irrespective of the specific pathways through which high exposure drives behavior change, both evidence and theory (not to mention a century of experience from the advertising industry) suggest that high frequency of messaging is a crucial component of successful health communication campaigns."

This paper examines the theory of behaviour change that underpinned a cluster randomised controlled trial (RCT) that DMI conducted in Burkina Faso to test whether a radio campaign focused on child health, broadcast between March 2012 and January 2015, could reduce under-5 mortality. (See Related Summaries, below, to learn more about midline results; endline results will be available in 2016.). The authors describe the design and implementation of the mass media intervention in detail, including the Saturation+ principles that underpinned the approach, the creative process, the lessons learned, and recommendations for implementing this intervention at scale. The implementation research synthesised in this paper is designed to enable the effective adoption and integration of evidence-based behaviour change communication (BCC) interventions into health care policy and practice.

In brief, the media intervention consisted of daily, locally developed 60-second spots and longer, interactive dramas that targeted changes to multiple, key behaviours to improve child survival. (Click here to view 3 videos of example spots.) "The primary audience is mothers...[I]t is safe to assume that virtually all mothers are highly motivated to protect their child with the proper knowledge of how to do so." Broadcast in 7 randomised geographic areas (clusters, which correspond to areas covered by local community FM radio stations) across Burkina Faso, 7 additional clusters served as controls. "[C]reative partnerships with local radio stations helped us obtain free airtime in exchange for training and investing in alternative energy supplies to solve frequent energy problems faced by the stations."

The campaign focused on the 3 principles of the Saturation+ approach to behaviour change:

1. Saturation (ensuring high exposure to messages) - In this project and others, DMI has found that achieving high intensity is most easily achieved by using short spots in local languages, broadcast several times a day for a sustained period (6-12 times per day for radio spots, at least 3 times per day for TV spots, and at least once a day for other formats. This format allows frequent daily broadcasts, across all peak listening times. It also allows for the production of precise health messages across a diversity of languages. Due to low television coverage in rural Burkina Faso, this particular campaign was broadcast on radio alone, yet used multiple formats to deliver the messages. The radio spots used emotion, humour, and dramatic techniques such as suspense in an effort to change behaviour, such as seeking treatment for malaria (these spots were broadcast more frequently during the months when malaria transmission is typically highest). DMI broadcast a new spot every week, played at least 10 times per day, over 35 months. DMI notes that the longer formats also need to reach audiences frequently. So, throughout the campaign, they broadcast 2-hour interactive programmes, 5 nights per week, on each of the 7 partner radio stations, representing a total of 70 hours per week of live radio. Producing a pre-recorded soap opera in 6 different languages would be cost-prohibitive. DMI created a system of self-contained modules that were written in French in the capital city, sent on USB keys through local transport companies to partner radio stations and improvised live by local actors on location in their own language within their 2-hour shows. These were followed by phone-ins to allow listeners to comment on the issues raised. "These longer dramas and interactive shows can add value by creating role models, demonstrating life skills, or allowing on-air dialogue with the public. They also help us to build relationships with partner stations and can thereby help to ensure that our spots are broadcast at the intensity required."
2. Science (basing design on data and modeling) - In its work, DMI uses data to quantify the geographic coverage, audience size, and market share of different media channels in different parts of the country, at different times of day, and with different demographic groups. In Burkina Faso, for example, they conducted a customised survey to estimate the market share and audience penetration of each radio station. DMI also developed a message calendar based on the predicted impact of each behavioural message on under-5 lives saved. Using the midline results of an independent evaluation of the campaign involving a behavioural survey of 5,000 mothers (see Related Summaries, below), DMI revised the message calendar to maximise the impact of the remaining months of the intervention. DMI stresses that qualitative research is also key to ensure message quality through:
   • formative research to identify barriers to behaviour change - One lesson from the process, which in Burkina Faso involved semi-structured individual interviews and focus group discussions: "reducing formative research down to a 1-page message brief for each target behavior is a critically important step in our creative process as it makes the research more accessible to the script writing team and helps to bridge the gap between research and creativity." This message brief might include, for example, contextual information about the behaviour, including Ministry of Health policy and guidelines, and information drawn from guidance from the United Nations Children's Fund (UNICEF) and the World Health Organization (WHO).
   • pretesting to judge comprehension and appeal - "For example, we pretested a spot in which a character impersonated a diarrhea germ and had a discussion with a baby. Our target audience could not grasp the concept of bacteria/germs nor young babies talking, so they did not understand this spot....In contrast, we pretested a spot that featured a beneficial 'genie' telling a mother and grandmother who are about to press and discard the mother's colostrum that this first milk is full of nutrition and protects the newborn against illness. This spot was accepted at pretesting, as it was a better fit to the Burkinabé context, in which people are very familiar with stories of genies."
   • feedback research through focus groups to find out whether people have heard and understood the messages and what the remaining obstacles to behaviour change are, as well as efforts to monitor the availability of commodities to ensure that the demand generated was met by sufficient supply. "Our research team was able to provide insight into the availability and quality of services available on the ground through their visits to health centers and by liaising with district medical officers. This was particularly important for the effectiveness of our treatment-seeking messages, which were service-dependent." And on independent endline analysis: "In general, since randomization of media interventions is rarely possible, we advocate the use of time-series or other quasi-experimental study designs to evaluate media campaigns and enable attribution of impact. It is important when designing an evaluation to carefully consider which outcomes will be measured, using health outcomes where feasible, and measuring knowledge, attitudes, and behavioral outcomes as indicators along the causal pathway of behavioral change."
3. Stories (focusing the dramatic climax on the target behaviour) - DMI references a 3-act story structure that mimics the process of behaviour change: Act I in which characters are given goals; Act II in which obstacles are thrown in front of the characters; and Act III in which the characters either change their goals or overcome the obstacles. The emotional turning point of most stories is at the end of Act II. DMI contends that formative research, when conducted with this structure in mind, can identify the most important emotion (e.g., fear or guilt) that prevents people from complying with the behaviour and the most important emotion (e.g., love) that motivates people to comply. "Grassroots recruitment of local scriptwriters is essential to develop a creative team that understands the language, context, and cultures of the target audience. Rather than try to outbid other NGOs [non-government organisations] for the existing talent pool, in Burkina Faso we advertised in university campuses, bars, and public meeting places and asked applicants to write and submit a story. This approach resulted in 600+ applications....The [team of 13] hired scriptwriters had a diverse range of previous employment experience, ranging from teachers to a security guard, and originated from 8 regions of the country."

The paper continues with a section on lessons learned and recommendations for scale-up. An excerpt: "Key lessons learned were the importance of maintaining close relationships with station managers and of regular site visits. This was crucial in ensuring that we were made aware of staff changes and power or equipment problems as soon as they occurred, thus preempting the danger of a station going off air. Another tool to motivate media partners is providing them with impact data specific to their audience. Being able to feed back information to radio stations, showing them how their efforts have improved health outcomes in their area, is a powerful motivator. Furthermore, we have provided basic training in how this information can be used by the stations themselves to demonstrate their effect and sell their airtime to others, in order to build capacity and thrive in a competitive media market. Taking a community radio intervention to scale in multilingual countries will inevitably require the translation and broadcasting of multiple messages. In Burkina Faso, for example, national coverage can be achieved by increasing our number of community radio station partners from 7 in the RCT to 29, taking the number of languages required from 6 to 12. Given this level of linguistic complexity, it is highly unlikely that qualitative research and pretesting of spots can be carried out in all languages. Despite this, we emphasize the importance of conducting formative and feedback research in as many languages and as many regions as is feasible. Wherever possible, we advocate training scriptwriters who speak local languages to assist the qualitative research team with pretesting and feedback research."