How many of us ever think about what happens after we flush? 

Yet it’s an issue that concerns governments, sanitation experts, urban planners and public health specialists around the world - particularly in India, where 60% of urban India is not connected to modern sewage systems and relies on on-site sanitation such as septic tanks and leaching pits. This makes faecal sludge management (FSM) a pressing but hidden public health issue.

That’s why five years ago, Madhu Krishna, then deputy director of WASH and communities at the Bill and Melinda Gates Foundation India, gave 主播大秀 Media Action this challenge:

“Could you make faecal sludge management an issue that is as important to people in urban India as air pollution has become? Could you get people to care about what happens after they pull the flush?”

Few homes in India's urban areas are connected to municipal sewerage, making waste management a major health issue. Credit: 主播大秀 Media Action

Our campaign #FlushKeBaad illustrated the sanitation value chain so that people could understand what happens after flushing. Credit: 主播大秀 Media Action

The main characters in our hit comedy-drama, Navrangi Re! Credit: 主播大秀 Media Action

The cast of Life Navrangi - our follow-up to Navrangi Re! Credit: 主播大秀 Media Action

The world’s hopes for a vaccine for COVID-19 cannot be overstated.

A vaccine will help prevent new infections, and more than that, it will help businesses and schools in hard-hit countries get back to normal. Vast amounts of money have been invested in finding a vaccine and media reports update us regularly on the progress of over 200 candidate vaccines under evaluation.

There is also important work on ensuring equitable access once a vaccine is available, and some mention of concern about vaccine hesitancy – the delay in acceptance or refusal of vaccines even when vaccine services are available. Public health officials recognise vaccine hesitancy and refusal is a problem, but there is little evidence that countries around the world have plans to address it. 

The vaccine hesitancy problem 

Even before the COVID-19 crisis, the WHO declared vaccination hesitancy one of the Top 10 threats to global health in 2019. At that time, the world saw spikes in vaccine-preventable diseases – for the measles, mumps and rubella vaccine slipped by 10 per cent. In reference to COVID-19, the WHO Director of the Department of Immunization, Vaccines and Biologicals, Katherine O’Brien, “We don’t have a vaccine yet and already there is an anti-vaccination voice on it.”

While many see a COVID-19 vaccine as the main route to restoring social and economic normalcy, a small minority of doubters could scupper the massive global effort to discover a vaccine and roll it out effectively.

There are studies, mostly in the US, that show a lack of confidence in a COVID-19 vaccine. A May 2020 Associated Press-NORC Center for Public Affairs Research found that 31% of Americans were unsure if they’d get vaccinated against COVID-19, with another one in five saying they would refuse the COVID-19 vaccine outright. These acceptance figures are a moving target as the science around the virus progresses and is shared, and people’s personal experience of the impact of COVID-19 is felt.

There is urgent need to get in front of this challenge – before a vaccine becomes available. Experts have called the need to improve public health communication and health literacy as the number one recommendation out of six for and response.

However, historically, health communication is to achieve maximum effect. 

Analysis from Gavi, the Vaccine Alliance, for example, finds that spending on creating demand for vaccines, and for broader social and behaviour change communication, between 2011 and 2015, represented just 1.2% of the money it dispersed.

Solutions exist - where is the will?

What those of us working in health communication know is that well-designed efforts can increase uptake of vaccines. Academics and communication practitioners know what works and what doesn’t, gleaned from experience from , routine immunisation, Ebola trials and  more broadly.

At a recent on “infodemiology” (the science of managing 'infodemics'), epidemiologist and Yale Institute for Global Health Director Saad Omar summarised key lessons around what works in addressing health misinformation, which is essential in addressing the persistence of anti-vaccine information. These are:

1) do not affirm a misperception,

2) avoid lingering on the myth,

3) connect to people’s values,

4) account for the anticipatory behaviour,

5) focus on narratives, and

6) avoid false assurances.

These align with those of others who work in the field of . A recent Johns Hopkins University sets out similar recommendations, emphasising the need to understand and inform the public and gain their confidence in vaccines early in the process.

Yet despite these recommendations, we are not seeing explicit investment in vaccine education in places where refusal of a COVID-19 vaccine is a possibility. There is also little data available outside the US on which geographic areas or communities may be resistant to a COVID-19 vaccine, which would help inform areas of immediate focus. (The , analysing five years of global vaccine confidence trends and including implications for new COVID-19 vaccines, is likely to aid in this effort).

The role of health communication

主播大秀 Media Action has over 20 years’ experience in health communication -- the practice of using a range of approaches, including mass media and other information communication technologies, social mobilisation and interpersonal communication, to improve health outcomes. This experience includes working on vaccine acceptance and in global heath emergencies.

And at this moment we are researching, producing and disseminating content on COVID-19 in more than 50 languages reaching tens of millions of people around the world. This content ranges from in-depth TV and radio discussion programmes featuring experts, to using narrative storytelling to tackle the more nuanced angles of the behavioural drivers that impact COVID-19 risk. We are also on how to report on COVID-19. All of this research and reach can be leveraged to address the vaccine uptake challenge immediately. 

Highlights from our work

As part of a Unicef intervention to mitigate the spread of poliovirus in Somalia, which re-emerged in 2013, we produced a rapid mass media response aimed at increasing the demand for the vaccine.

主播大秀 Media Action developed a 42-episode Somali-language radio programme called ‘Drops for Life.’ Broadcast on the 主播大秀 Somali Service, the programme was designed to prepare the ground for the arrival of the mobile polio vaccinators. It allowed people to digest relevant information in advance of the vaccination campaigns and made them more amenable to inviting polio vaccinators into their homes. It incorporated audience feedback and personal stories, and provided a space for them to ask questions to allay their fears.

The programme also addressed specific concerns around vaccination safety, which contributed to a history of attacks on health workers and low uptake.

Audiences placed high levels of trust in information gained from the programme, both because of the credibility attributed to the 主播大秀, and because it featured trusted individuals, such as doctors and sheikhs. The programme also built the capacity of vaccinators and health workers and enhanced the public’s trust in them. These factors – use of trusted media platforms and community members, appropriately timed and grounded in local realities, helped to quash the major barriers to vaccine uptake.

In Nigeria, we worked with mass media combined with community outreach to help overcome the personal and social barriers to vaccine uptake, especially for people in the Northern states where vaccine-preventable diseases, particularly polio, have been a higher risk. We recorded our popular Hausa-language radio drama in front of a live audience in rural and semi-urban communities, then followed the recordings with discussions with vaccinators and health workers, to provide communities with direct answers to questions about routine immunisation and polio vaccination.

that our audiences knew more about how polio is transmitted and prevented, and took action following vaccinator visits, compared to those who didn’t participate. Evidence also suggested that radio interventions helped to debunk misinformation and harmful myths around the polio vaccine, and that the drama was used as a tool to challenge vaccine refusal within families and beyond. This work finished in 2019, the same year Nigeria was declared “polio free”. 

We need to act now

Vulnerable countries urgently need a plan to address the risk of vaccine refusal, starting with investing in research that can isolate where and among whom the risk is likely to be highest. Health departments need support to as they prepare for a COVID-19 vaccine, by conducting this research and creating spaces and content that help answer people’s questions and address their fears. Let us draw on the vast experience of the health communication field to support the responsible, community-focused roll-out of national coronavirus vaccination programmes.

What we say and do now will impact how successful we will be in halting the spread of COVID-19.

As World Health Day approaches, and as we look towards the first-ever later this year, we’re sharing insights from 主播大秀 Media Action’s work to help health workers and communities work better together to build a healthier world.

In low-income countries in Africa and Asia, many health systems are staffed by community health workers. In Nepal they are known as Female Community Health Volunteers, in Ethiopia, Health Extension Workers, while in India and Bangladesh they are generally known as Frontline Health Workers.

Whilst the names may differ, most are women, most work in remote areas, and many are volunteers. They play a vital role connecting people to, and sometimes providing, basic primary care; referring patients to clinical services and motivating families to adopt heathier practices.

All are tasked with communicating about health, but often they lack sufficient training or engaging communication tools that would help them do this more effectively.

This is where 主播大秀 Media Action comes in. Over the last 10 years we’ve been supporting community health workers to better meet the needs of their communities. These are five important things we have learned in the process:

First, understand the world health workers live and work in

In Nepal, access to communities can be extremely challenging for Female Community Health Volunteers (FCHVs) due to large distances and difficult terrain between communities and health centres in rural areas. What’s more, FCHVs are often balancing their responsibilities with looking after family and, as many of them are volunteers, trying to earn an income.

Whilst access to mobile networks and internet is increasing, literacy rates remain low in rural areas and our research shows that some communities feel FCHVs should know more than they currently do. It became evident that updated training and tools that fit with the practicalities of FCHVs’ day-to-day lives and the changing community needs would help.

Most FCHVs have access to a basic mobile phone and mobile network, so we’re now working with our partners to explore how training and tools for basic mobile phones will help them to carry out their duties in remote areas. We’re also developing creative printed materials to support their interaction with people of all literacy levels in their communities.

In a similar project in Bangladesh, we discovered that health workers were using heavy, cumbersome flip charts to visit their clients in urban slums, so we developed a mobile app to help them undertake their roles more effectively. 

“Now I’m getting all the topics by using one app which is not possible with other tools (flash cards, flip charts, leaflets). I can deliver all relevant information by the app which was difficult for me before” said one community health worker who frequently used the app.

Second, use human centred design and build partnerships

In rural India, the catalyst for the development of our highly successful Mobile Kunji and Mobile Academy projects was women’s lack of access to traditional mass media platforms. At the start of this work, our formative research showed that only a few women watched television or listened to the radio, however 82% had access to some form of basic mobile phone. So, rather than setting up a parallel system, 主播大秀 Media Action leveraged the one available.

Using human centred design, our India team created content that worked on basic mobile phones and suited how health workers used them – to make and receive calls only. We created Mobile Academy, a training course for health workers, which is delivered through mobile audio messages, whilst Mobile Kunji is a set of visual cards and accompanying mobile audio messages that health workers can use during visits with families. Using these services and tools, our research has shown that health workers are able to better reach, engage, and influence families to improve their health.

This blog was originally posted on

One can’t talk about design without quoting Steve Jobs.

“Design is a funny word," he said, "Some people think design is how it looks. But of course, if you dig deeper, it’s really how it works.” He hit the bullseye as always. Look at the success of design-driven companies like AirBnB and Pinterest, or even digital giants like Google, eBay and LinkedIn, who have invested in the design of more engaging and differentiated user experiences.

During the last couple of years, human-centred design has acquired a somewhat elusive and awe-inspiring reputation among donors and implementers. Everyone wants it, yet struggles to see how it can fit in with achieving development goals.

At 主播大秀 Media Action, we use the power of media and communication to create social and behaviour change. For a lot of our work, like the mhealth services ,  and , we have been using human-centred design, long before it became a term de jour! “Admittedly I flip between being overjoyed that many in the development community have suddenly bought into design thinking, and being frustrated that this is seen as something new,” says my colleague Yvonne MacPherson, 主播大秀 Media Action’s US director.

Now that human-centred design is trendy, we need to make sure it is not treated as a separate, add-on activity or process. It is integral to “doing development”. Donors are now putting out separate calls for proposals just for human-centred design, presumably to support other implementation efforts.

This then begs the question, why are all implementers not using human-centred design principles in their work? And if they are not, what could be the reasons—lack of resources, time or access to technology? Which brings me to the biggest myth around human-centred design—that it can only be used to create digital or tech solutions. Which is why, I will use a no-tech (not even low-tech!) innovation to talk you through the process. This is a tool we have created for pregnant women in Bihar, where 60% of women aged between 15 and 59 years suffer from anaemia, the silent killer.

Our world is home to . The majority of these 10 to 24-year-olds live in Asia, with 48 million alone growing up in Bangladesh.  

And many of these young people are having sex. Bangladesh has one of the highest adolescent fertility rates in all of South Asia, coming in at . This is compared to a figure of 71 for Afghanistan and Nepal, which share the next highest adolescent birth rate in the region. In the US, this number stands at 21, in the UK, 14.

In Bangladesh, this high birth rate is driven by girls . Nearly three quarters of married Bangladeshi women become wives before turning 18 – compared to fewer than 3% of men. Media Action carried out research with adolescents, parents and teachers to better understand why. 

Outside of everyone’s comfort zone

We found that children and adults alike struggle to talk about sexual and reproductive health (SRH) in Bangladesh, .

Teenagers are embarrassed to seek out advice from their elders, due to social stigma and shyness. We also learned that parents don’t start these conversations either – aside from the heart-to-hearts mothers have with their daughters about periods.

SRH is a taboo topic, which parents feel is inappropriate to bring up with adolescents before they get married. Our research revealed that adults believe that telling teenagers about contraceptives promotes promiscuity.

As for teachers, they are often evasive and are known to sometimes skip the chapters on sexual and reproductive health in textbooks. Those we interviewed said they faced social barriers in discussing sex with students of the opposite gender to themselves. They also didn’t feel properly supported by their colleagues and management to have these kinds of conversations.

Educators are also discouraged by students’ reluctance to discuss sex with them in the classroom. Some NGOs run SRH programmes in schools but teenagers we spoke with said that these paint an incomplete picture of what they need to know.

Recognising these issues, by providing universal access to information and services. Girls are being taught . But this isn’t enough.

Getting the lowdown

Adolescents are unsurprisingly hungry to know more about the experiences they all have, but which are never spoken about.

This is where the radio show (Crossroads at 10 to 19) comes in. Combining drama, songs and interviews with both experts and ordinary teenagers, Dosh Unisher Mor aimed to give young people the comprehensive lowdown on SRH they crave. 

The show helped teenagers come to terms with the physical and psychological changes that go with puberty, by presenting these as natural and nothing to be ashamed of. Adolescent listeners said they learned new things from the show, particularly about the physical changes they were experiencing. For example, the programme corrected the mistaken belief, held by many of the boys we spoke to, that wet dreams are a disease.

The show also helps adolescents realise just how traumatic early marriage can be for girls. Listeners came to understand that getting pregnant at a young age puts mothers – and their babies – at risk of health complications and even death.

Some explicitly said that Dosh Unisher Mor led them to see early marriage as a damaging social convention they had the responsibility to protest against. One girl was even driven to stop a child marriage from happening – telling her parents about it, who in turn informed the police.

Filling the information gap through entertainment

Teenagers appreciated that Dosh Unisher Mor was not only educational, but also entertaining. They saw it as a show with the power to change attitudes and influence people by facilitating open and natural discussions, informed by detailed and comprehensive explanations.

As for parents, many said the show encouraged them and their children to speak more openly about these issues. Though we did interview some who explicitly said they were happier for their children to listen to Dosh Unisher Mor than have to have an embarrassing conversation!

Clearly there’s still a real information deficit to fill around SRH and early marriage in Bangladesh. Yet our adolescent listeners told us that Dosh Unisher Mor was the only radio show out there exclusively focused on SRH. This shouldn’t be the case. Shows like Dosh Unisher Mor have so much to offer young people and there should be more programmes out there like it.

is a development professional with a background in qualitative research, specifically in the areas of public health and communication.

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While the election of as the next director general of the World Health Organization (WHO) has been , I’ve been heartened by one of his top five priorities for when he assumes his new post. Dr Tedros has pledged to put the .

This ambition reflects the times we live in. The organisation Dr Tedros will soon lead has revealed that more than . The top five killers in 2015 were road accidents, lower respiratory infections (like pneumonia and bronchitis), self-harm, diarrhoeal diseases and drowning. 

Look deeper and you’ll see differences by country, age and sex

These mortality trends hit certain parts of the world and particular segments of society harder than others. Over two-thirds of these teenage deaths happen in the Global South, mainly countries in Africa and South East Asia. Teenage boys are more likely than girls to drown, who instead have a lot to fear from pregnancy-related complications. Younger adolescents lose their lives to lower respiratory infections. As they get older, they’re more likely to die at someone’s hands – including their own.

Clearly, adolescents are not a homogenous group. They face different risks that reflect the rapid physical, sexual and emotional changes, which are the hallmark of the teenage years. Not only that, they must also contend with challenges that stem from the roles they are given by the societies, communities and families they live in. To ensure that communication responses are as relevant as possible, these should be fine-tuned to suit the age group and gender of particular concern.

Thinking beyond the Global North

In addition to recognising that the needs of an 18-year-old girl as distinct from those of a 10-year-old boy, we also need to be careful not to assume that ‘Western’ afflictions aren’t more universal.

To take just one example, we now know that suicide isn’t just a serious public health problem among . Almost half of teenagers who take their own lives globally do so in lower middle income countries in South East Asia: over 10% of 13 to 15 year olds in say they've tried to kill themselves.

And yet services and support are often scarce in these settings. Even when support is available, teenagers and their families are unlikely to seek help because mental health is poorly understood and not openly discussed.

Talking about self-harm and , whether through drama, street theatre, factual programmes or through face-to-face conversations, can address gaps in people’s knowledge and their fear of stigma. Getting people informed and talking about these issues can in turn make it as normal to seek treatment for mental illness as getting a cast for a broken arm.

Fortunately, countries are starting to make progress in this area. India recently launched its . Ethiopia’s – when he was his country’s health minister – marks the need for targeted mental health prevention and support programmes for adolescents.

So what can media and communication do to help?

The helpfully runs through the evidence on how to keep adolescents alive and well, sharing 50 case studies from across the globe to help inspire us all. However, the unique role that media and communication can play, whilst mentioned, isn’t well explored. This is where organisations like ours can fill in the gaps.

Let’s take pregnancy as an example of an area where Media Action and other NGOs like it can make a big difference. Some girls get pregnant because they plan and want to have a baby. But considerable numbers of girls don’t know how to avoid getting pregnant and if they do, they often . In addition, many very young adolescents have their first sexual experience . Given the risks of pregnancy, especially at a young age, this lack of awareness and autonomy is incredibly worrying. Fortunately, the media can help inform young people and empower them to act on what they know.  

A number of media programmes around the world are tackling these challenges, like our very own (Let’s Talk!) in Zambia and (Crossroads at 10-19) in Bangladesh. Both shows provide an honest and safe space for adolescents to ask questions and voice their misgivings about safer sex, allowing them to make informed choices about effective contraception. They can also be directed towards trusted services and sources of support. Recent but unpublished research shows that listeners of Tikambe were more likely to: know more about contraception, have visited a health centre and feel more supported by the key people in their lives when it came to sexual health.     

On the communication front, the a decade-long British strategy, which ultimately led to a halving in teenage pregnancy rates over 16 years, in other countries. The communication part of the normalised conversations about sexual health between adolescents and their parents, showing that communication can help pave the way to record lows in teenage pregnancies.  

But we’re just scratching the surface of what media and communication can achieve for teenagers around the world. Given the myriad of threats facing young people today, it’s vital that we leverage all manner of approaches to help them cope. Fortunately for the generations coming up, these challenges are far from insurmountable; media and communication can be a key part of the toolbox of preventative measures.

 is a Health Adviser with 主播大秀 Media Action. She tweets as .

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We use the word ‘partnership’ a lot in the development world. At a global level, we’re all ‘partners’ – a giant family of policymakers, donors, practitioners, academics and companies working together to advance a shared vision of a world free from poverty, hunger and violent conflict.

We come together for mutual benefit, bringing our different skills, experiences and resources to the table, to solve deeply rooted problems. But because we’re human, partnerships – as with any relationship – can be fraught with friction and misunderstanding. 

At Media Action, we build partnerships so media and communication can make as positive a difference to people’s lives as possible. Our natural partners are, of course, other media organisations, often the local and national broadcasters in the countries where we work. We share a common interest in using media to provide a public service to enrich and enhance the lives of citizens.

But we have other, less obvious companions in our journey to make life better for people in the Global South. We also collaborate with governments and NGOs that don’t specialise in communication in order to . Like us, they share the belief that, when rooted in evidence, media and communication have a key role to play in maternal and child health.

What’s everyone bringing to the table?

And what can a media organisation like us bring to these ? Editorial acumen, technical know-how and tangible products. We provide high-quality media content that educates and entertains. Our programmes are custom-built to encourage social and behaviour change, creating demand for the maternal and child health services provided by our partners.

Of course, simply handing over a stack of DVDs does not a partnership make. So we also work with our partners to facilitate community discussions, which use our content to spark conversations about the kinds of issues addressed on TV and the radio. With some partners, this work goes further, with , skills they could then go on to use day in and day out.

Bringing their loyal audiences and in-depth knowledge of local people, our media partners are invaluable to us. They help us spread the benefits of media and communication further, to reach .  

We in turn can offer programmes that draw audiences in, , to help pique the interest of those who aren’t normally interested in health matters but make decisions within families. There aren’t many people who reject entertainment after all. Dramas can sway ‘’, who were previously somewhat ambivalent about maternal and child health, into pushing for their loved ones to take advantage of the services our partners offer.

What makes for a long and prosperous partnership?

Over the course of all this collaboration, we’ve learnt a few things about how to be a better partner and how to get the most out of working together. In many ways, it’s like a marriage or long-term relationship: if one side expects their meals to be cooked and the laundry to be done, but the other has no intention of doing that, there’s bound to be trouble! So it’s important to be about the relationship from the start.

This last piece of guidance has been particularly helpful to us, as we’ve found that partners have high expectations of us because of the 主播大秀 brand. Clarity from the outset and a joint plan can help smooth out problems that may arise if those expectations are unrealistic.

We’ve also discovered that involving partners in content creation elevates projects into genuinely joint ventures that everyone has a stake in. Similarly, it’s worth providing ongoing support to partners so they can adapt to different scenarios and to ease the burden of carrying out outreach, which can be time-consuming and complex.

Ultimately, and at the risk of sounding obvious, it’s all about communication: listening and talking to each other…solving problems together…working for a common goal. That’s how sustainable change happens.

If you’d like to find out more about how 主播大秀 Media Action used media and communication to improve maternal, newborn and child health, go to our digital platform, .

Sophia Wilkinson is 主播大秀 Media Action’s Acting Head of Health and Resilience; she was previously the organisation’s Senior Health Adviser. Sophia’s most recent publication is , which reflects on 主播大秀 Media Action’s maternal and child health partnerships with governmental and NGOs in Bangladesh, India and Ethiopia.  Sophia tweets as .

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How we view our role and relationships within our communities shapes how we behave – . When widespread, these views constitute ‘social norms’, which people tend to follow because they believe that others do and because they think it’s expected of them. Media Action’s programmes aim to challenge social norms that can lead to people risking their health and reinforce those that support people to make healthier choices.

Donors increasingly want proof that we’re changing norms at scale. But it’s not easy either to or to identify exactly how media influences desired outcomes, such as children getting vaccinated or .

These are some of the challenges we face as Media Action’s research team. How do we design research to measure social norms and track whether they’re changing? We came up against this question when evaluating whether our had changed social norms in Ethiopia.

We set out to understand whether our programmes had convinced families to by, for example, saving money and planning how to travel to the hospital. In Ethiopia, preparing for a baby’s arrival typically means planning the important post-birth thanksgiving ceremonies. Women are judged negatively if they don’t put on a good spread but the costs of hosting this celebration mean that there’s less money to get a woman to a facility when the time comes.

We primarily used qualitative methods to understand social norms but we also undertook large-scale surveys to understand how we were shaping social norms at a population level.

To highlight challenges around researching social norms with surveys – and how they might be overcome – here are five common responses heard in the field in Ethiopia: 

1. ‘How would I know what other people think?’

Though intuitive in English, it’s not always obvious in other languages that asking someone ‘what would your neighbour think?’ really means ‘what do you think your neighbour would think?’. Respondents sometimes take the question very literally and reply that they ‘didn’t know the minds of other people’.   

, where interviewees reflect on what they understand by a question, and careful piloting of questions can reveal when something isn’t interpreted as intended. To get the wording of a question right, it’s essential to take the time to test and refine translations into local languages and carefully train field interviewers.

2. ‘Which people?’

When asked about ‘other people in the community’, interviewees often weren’t sure who they were meant to be thinking about. We consequently explained what we meant to respondents, to help them move from an amorphous sense of ‘other people’ to something more meaningful. For example: ‘If you think of five women you know, how many of them would start going for check-ups in the first three months of pregnancy?’  

3. ‘It’s none of my business!’

Our team found people in Amhara (a region in northern Ethiopia where the research took place) to be quite reserved. It’s an area where it seemed to be impolite to speculate on the lives of others, not least to an outsider with a clipboard.

Surveying was as much an art as a science, with proving to be as important as good survey design.

When it comes to rapport the ordering of questions is important. First of all, you can turn people off a survey by leading with potentially sensitive questions. How willing would you be to tell someone what you earn or weigh when you just met them?

Second, it’s easier to get good answers to tricky questions (like those around social norms) if they’re asked some way into the survey after rapport has been built. But these questions can’t be left too late. People often find talking about things like community dynamics tiring, so you have to broach these topics while people still have enough energy to discuss them.

Finally, it’s important to brief interviewers well so they’re confident of the research aims. They’ll also be better at reassuring participants they’re not trying to probe into their private lives, but rather uncover the practices and perceptions of their community as a whole.

4. ’I don’t know’   

Respondents are often stumped by questions – particularly by those that ask to what extent they agree with a given statement. However, presenting them with a range of simple and concrete options can help elicit answers.

For example, to determine whether respondents believe their community sees something as appropriate or expected, we presented them with options such as: ‘they would think it’s OK’, ‘they would think it’s not OK’ and ‘they wouldn’t care’.

To determine what respondents think people in the community are actually doing, we presented them with choices like ‘none or a few do it’ and ‘almost all do it’.

We found that listing these options helped increase understanding and made the surveys less demanding of participants, resulting in fewer ‘don’t knows’.

5. ‘Let me tell you what happened to me during my last pregnancy…’

When a respondent has to choose from a limited number of options, there’s no way of recording the rich detail someone might provide through sharing their experiences in a more narrative form. Within the context of a survey, personal stories become conundrums (how do I classify this?) rather than goldmines of information. This tension demonstrates why qualitative research remains invaluable.

Illustrating this, we recently used a to allow mothers to tell us the journey of their pregnancy. Asking questions like ‘Would you say that your story of pregnancy is the same as most of the mothers in your community?’ helped us understand whether or not interviewees were conforming to norms.

We’re continually exploring ways to improve our surveys to pinpoint what social norms are and how they’re changing, always with the aim of truly reflecting people’s perceptions and helping them improve their health.

Hilina Assefa is a Senior Research Officer with 主播大秀 Media Action’s Ethiopia team; Lois Aspinall is a Research Manager with the UK office.

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Following the launch of our  site, Emebet Wuhib-Mutungi explains how influencing mothers-in-law and husbands can help improve the health of mothers and their babies. 

 because of complications caused by pregnancy or giving birth. Almost all of these women live in the Global South. And most could be saved through simple precautions, like going for regular antenatal check-ups.

But as we discovered through  (watch the video below for more background), expectant mothers often don’t go for check-ups early enough. Our research into people’s beliefs suggests this is because Bangladeshis view pregnancy as a ‘natural process that doesn’t need special attention’, while in Ethiopia, going for a check-up is seen as inviting ‘bad luck’. .

What do you do when your audience is difficult to reach, tough to keep engaged and doesn’t understand concepts you take for granted? Priyanka Dutt offers some words of advice from her team’s experience of running a , northern India.  

Anyone working in international development will attest that human-centred design (HCD) has been a ‘trending topic’ in recent years. Design thinking has been applied to a range of challenges, from to building an . Melinda Gates even hailed HCD as the innovation in the developing world.

But what exactly is ? It involves bringing together multi-disciplinary teams – think creative writers working alongside ICT specialists – to address challenges through rapid prototyping and repeated testing. At the core of HCD is building empathy with the people you’re designing for with the overarching aim of producing something genuinely valuable to them.

Marrying these principles with our own core value of putting audiences at the heart of everything we do, we decided to set up a ‘’ in Bihar, in northern India, which aimed to improve child and maternal health through communication. We saw Bihar as a great site for HCD-style innovation because it offered us the scope to test and fine tune new ways of using communication to promote healthy behaviours for women and children alike.

Bihar is home to 29 million women of reproductive age, who give birth 3 million times every year. And although Bihar’s maternal mortality rate has to 93 per 100,000 live births, it is still well above the Sustainable Development Goals of 70. As for the communication challenges, less than a fifth of these women watch TV and only 12% listen to the radio.

Yet the lab’s early creations achieved a great deal. Over 50,000 people have graduated from our training course, which is delivered through mobile phone audio messages. The course teaches health workers how to communicate more effectively to persuade families to lead healthier lives.

We also produced a set of cards and audio messages delivered via mobile phone – called – for health workers to use during their visits with families. The shows that families subsequently asked health workers more questions and were more likely to follow advice on preparing for birth, family planning and how to feed babies.

Rethinking strategy: learning from failure

High on our early successes, we set about developing (a baby’s gurgle in Hindi). This programme sends weekly audio messages about pregnancy, child birth, and child care, directly to families’ mobile phones, from the second trimester of pregnancy until the child is one year old. The aim was that Kilkari would be listened to across Bihar, by the most vulnerable families, with the greatest need and least access to information and services.

Drawing on lessons from two similar services from around the world, and , in addition to our own prior experience in Bihar, we were confident Kilkari would be a success. Just to be certain, we ran some tests before rollout and found that we had failed in our vision – and spectacularly so. We weren’t getting through to our main audience, women, as we weren’t using the right channels and language.

In the end, we went back to the drawing board on Kilkari four times, simplifying and stripping down the content time and again, until we got it right. Through repeated prototype-test-redesign cycles, we made the vitally important discovery that our basic assumptions about our audiences were wrong. So we went back to basics and asked ourselves the following questions to push us to rethink our strategy:

1. Is the content relevant and easy to understand?

We discovered that our content confused the audiences we were targeting, who didn’t understand even simple Hindi words like health (swasthya). Men understood more than women – likely due to their greater literacy and mobility – but Kilkari’s female focus meant that this wasn’t particularly helpful.

Audiences also struggled with other concepts we take for granted. They mainly think of time in mornings, afternoons, evenings and nights, but we’d referred to hours and minutes in our programming, time references which simply don’t exist for them. 

Finally, we also found that the speed and style of content used for Mobile Kunji and Mobile Academy was overwhelming for Kilkari’s audience. For example, dramatising content confused our listeners, who didn’t understand why there were so many people on the phone, all talking to them at once. We needed to have a single voice and a single take-away, simplified to the most basic information audiences needed.

2. Are we getting through to our target audience?

We primarily wanted to reach women, but discovered that it was mainly men who owned phones with the credit needed to receive messages from Kilkari, a paid subscription-based service. 

In response, we used tactics to prompt men to share information with their wives. For example, calls were scheduled for the evening when men were more likely to be at home, increasing the chances that they’d pass on what they heard. 

To drive up subscriptions, we also ran promotions targeting men, which presented the Kilkari subscriber as a smart and engaged role model father, who cares about the health and well-being of his family.

3. Can we do more to keep our target audience engaged? 

We did a for Kilkari, partnering with phone companies to promote the service at 20,000 shops. This went hand-in-hand with community outreach through songs, street theatre, films, quizzes and much else. As a result, we initially got a lot of subscribers, but the drop-out rate was high, suggesting that the service wasn’t relevant to those signing up.

Applying HCD principles, we redefined our audience and rapidly tested solutions to come up with a new and improved marketing strategy. We partnered with community health workers, who were already in contact with the families expecting babies we were trying to reach and so could help us promote Kilkari to its intended audience.

We incentivised health workers by offering them free mobile talk time for every subscription they secured, and gave them even more minutes if subscribers stuck with the service for more than two months.  

In the end, our total number of subscriptions dropped slightly, but those who signed up did so for the long haul – our dropout rate fell to less than 10%.

From lab design to adapting for scale and sustainability

Ultimately, the lessons we learned from our mistakes paid off. Flash forward to January 2016, when the . Kilkari is currently listened to by 1.6 million families in 11 states across India, every week. In a survey of Kilkari’s listeners, three out of four women said they frequently followed advice they’d heard on the service.

We’ll remember Kilkari as the project that taught us the most, not just about how to design for our audiences but also about the value of learning from failure. There’s also the long-lasting satisfaction that comes with finally getting it right.

If you want to find out more about how 主播大秀 Media Action used media and communication at scale to improve maternal, newborn and child health, go to our digital platform, .

Priyanka Dutt is Country Director of 主播大秀 Media Action’s India office. Priyanka’s most recent publication is , which reflects on 主播大秀 Media Action’s Shaping Demand and Practices initiative to improve family health in Bihar, northern India. She tweets as . 

To mark the launch of our site, Sophia Wilkinson explains how health communication can make a big difference at scale – for less than the cost of a can of coke per person.

“But what about the impact?”

This is the question I'm asked the most after I’ve told an audience that, quite literally, millions of people listen to our radio shows and watch our TV programmes about . The other question I routinely get is:

“I don’t care how big your audience is! What I want to know is whether anything has changed?”

What people often don’t realise is that the more people you reach, the bigger the difference you can make. You don’t have to choose between the two.

Skilfully designed and well-executed media and communication projects can not only change behaviour and norms, they can do so at scale. Offering both quality and quantity, such interventions should be immensely attractive to those working to solve the world’s costliest and most widespread health challenges.  

I’m going to brag. In Ethiopia alone, some listened to our radio shows about different aspects of pregnancy, birth and newborn health over the course of just one year – and 14 million did so regularly. This means in the three states where we surveyed – Amhara, Oromia and SNNPR (Southern Nations, Nationalities, and Peoples' Region) – almost half of all adults listened to our shows.

But aside from professional pride, why does this box office success matter when you’re not looking to drive up profits from ticket sales? 

It matters because of the scale of the challenges we’re trying to solve.

In Ethiopia, , 29 will die before they’re even a month old and 48 won’t make it to their first birthday. And every year, due to pregnancy-related complications.

Of course, we all know that the death of many of these mothers and newborns could be avoided. But it’s not just about providing good quality, accessible health services. It also requires lots of people to do things differently in their day-to-day lives. Millions. Not just hundreds.

The Ethiopian women who listened to our shows did just that. They were more likely to have: one, received antenatal care, two, made arrangements for having their baby in a health facility and, three, given birth in a facility or with a skilled attendant looking after them.  

There's a lack of data on what ordinary people think, feel and want in developing countries. Our new aims to help fix that. Sonia Whitehead runs through five questions the portal can help answer on governance, media and resilience.

The development world is all aflutter about data. There’s much talk of a , the sector’s hiring and the World Bank just launched a to ‘data crunch the world’.  

Not to dampen all this excitement but we need a lot more data about people in the Global South before it can become a transformative force there. Addressing this lack of data will speed up progress on everything from to .  

Enter our new  (view on desktop), which brings together data, reports and visualisations from surveys conducted in 13 developing countries that there aren't a lot of statistics about. Over five years, we asked more than 75,000 (rarely polled) people about what they think, feel and want. The portal covers a range of issues from what they’re most worried about to how interested they are in politics.  

We want these insights to help development leaders, practitioners and researchers better understand ordinary people in the developing world so they can produce more effective strategies, projects and communications.

To mark the launch of the portal, we run through five questions that it can help answer on , and , while also showcasing the different types of content available on the portal.

1. What sources of information do people trust?

Being a media organisation, we wanted to know whether people believe what they hear on the airwaves, see on TV and read online. We found that trust levels in radio are universally high, at over 80% in , and , and reaching 90% in .

However, people are more circumspect about the truthfulness of the internet, with the , which is concerning given that say they go online in order to read the news.

To illustrate these (and other) insights into what media people think of different sources of information, we produced a series of visualisations – some of the ones for Kenya are previewed below (media visual available , governance one ): 

Bangladesh-based researcher Mahmuda Hoque explains how her team created a story about “Maya”, a 19-year-old mother, to help bring their findings about antenatal preparations to life.

Researchers often uncover insights with real practical relevance but then struggle to communicate their findings compellingly to those who can make use of them.

I came up against this predicament myself when my team here in Bangladesh surveyed 3,000 mothers, 2,000 fathers and 2,000 mothers-in-law as part of a study about maternal, newborn and child health. One of the aims of our study was to explore which factors helped pregnant women prepare sufficiently – and feel sufficiently prepared – for the birth of their child. The findings would go on to inform the .

We found that knowing what precautionary steps to take ahead of giving birth was the most important factor. The next most significant factor was discussing the issues with family and friends, followed by living in a society where it was common for families to prepare for birth, having a positive attitude and believing in one’s ability to take action.

We wanted to share our results with the project and production team as it was important for them to understand the driving forces behind birth preparedness and their relative importance. But we were worried that they wouldn’t really engage with what we’d discovered.

Bringing numbers to life

You see, we’d reached our findings using structural equation modelling (SEM), which encompasses a series of statistical methods. SEM involves creating a model of how you think factors, such as knowledge and social norms, influence behaviour and then testing it with real-life data. The SEM model is rather off-putting to a layperson due to its complexity, associated jargon (regression analysis, factor analysis, simultaneous equation modeling) and all of the lines and numbers needed to draw it out. Take a look:

Our most popular blogs of the year, featuring: discussion of alternatives to counter-propaganda, tips for successful health communication and recommendations of both development films to watch and Twitter accounts to follow.

It’s been a busy first few months for the Insight blog. Since our launch at the end of June, we’ve covered a diverse array of topics, from and the , to and .

We’ve summarised key finding of our reports on , and , as well as giving a behind-the-scenes look at our , which pushed the envelope in generating media development evidence.

With an eye on what the wider international development sector’s been up to, we’ve responded to the and marked International Human Rights Day with . It’s also been fantastic to have featured guest blogs by experts from the and the – and we hope to have many more contributions next year (email us if you’re interested). 

So as we reflect on 2016, here are our five most popular blogs of the year:  

To help reboot your Twitter timeline, we recommended some international development accounts – focusing on governance, health and humanitarian affairs – that are well worth following. We aimed to feature a variety of voices from across the great expanse of the Twittersphere, and included some familiar handles while introducing to some new faces who should definitely be on your radar.

The effectiveness of IS’s international communication machine, along with that of other extremist groups, has prompted increasingly urgent attempts at crafting effective information responses by policy makers around the world.

Reflecting on these efforts, James Deane and Will Taylor expressed their concern that investing in ‘counter-narratives’ – what some would term counter-propaganda – is not always supported by good evidence. And yet it is here where increasing resources are being focused sometimes, they feared, at the expense of other efforts designed to support free and independent media and other information efforts that might be more effective at reducing violent extremism.

Caroline Sugg summarised five recommendations for accelerating progress in global health communication from our  looking at what makes  excellent health communication, how to fund it and – most crucially – why it should be at the centre of public health work.

Panellists stressed the importance of empathy and community engagement, the need to go ‘beyond messaging’ in communication efforts and invest in evidence and the imperative to prioritise local ownership

For more on this topic,  read Caroline Sugg’s paper.

Films in the international development sector are often associated with fundraising but they can also serve as a form of aid in themselves. Films can help mothers manage a pregnancy, assist refugees as they navigate life in an unfamiliar country and influence perceptions of what politicians can achieve.

We selected five examples of ‘film aid’, including a drama series for teenagers aimed at tackling risky sexual behaviour, a skit to warn refugees about scammers and Nepal’s version of The West Wing.

The World Health Organization’s Dr Venkatraman Chandra-Mouli and Marina Plesons looked at how two education programmes used community engagement to promote young people’s sexual and reproductive health in Pakistan. Their guest blog examined how Aahung and Rutgers WPF – a Pakistani and Dutch organisation respectively – have adapted to local culture and worked with the media to respond to backlash to their sensitive work.

That’s all from the Insight blog for 2016. Looking ahead to next year, 主播大秀 Media Action will launch its new data portal. We’re also due to publish blogs on conducting research in Syria, shifting social norms in Ethiopia and accountability in Somaliland so watch this space!               

 is Digital Editor of the Media Action Insight blog; she tweets as . 

How can community engagement be used to promote young people’s sexual and reproductive health in conservative countries? Two education programmes in Pakistan offer some answers. 

Around the world, there is deep-seated discomfort about adolescent sexuality outside of marriage. Many don’t accept that teenagers have sex; those that do typically see it as a problem only made worse by sexuality education. As a result, policymakers are reticent, school heads and teachers are uncomfortable and community groups are often opposed to sexuality education, paralysing action in many countries.

There are consequently to educate young people about sexual and reproductive health in an age-appropriate and context-specific way. Yet a small number of organisations, including and in Pakistan – an indigenous and Dutch organisation, respectively – are coming to understand and navigate these obstacles, by learning through their own experience of engaging with communities.

Adapting to Pakistani society and culture

Recognising societal and cultural barriers to sexuality education, both Aahung and Rutgers WPF adapted World Health Organization guidelines for life skills-based education (LSBE) to the local context in Pakistan. LSBE aims to inform students about health while equipping them with skills to better manage their own lives and make healthier decisions.

Before engaging with stakeholders, Aahung carried out a power mapping exercise to identify influential community members. It then organised a series of communication-focused activities, such as learning forums and in-person meetings, to gain support from local religious groups and school associations up to the Department of Education.

Having consulted with these communities, Aahung recognised it would be culturally inappropriate to directly address sensitive topics like pre-marital sexual activity by talking about contraceptives. Instead, the organisation targets related problems – including child marriage and gender-based violence – identified as problems by local actors themselves.  

In this way, Aahung simultaneously serves these community interests while adhering to internationally established recommendations by focusing on common intermediate outcomes, such as comfort with one’s own body, communication skills, confidence and decision-making abilities.

Successfully reaching adolescents also requires embracing those in their immediate circles of influence. Realising this, Aahung supports the sensitisation and counselling of parents and the wider community by school administrators and teachers. To increase transparency, Aahung held public theatre performances and discussion sessions to demystify LSBE and win people over to its way of working. Rutgers WPF created a Parents Involvement Strategy in 2011 in pursuit of this same goal. 

Engaging media to prevent and respond to backlash

Media can be both a friend and foe to sexuality education efforts, as both organisations have seen.

In 2011 and 2012, conservative media outlets linked to a religious political party, Jamat-ul-Islami, criticised Rutgers WPF for ‘breaking the moral fabric of Pakistan’ and corrupting the minds of pupils. Following parliamentary discussions, the organisation’s work was stopped in Punjab and it was advised to get the content vetted by religious scholars in Sindh.

In response, Rutgers WPF reached out to a small group of respected and well-known journalists from print, radio and television to help facilitate a dialogue with mass media personnel in the affected provinces. This stimulated public discussion of how LSBE could address the vulnerabilities of adolescents.

Additionally, school visits demonstrated to media personnel how the programme increased the confidence and performance of students and teachers. They saw for themselves that the accusations about Rutgers WPF (e.g. that it was teaching 11-year-old children how to have sex) were false. The participating journalists went on to produce a number of stories about what they learned.  

Rutgers WPF also arranged for progressive religious scholars to review the content of its LBSE curriculum and supplement its content with messages from the Koran. This work fed into a series of meetings with parliamentarians, policy makers, religious scholars and media personnel that culminated in permission to resume LSBE in schools in Sindh.

While Aahung also underwent a similar review, it decided against including religious content in the curriculum. Instead, it used a human rights-based approach to bring legitimacy to its work, demonstrating that different approaches to sexuality education can be successful in the same context.  

Aahung and Rutgers WFP recognise that it’s not enough to run effective education programmes if they aren’t accepted locally and by society-at-large. Both organisations know they must be ready to respond to occasional backlash (often coordinated) from media, religious institutions and other groups. Yet they also value the media as an ally in preventing and responding to this same backlash. A two-pronged approach, whereby these organisations reach out to local communities while simultaneously working with the media, secures both organisations’ local support as well as a network of journalists ready to champion their cause in the face of heated opposition.

For further information, read the case study summaries of and .

For additional detail on LSBE in Pakistan, read this .

Dr Venkatraman Chandra-Mouli works on Adolescent Sexual and Reproductive Health (ASRH) in the World Health Organization’s Department of Reproductive Health and Research. With over 25 years of experience, he focuses on building the evidence base on ASRH, and supporting countries to translate this evidence into action.

Marina Plesons is a public health student interning with Dr Chandra-Mouli; she is also the co-founder of .

This blog was developed with input from Sheena Hadi, Executive Director of Aahung, and Qadeer Baig, Pakistan Country Representative for Rutgers WPF.