health

Effect of a mass radio campaign on family behaviours and child survival in Burkina Faso: a repeated cross-sectional, cluster-randomised trial

We found no evidence of an effect of a mass media campaign on child mortality. This finding comes against a background of rapidly decreasing mortality in both groups, which will have reduced our power to detect an effect on mortality (set at 80% to detect a 20% reduction in mortality). The decrease in mortality we recorded is broadly consistent with estimates for Burkina Faso as a whole from the UN Inter-Agency Group for Child Mortality Estimation (IGME). Recent improvements in child survival could reflect changes in national health policies, in particular two rounds of free national distribution of insecticide-treated bednets (2010 and 2013), and the addition of the pneumococcal and rotavirus vaccines to the expanded programme for immunisation in 2013. However, routine health facility data did provide evidence of increased utilisation of health services in intervention clusters relative to control clusters, especially with respect to care seeking for childhood illness. Self-reported behaviours might have been over-reported due to socially desirable bias, especially in the intervention group as a consequence of DMI’s campaign itself. Nevertheless, we observed some evidence of improved care seeking and treatment in the midline survey.9x9Institut National de la Statistique et de la Démographie (INSD). Enquête démographique et de santé et à indicateurs multiples du Burkina Faso 2010. INSD,
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With only a limited number of clusters available, a major limitation of our trial is that, despite randomisation, important differences between the intervention and control groups at baseline were not unlikely.14x14Hayes, RJ and Moulton, LH. Cluster randomised trials. Chapman and Hall,
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The DMI campaign seems to have reached a high proportion of the primary target population as a high proportion of mothers interviewed in the intervention group reported recognising DMI’s spots and listening to the long format programmes. One in five women in the control clusters also reported recognising the spots or long format programme. Excluding the control cluster in which contamination occurred, only a few women mentioned one of DMI’s radio partners when asked on which radio station they listened to these broadcasts, which could suggest courtesy bias or confusion with other radio programmes.

In interpreting these results it should be considered that our survey data are likely to have much lower power than the facility data to detect a change in care seeking. While the survey data include 1000 or fewer sick children per group, the facility data record tens of thousands of consultations. However, both sources of data are prone to errors. Retrospective reporting of illness episodes and care seeking in surveys is known to have important limitations. We used a recall period of 2 weeks, as used in DHS, but it has been shown that recall of disease episodes tends to decline after a few days,20x20Feikin, DR, Audi, A, Olack, B et al. Evaluation of the optimal recall period for disease symptoms in home-based morbidity surveillance in rural and urban Kenya. Int J Epidemiol. 2010;
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The facility data suggest a large increase in under-5 consultations in the intervention group in the first year of the intervention. The estimated impacts in subsequent years are smaller. While this apparent decline could be a chance finding, it might reflect attenuation in the effect of the intervention. In Burkina Faso, in-depth interviews with health workers and patients have revealed low satisfaction with the quality of care in public facilities.25x25Gemignani, R and Wodon, Q. How households choose between health providers? Results from qualitative fieldwork in Burkina Faso. World Bank,
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Our findings showed no effect of the campaign on self-reported habitual behaviours, such as child feeding practices, handwashing, and child stool disposal practices. The campaign’s broadcasts were heavily weighted to care seeking rather than home-based behaviours, and as we have discussed previously, it might be harder to achieve sustained changes in habitual behaviours that need to be performed daily with little obvious immediate benefit, than for behaviours that are only performed occasionally and for which some immediate benefit may be perceived.9x9Institut National de la Statistique et de la Démographie (INSD). Enquête démographique et de santé et à indicateurs multiples du Burkina Faso 2010. INSD,
Calverton (MD); 2012 ()www.unicef.org/bfa/french/bf_eds_2010.pdf. ()
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While we detected evidence that the intervention was associated with an increase in care-seeking in facilities we did not detect any evidence of a reduction in mortality. There are several possible explanations for this apparent inconsistency. First, our mortality data do not exclude the possibility of an impact on mortality with the lower bounds of the 95% confidence interval for the mortality risk ratio compatible with an important reduction in mortality. The impact of the campaign on child mortality has been modelled using the Lives Saved Tool and showed an estimated 8% reduction in the first year, and 5% reduction in the second and third years (unpublished data). In addition, mortality at baseline differed between the two groups despite randomisation. Although we adjusted for pre-intervention mortality risk and a confounder score, which performed reasonably well in explaining the baseline mortality imbalance, we cannot exclude the possibility of residual confounding which might have masked an intervention effect. Second, while the numbers of consultations with diagnoses of malaria, pneumonia and diarrhoea, three of the leading causes of child death in Burkina Faso, all increased (unpublished data), we have no data on the severity of the episodes for which children were taken to facilities. If most of the increase in consultations was due to children with mild self-limiting illness, then limited impact on mortality might be expected. In some parts of Burkina Faso a preference for traditional care has been reported for some severe manifestations of illness, such as cerebral malaria.29x29Beiersmann, C, Sanou, A, Wladarsch, E, De Allegri, M, Kouyaté, B, and Müller, O. Malaria in rural Burkina Fao: local illness concepts, patterns of traditional treatment and influence on health-seeking behaviour. Malar J. 2007;
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Third, if the quality of care received at the facility was low, this could limit any mortality reduction through increased care seeking. An evaluation of the quality of care at health facilities for children under-5, conducted in 2011 in two regions in the north of Burkina Faso, found that on average only six of ten tasks that should be performed as part of IMCI were performed.31x31Kouanda, S and Baguiya, A. Evaluation de la qualité des soins prodigués aux enfants de moins de cinq ans dans les formations sanitaires des régions du Nord et de Centre-Nord du Burkina Faso. Ministère de la Santé du Burkina Faso,
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In summary, there is evidence that DMI’s campaign led to increased use of health facilities, especially by sick children. However, we noted no effect of the campaign on child mortality. The small number of clusters available for randomisation together with the substantial between-cluster heterogeneity at baseline, and rapidly decreasing mortality, limited the power of the study to detect modest changes in behaviour or mortality. Caution should be exercised in interpreting these results since, despite randomisation, there were important differences between intervention and control clusters at baseline. Nevertheless, this study provides some of the best evidence available that a mass media campaign alone can increase health facility utilisation for maternal and child health in a low-income, rural setting.


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