Media, Social Pressure, and Combating Misinformation: Experimental Evidence on Mass Media and Contraception Use in Burkina Faso

"...a high-quality mass media public health campaign based on the lessons from behavioral science..., delivered at scale, effectively challenged misconceptions about contraception and increased modern contraception use."

Although the ability to control fertility is associated with many benefits, social norms and misinformation can discourage contraception use in many countries. Many women say they would like to have greater control over the number and timing of births, but they are not using contraception. Partnering with Development Media International (DMI), researchers used a randomised experiment covering 5 million people in Burkina Faso to examine the impact of both general exposure to mass media and an intensive evidence-based family planning campaign on contraception use.

Burkina Faso has a particularly localised, radio-dominated media environment. Radio penetration is high: 68% of households nationally own a radio, and 56% of the population listens to the radio at least once a week. Data from the study area suggests that the average woman listens to the radio 3.2 hours a week.

To measure the impact of increasing exposure to mass media in general, the researchers distributed solar radios to 1,550 women in 1,400 randomly selected households who had no radio at baseline. To measure the impact of the radio campaign, researchers randomly allocated 16 community radio stations between an intervention group (8 stations) where the media campaign took place and a comparison group (8 stations) where regular programing continued. Of the 1,343 households found to have no radio at baseline in campaign areas, half received radios for all the women in those households. This design allowed researchers to first measure the impact of increasing exposure to mass media in areas where regular programming continued as usual for households with no radio at baseline. It also provided two different methods to measure the impact of DMI's radio campaign: by comparing women who received a radio to women who did not in campaign areas, and by comparing all women living in campaign areas with those in noncampaign areas.

The 2.5-year campaign (June 2016 - December 2018) was designed to follow the lessons from behavioural science: making family planning issues highly salient, addressing identified information gaps, and being entertaining. Specifically, DMI aimed to increase knowledge and acceptability of contraceptives, as well as address misconceptions about the benefits and risks of high fertility, through 90-second radio spots broadcast ten times a day and three one-hour phone-in programmes a week - in line with the Saturation+ approach developed by DMI and described at Related Summaries, below. Messages focused on the health benefits of delaying first pregnancies, increasing the time interval between pregnancies, and reducing the number of total children per woman. The campaign also provided information on different types of safe modern contraceptive methods and discussed the benefits of family planning for the family's health and financial wellbeing. The campaign replaced 17% of radios' peak listening time with new (often female-presented) content.

To evaluate the impact on contraceptive use, perceptions of family planning, and general gender norms, researchers collected survey data from 7,500 women of reproductive age (15-49 years old) and 461 clinics, as well as radio station logs. They also gathered monthly administrative data from the Ministry of Health on the number of contraceptives distributed by all clinics located in broadcast areas of study radio stations. One initial concern with the family planning campaign was the risk of potentially increasing domestic violence for women who disagreed with their husband on contraception decision. To monitor this risk, researchers collected data on domestic violence to verify that the campaign had no effect on that outcome. DMI also conducted intensive formative research during the campaign implementation and found no evidence that the prevalence of domestic violence increased due to the campaign.

Results showed that women receiving radios in status quo areas reduced contraception use by 5.2 percentage points or -16%. This negative effect is concentrated among those who wanted fewer children, consistent with mass media increasing social pressure to conform to the modal behaviour in the media market. Specifically, 3 factors help explain these results:

1. While exposure to family planning messaging in noncampaign areas increased by 19 percentage points, these messages were not well aligned with behaviour change principles (e.g., they simply told households where they can receive contraception and reminded them when the free contraception week is - facts most listeners already know). They did not effectively counter misinformation about contraception.
2. While local community radios did not have an anti-family planning agenda (all stations were willing to broadcast the campaign), they are very male dominated (women host/speak roughly 17% of peak listening time). In addition, through call-in shows (17% of peak time), they provide a platform for conservative views that are prevalent in the community. The researchers found some evidence that owning a radio in noncampaign area shifted women to more conservative gender norms, although it did not increase their desired fertility.
3. Households that want fewer children and are more pro-family planning may have felt additional pressure to act in line with the behaviour of their peers.

In campaign areas, the negative impact of radio access on the modern contraceptive prevalence rate (mCPR) was more than compensated for by the DMI campaign. Receiving a radio in campaign areas increased contraception use by 5.8 percentage points (+17.5%). Overall, women in campaign areas were 5.9 percentage points more likely to use modern contraception than those in noncampaign areas, a 20% increase relative to the control rate of 29.5%. Clinic surveys show a 32% increase in family planning consultations in clinics operating within 50 kilometers of campaign radio stations. Administrative data show 11% more injectables and 21% more pills were distributed in campaign areas. Also, births were 10% lower, misperceptions about contraception were lower, and reported welfare was 0.27 standard deviations higher in campaign areas vs. noncampaign areas.

Increased knowledge and a decline in misconceptions about the potential side effects of modern methods appear to explain the increase in mCPR in campaign areas. Women in campaign areas were 9 percentage points (35%) less likely to say modern contraceptive methods can make a woman sterile. Women in campaign areas were 7.8 percentage points more likely (a 14% increase from 54.7% of women in the comparison group) to say that women should control fertility decisions. The researchers found that the campaign made women substitute less-reliable sources of information on family planning (other women in the community) to more reliable (radio) sources.

The researchers estimate that at least 37,000 additional women were using modern contraception because of the pilot mass media campaign, suggesting an annual cost per additional woman using modern contraception in the pilot of US$42.50. DMI scaled up the campaign in January 2019 to involve 39 radio stations, an increase from 8 in the pilot study, reaching 80% of Burkina Faso's population. Under reasonable assumptions, the annual cost dropped to US$7.7 when the media campaign was scaled nationwide. The researchers estimate this scale-up lead to 225,000 additional women using modern contraception in Burkina Faso and roughly 10,000 fewer births a year.

DMI also scaled up delivery of campaigns promoting contraception in several countries, including Ethiopia, Madagascar, Malawi, Mozambique, Tanzania, Uganda, and Zambia. Other non-governmental organisations adopted DMI's approach and are conducting radio campaigns in other contexts.