Systematic Review of the Effectiveness of Mass Media Interventions for Child Survival in Low- and Middle-Income Countries
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Auteurs : Danielle A. Naugle ; Robert C. HornikSource :
- Journal of Health Communication [ 1081-0730 ] ; 2014.
Abstract
Through a systematic review of the literature, this article summarizes and evaluates evidence for the effectiveness of mass media interventions for child survival. To be included, studies had to describe a mass media intervention; address a child survival health topic; present quantitative data from a low- or middle-income country; use an evaluation design that compared outcomes using pre- and postintervention data, treatment versus comparison groups, or postintervention data across levels of exposure; and report a behavioral or health outcome. The 111 campaign evaluations that met the inclusion criteria included 15 diarrheal disease, 8 immunization, 2 malaria, 14 nutrition, 1 preventing mother-to-child transmission of HIV, 4 respiratory disease, and 67 reproductive health interventions. These evaluations were then sorted into weak (
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DOI: 10.1080/10810730.2014.918217
PubMed: 25207453
PubMed Central: 4205927
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<front><div type="abstract" xml:lang="en"><p>Through a systematic review of the literature, this article summarizes and evaluates evidence for the effectiveness of mass media interventions for child survival. To be included, studies had to describe a mass media intervention; address a child survival health topic; present quantitative data from a low- or middle-income country; use an evaluation design that compared outcomes using pre- and postintervention data, treatment versus comparison groups, or postintervention data across levels of exposure; and report a behavioral or health outcome. The 111 campaign evaluations that met the inclusion criteria included 15 diarrheal disease, 8 immunization, 2 malaria, 14 nutrition, 1 preventing mother-to-child transmission of HIV, 4 respiratory disease, and 67 reproductive health interventions. These evaluations were then sorted into weak (<italic>n =</italic>
33), moderate (<italic>n</italic>
= 32), and stronger evaluations (<italic>n</italic>
= 46) on the basis of the sampling method, the evaluation design, and efforts to address threats to inference of mass media effects. The moderate and stronger evaluations provide evidence that mass media-centric campaigns can positively impact a wide range of child survival health behaviors.</p>
</div>
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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Health Commun</journal-id>
<journal-id journal-id-type="iso-abbrev">J Health Commun</journal-id>
<journal-id journal-id-type="publisher-id">uhcm20</journal-id>
<journal-id journal-id-type="archive">UHCM</journal-id>
<journal-title-group><journal-title>Journal of Health Communication</journal-title>
</journal-title-group>
<issn pub-type="ppub">1081-0730</issn>
<issn pub-type="epub">1087-0415</issn>
<publisher><publisher-name>Taylor & Francis Group</publisher-name>
</publisher>
</journal-meta>
<article-meta><article-id pub-id-type="pmid">25207453</article-id>
<article-id pub-id-type="pmc">4205927</article-id>
<article-id pub-id-type="publisher-id">918217</article-id>
<article-id pub-id-type="doi">10.1080/10810730.2014.918217</article-id>
<article-id pub-id-type="coden">Journal of Health Communication, Vol. 19, No. S1, pp. 190–215</article-id>
<article-categories><subj-group subj-group-type="heading"><subject>Commissioned Review Article</subject>
</subj-group>
</article-categories>
<title-group><article-title>Systematic Review of the Effectiveness of Mass Media Interventions for Child Survival in Low- and Middle-Income Countries</article-title>
</title-group>
<contrib-group><contrib contrib-type="author"><name><surname>Naugle</surname>
<given-names>Danielle A.</given-names>
</name>
<xref ref-type="aff" rid="AF0001"><sup>a</sup>
</xref>
<xref ref-type="corresp" rid="d12711e22"><sup>*</sup>
</xref>
<email xlink:href="dnaugle@asc.upenn.edu">dnaugle@asc.upenn.edu</email>
</contrib>
<contrib contrib-type="author"><name><surname>Hornik</surname>
<given-names>Robert C.</given-names>
</name>
<xref ref-type="aff" rid="AF0001"><sup>a</sup>
</xref>
</contrib>
<aff id="AF0001"><label><sup>a</sup>
</label>
<institution><named-content content-type="institution-name">Annenberg School for Communication, University of Pennsylvania</named-content>
</institution>
,<named-content content-type="city">Philadelphia</named-content>
,<named-content content-type="state">Pennsylvania</named-content>
,<country>USA</country>
</aff>
</contrib-group>
<author-notes><corresp id="d12711e22"><institution><named-content content-type="institution-name">Annenberg School for Communication, University of Pennsylvania, 3620 Walnut Street</named-content>
</institution>
,
<named-content content-type="city">Philadelphia</named-content>
,
<named-content content-type="state">PA</named-content>
,
<named-content content-type="postalcode">19104</named-content>
,
<country>USA</country>
E-mail:
<email xlink:href="dnaugle@asc.upenn.edu">dnaugle@asc.upenn.edu</email>
</corresp>
</author-notes>
<pub-date pub-type="ppub"><day>6</day>
<month>5</month>
<year>2014</year>
</pub-date>
<pub-date pub-type="epub"><day>10</day>
<month>9</month>
<year>2014</year>
</pub-date>
<volume>19</volume>
<issue>sup1</issue>
<issue-title>Population-Level Behavior Change to Enhance Child Survival and Development in Low- and Middle-Income Countries: A Review of the Evidence</issue-title>
<fpage seq="10">190</fpage>
<lpage>215</lpage>
<permissions><copyright-statement>Copyright Danielle A. Naugle and Robert C. Hornik</copyright-statement>
<copyright-year>2014</copyright-year>
<copyright-holder>Danielle A. Naugle and Robert C. Hornik</copyright-holder>
<license license-type="open-access"><license-p>This is an Open Access article. Non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly attributed, cited, and is not altered, transformed, or built upon in any way, is permitted. The moral rights of the named author(s) have been asserted.</license-p>
</license>
</permissions>
<self-uri content-type="pdf" xlink:type="simple" xlink:href="uhcm-19-190.pdf"></self-uri>
<abstract><p>Through a systematic review of the literature, this article summarizes and evaluates evidence for the effectiveness of mass media interventions for child survival. To be included, studies had to describe a mass media intervention; address a child survival health topic; present quantitative data from a low- or middle-income country; use an evaluation design that compared outcomes using pre- and postintervention data, treatment versus comparison groups, or postintervention data across levels of exposure; and report a behavioral or health outcome. The 111 campaign evaluations that met the inclusion criteria included 15 diarrheal disease, 8 immunization, 2 malaria, 14 nutrition, 1 preventing mother-to-child transmission of HIV, 4 respiratory disease, and 67 reproductive health interventions. These evaluations were then sorted into weak (<italic>n =</italic>
33), moderate (<italic>n</italic>
= 32), and stronger evaluations (<italic>n</italic>
= 46) on the basis of the sampling method, the evaluation design, and efforts to address threats to inference of mass media effects. The moderate and stronger evaluations provide evidence that mass media-centric campaigns can positively impact a wide range of child survival health behaviors.</p>
</abstract>
<funding-group><award-group><funding-source>This research was funded by USAID and the Annenberg School for Communication. The views and opinions expressed in this article are those of the authors and not necessarily the views and opinions of USAID or of the Annenberg School for Communication.</funding-source>
</award-group>
</funding-group>
<counts><fig-count count="1"></fig-count>
<table-count count="4"></table-count>
<ref-count count="130"></ref-count>
<page-count count="26"></page-count>
</counts>
</article-meta>
</front>
<body><p>Beginning in the 1960s, ministries of health in low- and middle-income countries partnered with international organizations to implement interventions addressing maternal and child health. Although global child mortality rates have declined by 70% in the past 50 years, more than 7 million children under the age of 5 years still die each year. In 2012, the Child Survival Call to Action (<ext-link ext-link-type="uri" xlink:href="http://apromiserenewed.org/A_Call_to_Action.html">http://apromiserenewed.org/A_Call_to_Action.html</ext-link>
), a renewed international commitment to ending preventable child deaths by 2035, prompted a series of systematic reviews of the evidence for enhancing child survival and development in low- and middle-income countries through population-level behavior change (Fox & Obregón, <xref rid="CIT0033" ref-type="bibr">2014</xref>
). As part of the Evidence Summit on Enhancing Child Survival and Development in Lower- and Middle-Income Countries by Achieving Population-Level Behavior Change (Evidence Summit), evidence review teams were tasked with synthesizing the evidence in six major domains: supporting children and caregivers, empowering communities, sustainable health systems and policy supports, gender dynamics, stigma and discrimination, and advances in science, technology, and innovation (Balster, Levy, & Stammer, 2014). This article aimed to supplement the work of the evidence review teams by focusing specifically on mass media interventions. Toward that goal, this article summarizes and evaluates the evidence for the effectiveness of mass media interventions for child survival–related health topics including diarrheal diseases, immunization, malaria, nutrition, preventing mother-to-child transmission of HIV, reproductive health, and respiratory infections.</p>
<p>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. The use of mass media to address public health concerns is not intended as a magic bullet, but rather as one of a number of potential intervention strategies that may be more or less appropriate under given circumstances.</p>
<sec id="S002"><title>Prior Published Reviews</title>
<p>The majority of published reviews to date on health topics relevant to child survival in low- and middle-income countries do not mention mass media interventions at all. Others cover mass media only tangentially, noting it as a possible strategy (Briscoe & Aboud, <xref rid="CIT0023" ref-type="bibr">2012</xref>
; Chopra, Sharkey, Dalmiya, Anthony, & Binkin, <xref rid="CIT0025" ref-type="bibr">2012</xref>
; Pegurri, Fox-Rushby, & Damian, <xref rid="CIT0089" ref-type="bibr">2005</xref>
). Of the reviews that do address mass media health communication in low- and middle-income countries, many highlight HIV/AIDS and reproductive health interventions because they comprise the bulk of the published literature in this area (HIV: Bertrand, O'Reilly, Denison, Anhang, & Sweat, <xref rid="CIT0015" ref-type="bibr">2006</xref>
; Myhre & Flora, <xref rid="CIT0082" ref-type="bibr">2000</xref>
; Noar, Palmgreen, Chabot, Dobransky, & Zimmerman, <xref rid="CIT0084" ref-type="bibr">2009</xref>
; reproductive health: Basten, <xref rid="CIT0013" ref-type="bibr">2009</xref>
; Hornik & McAnany, <xref rid="CIT0047" ref-type="bibr">2001</xref>
; Snyder, Nafissatou, & Badiane, <xref rid="CIT0105" ref-type="bibr">2003</xref>
; Storey et al., <xref rid="CIT0109" ref-type="bibr">2011</xref>
). HIV/AIDS interventions, with the exception of campaigns focusing specifically on preventing mother-to-child transmission (PMTCT), are beyond the scope of this review, but reproductive health interventions are relevant, since child timing and spacing is related to child survival.</p>
<p>Four prior reviews include substantial discussion of mass media campaigns promoting reproductive health in low- and middle-income countries. In a meta-analysis of integrated family planning campaigns that received technical assistance from the Johns Hopkins Bloomberg School of Public Health/Center for Communication Programs (JHU/CCP) between 1986 and 2001, Snyder, Nafissatou, and Badiane (<xref rid="CIT0105" ref-type="bibr">2003</xref>
) identified an average effect size of .07 for mass media campaigns addressing the use of modern methods (on the basis of data from 15 of the 39 campaigns). In a review of mass media effects on fertility, Hornik and McAnany (<xref rid="CIT0047" ref-type="bibr">2001</xref>
) dedicated a section to the evaluations of family planning interventions in twelve low- and middle-income countries between 1976 and 1999. They found that although there is evidence for the effectiveness of mass mediated programs in increasing demand for contraceptive services at clinics, there is much less evidence for an effect on population-level behavior and even less for long-term effects. Once the intervention ceases, clinic demand tends to rejoin the preintervention trend. Basten (<xref rid="CIT0013" ref-type="bibr">2009</xref>
) reviewed edutainment interventions for reproductive health and found evidence suggesting that soap operas can be effective in changing attitudes and behaviors related to reproductive health. A report by Storey and colleagues (<xref rid="CIT0109" ref-type="bibr">2011</xref>
) summarized social and behavior change interventions in the area of reproductive health, maternal health, neonatal health, and child health and nutrition. After searching PubMed, Scopus, and Popline for studies published between <xref rid="CIT0108" ref-type="bibr">2000</xref>
and 2010, they identified 19 articles with mass media interventions in low- and middle-income countries. Of those, seven also meet our inclusion criteria as described below (six family-planning campaigns and one iron deficiency anemia campaign), and the rest either deal with HIV/AIDS or do not have a behavioral outcome. The authors concluded that mass media campaigns that are theory-based, targeted, and use multiple media channels can affect reproductive health behavior through ideation/social diffusion.</p>
<p>Two reviews, both written by Green (<xref rid="CIT0035" ref-type="bibr">1989</xref>
, <xref rid="CIT0036" ref-type="bibr">1999</xref>
), that evaluate the effects of mass media on breastfeeding between 1980 and 1999 are also relevant. Although mass media-centric programs have been effective in improving breastfeeding behaviors, Green (<xref rid="CIT0035" ref-type="bibr">1989</xref>
, <xref rid="CIT0036" ref-type="bibr">1999</xref>
) found that many of the intervention and evaluation designs do not permit causal inferences; other program components may have been responsible for some or all of the observed effect.</p>
<p>Wakefield, Loken, and Hornik (<xref rid="CIT0125" ref-type="bibr">2010</xref>
) covered a range of child survival health topics in a systematic examination of reviews and notable studies published after 1998 and retrieved from Medline, PsycINFO, Embase, Soclit, ERIC, and Communication and Mass Media Complete. They found moderate evidence for the effectiveness of mass media campaigns on family planning, immunization, and diarrheal disease, and weak evidence for mass media breastfeeding interventions. They concluded that programs in which mass media is part of a multifaceted intervention strategy are more likely to be successful than mass media alone and that one-off or episodic behaviors are more amenable to mass media effects than habitual or ongoing behaviors.</p>
<p>These reviews highlight the potential for mass media to impact child survival, but underscore the reality that health communication campaigns are almost always implemented in conjunction with other interventions making it difficult to isolate independent effects. Although randomized controlled trials are the gold standard for establishing cause and effect, they generally are not appropriate for mass mediated public health campaigns. For those campaigns, interventions with mutually reinforcing program components are widely considered best practice. Furthermore, policy interest is in campaigns that operate on a large scale and over time rather than in the tightly controlled and focused interventions that are well studied with randomized controlled designs. As a result, evaluators use a variety of methods to link mass media messages to behavior change and often, as with the intervention itself, the most successful evaluation is one that combines several methods.</p>
</sec>
<sec sec-type="methods" id="S003"><title>Method</title>
<sec id="S003-S2001"><title>Search Strategy</title>
<p>This article provides a systematic review of the literature containing evidence about the effects of mass media interventions on child survival–related behavior change in low- and middle-income countries. It attempts to address what has been done, what has been successful, and what knowledge gaps remain. 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. Descriptive studies, studies on general mass media effects as opposed to purposeful interventions, and studies reporting only outcomes in knowledge, attitudes or intentions were excluded.</p>
<p>We conducted a two-phase search strategy to locate as many full-text English-language evaluations as possible between 1960 and May 2013 in both the published and gray literature. First, we searched electronic databases including Communication and Mass Media Complete, Embase, PsychInfo, and Medline/PubMed for articles mentioning a communication related term in the title in conjunction with the name of a low- or middle-income country in the title or abstract and any of a set of terms associated with the seven health topics relevant to child survival (for an example, see online supplemental archives). The search returned 3,861 titles and abstracts that were screened for duplication and relevance (Figure <xref rid="F0001" ref-type="fig">1</xref>
). Of those, 119 full-text articles were considered relevant and were assessed for eligibility. In the second phase of the search, bibliographies of the retrieved articles, the search results of the Evidence Summit (Balster et al., <xref rid="CIT0012" ref-type="bibr">2014</xref>
), and the website of the Center for Communication Programs were examined for relevant material resulting in 106 additional titles. The authors used a variety of methods to locate promising abstracts and recover the full-text documents which were then assessed for eligibility.
<fig id="F0001" orientation="portrait" position="float"><label>Figure 1</label>
<caption><p>PRISMA flow diagram.</p>
</caption>
<graphic xlink:href="uhcm-19-190-g001"></graphic>
</fig>
</p>
<p>A total of 120 full-text articles including 13 diarrheal disease, 15 immunization, 25 malaria, 16 nutrition, 5 PMTCT, 2 respiratory infections, and 44 reproductive health studies were excluded after careful review. In general, the excluded studies failed to meet several criteria: 52% percent did not have a purposeful mass media intervention, 3% did not deal with one of the stated child survival health topics, 7% did not present quantitative data from a low- or middle-income country, 41% did not incorporate at least one comparison group, and 54% did not measure and report a behavioral or health outcome.</p>
<p>The search process resulted in a total of 106 articles that met the inclusion criteria including 11 diarrheal disease, 6 immunization, 2 malaria, 14 nutrition, 1 PMTCT, 4 respiratory infection, and 68 reproductive health studies (Table <xref rid="T0001" ref-type="table">1</xref>
). All together, the studies describe 111 campaigns in 46 low- and middle-income countries. Some of the articles describe multiple campaigns (Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
, for example, describes eight campaigns), whereas some campaigns are described in multiple papers. In addition, some campaigns address multiple child survival topics and were included in each of the health topics for which they provided behavioral outcome measures (e.g., the Smiling Sun Campaign in Bangladesh was included in both the immunization and reproductive health sections).
<table-wrap orientation="portrait" id="T0001" position="float"><label>Table 1.</label>
<caption><title> Summary of systematic review search results</title>
</caption>
<pmc-comment>OASIS TABLE HERE</pmc-comment>
<table frame="hsides" rules="groups"><colgroup><col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
</colgroup>
<thead valign="bottom"><tr><th align="left">Child survival health topic</th>
<th align="center">Full-text articles assessed for eligibility</th>
<th align="center">Full-text articles excluded with reasons</th>
<th align="center">Studies included in synthesis</th>
<th align="center">Campaigns</th>
</tr>
</thead>
<tbody><tr><td align="left">Diarrheal disease</td>
<td align="right">24</td>
<td align="right">13</td>
<td align="right">11</td>
<td align="right">15</td>
</tr>
<tr><td align="left">Immunization</td>
<td align="right">21</td>
<td align="right">15</td>
<td align="right">6</td>
<td align="right">8</td>
</tr>
<tr><td align="left">Malaria</td>
<td align="right">27</td>
<td align="right">25</td>
<td align="right">2</td>
<td align="right">2</td>
</tr>
<tr><td align="left">Nutrition</td>
<td align="right">30</td>
<td align="right">16</td>
<td align="right">14</td>
<td align="right">14</td>
</tr>
<tr><td align="left">PMTCT</td>
<td align="right">6</td>
<td align="right">5</td>
<td align="right">1</td>
<td align="right">1</td>
</tr>
<tr><td align="left">Respiratory disease</td>
<td align="right">6</td>
<td align="right">2</td>
<td align="right">4</td>
<td align="right">4</td>
</tr>
<tr><td align="left">Reproductive health</td>
<td align="right">112</td>
<td align="right">44</td>
<td align="right">68</td>
<td align="right">67</td>
</tr>
<tr><td align="left">Total</td>
<td align="right">226</td>
<td align="right">120</td>
<td align="right">106</td>
<td align="right">111</td>
</tr>
<tr><td colspan="5" align="left"><italic>Note.</italic>
Some articles describe more than one campaign, and some campaigns are described by more than one article. PMTCT = Preventing mother-to-child transmission.</td>
</tr>
</tbody>
</table>
</table-wrap>
</p>
<p>For each of the included studies, descriptive tables were created to capture important features of the mass media campaigns and their corresponding evaluations (accessible in online supplemental archives). These details were then transferred to an excel spreadsheet to facilitate a summary description of the interventions (accessible in online supplemental archives). As described in more detail below, evidence for the success of the mass media campaigns was assessed by categorizing the evaluations as weak, moderate, or stronger and drawing conclusions from the moderate and stronger evaluations about the potential for mass media campaigns to impact behavioral and health outcomes related to child survival.</p>
</sec>
</sec>
<sec sec-type="results" id="S004"><title>Results</title>
<sec id="S004-S2001"><title>What Has Been Done?</title>
<p>We 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 (Noar, <xref rid="CIT0083" ref-type="bibr">2006</xref>
). Unfortunately, it is often not clear from the written evaluation whether each of these components was incorporated in the campaign design, rendering the information difficult to code. Details about formative research and message pretesting, although surely underreported, were relatively straightforward to code. Use of theory, however, was difficult to code because it was often unclear when authors claimed to use theory whether it was employed in the design of the campaign, the evaluation, or simply post hoc in the written article. Consequently, the results can more accurately be understood as reflecting the details provided by campaign evaluators rather than what the campaigns actually did or did not do. We will review the interventions by major health topics affecting child survival. For a summary of campaign regions, decades, and communication channels see Table <xref rid="T0002" ref-type="table">2</xref>
.
<table-wrap orientation="landscape" id="T0002" position="float"><label>Table 2.</label>
<caption><title> Summary of campaign region, decade, and communication channels</title>
</caption>
<pmc-comment>OASIS TABLE HERE</pmc-comment>
<table frame="hsides" rules="groups"><colgroup><col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
</colgroup>
<thead valign="bottom"><tr><th align="left">Health topic</th>
<th align="center"><italic>n</italic>
</th>
<th align="center">East Asia and the Pacific</th>
<th align="center">Europe and Central Asia</th>
<th align="center">Latin America and Caribbean</th>
<th align="center">Middle East and North Africa</th>
<th align="center">South Asia</th>
<th align="center">Sub-Saharan Africa</th>
<th align="center">1960s</th>
<th align="center">1970s</th>
<th align="center">1980s</th>
<th align="center">1990s</th>
<th align="center">2000</th>
<th align="center">2010</th>
<th align="center">Television</th>
<th align="center">Radio</th>
<th align="center">Newspapers</th>
<th align="center">Interpersonal communication</th>
</tr>
</thead>
<tbody><tr><td align="left">Diarrheal disease</td>
<td align="right">15</td>
<td align="center">2</td>
<td align="center">0</td>
<td align="center">2</td>
<td align="center">1</td>
<td align="center">2</td>
<td align="center">8</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">10</td>
<td align="center">2</td>
<td align="center">3</td>
<td align="center">0</td>
<td align="center">5</td>
<td align="center">12</td>
<td align="center">1</td>
<td align="center">13</td>
</tr>
<tr><td align="left">Immunization</td>
<td align="right">8</td>
<td align="center">1</td>
<td align="center">0</td>
<td align="center">3</td>
<td align="center">0</td>
<td align="center">2</td>
<td align="center">2</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">3</td>
<td align="center">4</td>
<td align="center">1</td>
<td align="center">0</td>
<td align="center">6</td>
<td align="center">8</td>
<td align="center">3</td>
<td align="center">6</td>
</tr>
<tr><td align="left">Malaria</td>
<td align="right">2</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">2</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">1</td>
<td align="center">1</td>
<td align="center">1</td>
<td align="center">1</td>
<td align="center">0</td>
<td align="center">1</td>
</tr>
<tr><td align="left">Nutrition</td>
<td align="right">14</td>
<td align="center">4</td>
<td align="center">1</td>
<td align="center">6</td>
<td align="center">1</td>
<td align="center">0</td>
<td align="center">2</td>
<td align="center">0</td>
<td align="center">1</td>
<td align="center">4</td>
<td align="center">4</td>
<td align="center">4</td>
<td align="center">1</td>
<td align="center">8</td>
<td align="center">11</td>
<td align="center">4</td>
<td align="center">10</td>
</tr>
<tr><td align="left">PMTCT</td>
<td align="right">1</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">1</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">1</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">1</td>
<td align="center">0</td>
<td align="center">0</td>
</tr>
<tr><td align="left">Respiratory disease</td>
<td align="right">4</td>
<td align="center">1</td>
<td align="center">0</td>
<td align="center">2</td>
<td align="center">0</td>
<td align="center">1</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">3</td>
<td align="center">1</td>
<td align="center">0</td>
<td align="center">4</td>
<td align="center">4</td>
<td align="center">4</td>
<td align="center">3</td>
</tr>
<tr><td align="left">All child survival</td>
<td align="right">44</td>
<td align="center">8</td>
<td align="center">1</td>
<td align="center">13</td>
<td align="center">2</td>
<td align="center">5</td>
<td align="center">15</td>
<td align="center">0</td>
<td align="center">1</td>
<td align="center">17</td>
<td align="center">13</td>
<td align="center">11</td>
<td align="center">2</td>
<td align="center">24</td>
<td align="center">37</td>
<td align="center">12</td>
<td align="center">33</td>
</tr>
<tr><td> </td>
<td> </td>
<td align="center">18%</td>
<td align="center">2%</td>
<td align="center">30%</td>
<td align="center">5%</td>
<td align="center">11%</td>
<td align="center">34%</td>
<td align="center">0%</td>
<td align="center">2%</td>
<td align="center">39%</td>
<td align="center">30%</td>
<td align="center">25%</td>
<td align="center">5%</td>
<td align="center">55%</td>
<td align="center">84%</td>
<td align="center">27%</td>
<td align="center">75%</td>
</tr>
<tr><td align="left">Reproductive health</td>
<td align="right">67</td>
<td align="center">8</td>
<td align="center">1</td>
<td align="center">15</td>
<td align="center">8</td>
<td align="center">11</td>
<td align="center">24</td>
<td align="center">4</td>
<td align="center">10</td>
<td align="center">11</td>
<td align="center">28</td>
<td align="center">13</td>
<td align="center">1</td>
<td align="center">37</td>
<td align="center">60</td>
<td align="center">19</td>
<td align="center">25</td>
</tr>
<tr><td> </td>
<td> </td>
<td align="center">12%</td>
<td align="center">1%</td>
<td align="center">22%</td>
<td align="center">12%</td>
<td align="center">16%</td>
<td align="center">36%</td>
<td align="center">6%</td>
<td align="center">15%</td>
<td align="center">16%</td>
<td align="center">42%</td>
<td align="center">19%</td>
<td align="center">1%</td>
<td align="center">55%</td>
<td align="center">90%</td>
<td align="center">28%</td>
<td align="center">37%</td>
</tr>
<tr><td colspan="18" align="left"><italic>Note.</italic>
PMTCT = preventing mother-to-child transmission.</td>
</tr>
</tbody>
</table>
</table-wrap>
</p>
<sec><title>Diarrheal Disease</title>
<p>A total of 11 studies describing 15 diarrheal disease campaigns met our inclusion criteria. The campaigns took place primarily in Sub-Saharan Africa (Burkina Faso, Burundi, Democratic Republic of the Congo [formerly Zaire], The Gambia, Ghana, Kenya, Lesotho, and Swaziland) with additional campaigns in Ecuador, Egypt, India, Indonesia, Mexico, and Pakistan. Ten campaigns took place in the 1980s, two in the <xref rid="CIT0062" ref-type="bibr">1990</xref>
s, and three after the year 2000. Eleven of the campaigns promoted the use of oral rehydration therapy, either a homemade water-sugar-salt solution or manufactured packets of oral rehydration solution, to prevent dehydration during diarrheal episodes. The diarrheal disease campaigns that did not promote oral rehydration therapy addressed proper stool disposal and/or handwashing (Curtis et al., <xref rid="CIT0026" ref-type="bibr">2001</xref>
; Scott, Schmidt, Aunger, Carbrah-Aidoo, & Animashaun, 2008), water purification (JHU/CCP, 2008), or increased fluid intake (but not specifically oral rehydration therapy) during episodes of diarrhea (Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
). Of the studies, 80% described formative research, 80% mentioned a behavior change theory (most commonly the theory of reasoned action, health belief model, and social marketing), and 53% pretested campaign messages.</p>
<p>All of the campaigns targeted caretakers of children under the age of 5 years. One also targeted community leaders and important others (mothers-in-law, fathers, neighbors; Curtis et al., <xref rid="CIT0026" ref-type="bibr">2001</xref>
). In general, the campaigns aimed to increase knowledge of the causes and consequences of diarrhea in young children and change beliefs and behaviors regarding the treatment of diarrhea. Only one campaign tried to increase social network discussion (Curtis et al., <xref rid="CIT0026" ref-type="bibr">2001</xref>
) or change social norms (JHU/CCP, 2008). In terms of channels, 80% of the campaigns used the radio and 33% used the television, most often in the form of radio and television spots (47% and 27%, respectively). One campaign also used a television drama and television programs (JHU/CCP, 2008), one used a song played on the radio (Scott et al., <xref rid="CIT0100" ref-type="bibr">2008</xref>
), and one used radio programs (Curtis et al., <xref rid="CIT0026" ref-type="bibr">2001</xref>
). Pamphlets (60%), posters (40%), and billboards (33%) were widely used, whereas only one campaign used newspapers (JHU/CCP, 2008), two used mobile cinema (Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
; Kenya et al., <xref rid="CIT0062" ref-type="bibr">1990</xref>
), two used promotional materials (Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
; Kassegne, Kays, & Nzohabonayo, <xref rid="CIT0061" ref-type="bibr">2011</xref>
), and one used flipcharts (Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
). Of the diarrheal disease campaigns, 87% included a complementary interpersonal communication component either in the form of training of service providers (40%), community health workers (27%), or retailers (7%), or community events (20%) and school-based activities (20%). Most of the campaigns lasted fewer than 2 years, with five campaigns lasting longer (Curtis et al., <xref rid="CIT0026" ref-type="bibr">2001</xref>
; Fox, 1998; Gutiérrez et al., <xref rid="CIT0042" ref-type="bibr">1996</xref>
; Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
; Miller & Hirschhorn, <xref rid="CIT0079" ref-type="bibr">1995</xref>
). Only three campaigns provided any information about the frequency of message delivery, indicating that messages were aired daily (Fox, 1998; Kassegne et al., <xref rid="CIT0061" ref-type="bibr">2011</xref>
; Miller & Hirschhorn, <xref rid="CIT0079" ref-type="bibr">1995</xref>
; Scott et al., <xref rid="CIT0100" ref-type="bibr">2008</xref>
).</p>
</sec>
<sec><title>Immunization</title>
<p>Six studies describing eight immunization campaigns met our inclusion criteria. The campaigns took place in Bangladesh, Democratic Republic of the Congo, Ecuador, Lesotho, Mexico, Peru, and the Philippines in the 1980s and 1990s. Only one campaign took place after the year 2000 (Guilkey & Hutchinson, <xref rid="CIT0040" ref-type="bibr">2011</xref>
). The campaigns generally focused on more than one of the routine childhood vaccinations including polio (75%); diphtheria, pertussis, and tetanus (63%); measles (88%); and tuberculosis (50%). They aimed to increase utilization of vaccination services by informing parents of (a) the role vaccinations play in preventing common childhood illnesses and (b) when and where vaccinations are offered free of charge. One campaign also mentioned engaging in advocacy (Guilkey & Hutchinson, <xref rid="CIT0040" ref-type="bibr">2011</xref>
). Of the studies, 75% described formative research and 75% mentioned a behavior change theory including the theory of reasoned action, health belief model, entertainment-education, social cognitive theory, and applied behavioral analysis. Sixty-three percent claimed to have pretested messages.</p>
<p>In general, the immunization campaigns targeted caretakers of children under age 5 years using radio (100%), television (75%), and newspapers (38%). The most common format was radio and television spots, but one campaign also used a television drama and quiz show (Guilkey & Hutchinson, <xref rid="CIT0040" ref-type="bibr">2011</xref>
) and one campaign used a radio song (Pérez-Cuevas et al., <xref rid="CIT0090" ref-type="bibr">1999</xref>
). Pamphlets and posters were used by half of the campaigns, whereas only two used promotional materials (Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
), and one each used billboards (Guilkey & Hutchinson, <xref rid="CIT0040" ref-type="bibr">2011</xref>
), flipcharts (Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
), or mobile loudspeakers (Quaiyum, Tunon, Baqui, Yum, & Khatun, 1997). All but two of the immunization campaigns included an interpersonal component, most commonly immunization days (Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
; Pérez-Cuevas et al., <xref rid="CIT0090" ref-type="bibr">1999</xref>
; Quaiyum et al., <xref rid="CIT0094" ref-type="bibr">1997</xref>
), the training of service providers (Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
), community events (Guilkey & Hutchinson, <xref rid="CIT0040" ref-type="bibr">2011</xref>
; Quaiyum et al., <xref rid="CIT0094" ref-type="bibr">1997</xref>
), and activities in schools (Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
). Most of the campaigns lasted less than 1 year, with only two extending for longer periods of time (Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
). None of the campaigns provided information about the frequency of message delivery.</p>
</sec>
<sec><title>Malaria</title>
<p>Only two studies describing malaria campaigns met our inclusion criteria. One campaign in The Gambia was not really a mass media campaign, but was included in this review because it had the potential to be scaled up and because evaluations of mass media campaigns addressing malaria are rare. In this campaign, audio messages in the form of songs encouraging people to repair holes in their bed nets were disseminated on cassette tapes in a Gambian village between August and November 2003 (Panter-Brick, Clarke, Lomas, Pinder, & Lindsay, <xref rid="CIT0087" ref-type="bibr">2006</xref>
). The Knock Out Malaria campaign in Cameroon comprised two 3-month campaign waves (July to October 2011 and April to July 2012). The campaign engaged famous local artists to promote consistent use of bed nets through catchy radio songs and spots and television music videos that quickly went viral (Bowen, <xref rid="CIT0022" ref-type="bibr">2013</xref>
). The Knock Out Malaria campaign also used billboards and mobile phone texts to disseminate messages. Both studies described formative research and a theoretical framework, but neither explicitly mentioned pretesting campaign messages. The messages were directed to the general public, encouraging everyone to sleep under well-maintained mosquito nets.</p>
</sec>
<sec><title>Nutrition</title>
<p>Fourteen studies describing fourteen nutrition campaigns met our inclusion criteria. The campaigns took place in Bolivia, Brazil, China, Honduras, Indonesia, Jordan, Kazakhstan, Mali, Mexico, Trinidad and Tobago, and Uganda. The interventions addressed a wide variety of nutrition topics including breastfeeding, complementary feeding, and/or adequate nutritional intake. Breastfeeding campaigns often focus on the importance of early initiation, giving colostrum, breastfeeding exclusively for the first 6 months, continued breastfeeding for 2 years, and the timely introduction of complementary foods (Ferreira Rea & Berquo, <xref rid="CIT0030" ref-type="bibr">1990</xref>
; Gueri, Jutsum, & White, <xref rid="CIT0037" ref-type="bibr">1978</xref>
; Gupta, Katende, & Bessinger, <xref rid="CIT0039" ref-type="bibr">2004</xref>
; Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
; Huffman, Panagides, Rosenbaum, & Parlato, <xref rid="CIT0049" ref-type="bibr">1991</xref>
; Monterrosa et al., <xref rid="CIT0081" ref-type="bibr">2013</xref>
). Interventions addressing complementary feeding of children between 6 and 24 months of age emphasized not giving food and water until 6 months of age, continued breastfeeding, hands-on feeding practices, meal frequency, and meal diversity (Bonvecchio et al., <xref rid="CIT0019" ref-type="bibr">2007</xref>
; Huffman et al., <xref rid="CIT0049" ref-type="bibr">1991</xref>
; Monterrosa et al., <xref rid="CIT0081" ref-type="bibr">2013</xref>
; Sun et al., <xref rid="CIT0110" ref-type="bibr">2011</xref>
). Adequate nutritional intake interventions promoted the consumption of supplements/fortified foods (Bonvecchio et al., <xref rid="CIT0019" ref-type="bibr">2007</xref>
; Sun et al., <xref rid="CIT0110" ref-type="bibr">2011</xref>
; Sun, Guo, Wang, & Sun, <xref rid="CIT0111" ref-type="bibr">2007</xref>
; Warnick et al., <xref rid="CIT0126" ref-type="bibr">2004</xref>
) or foods naturally rich in essential nutrients such as vitamin A (De Pee et al., <xref rid="CIT0027" ref-type="bibr">1998</xref>
; Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
; Monterrosa et al., <xref rid="CIT0081" ref-type="bibr">2013</xref>
; Parvanta, Gottert, Anthony, & Parlato, <xref rid="CIT0088" ref-type="bibr">1997</xref>
) or iron (Baizhumanova et al., <xref rid="CIT0011" ref-type="bibr">2010</xref>
; Monterrosa et al., 2013; Sun et al., <xref rid="CIT0111" ref-type="bibr">2007</xref>
). Of the studies, 57% described some formative research, 71% mentioned a theoretical framework, most commonly social marketing, the theory of reasoned action, and the health belief model, and 36% pretested messages.</p>
<p>The nutrition campaigns targeted primarily women of reproductive age. Two campaigns each also targeted men of reproductive age (Gupta et al., <xref rid="CIT0039" ref-type="bibr">2004</xref>
; Parvanta et al., <xref rid="CIT0088" ref-type="bibr">1997</xref>
), health workers (Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
; Sun et al., <xref rid="CIT0110" ref-type="bibr">2011</xref>
), or caregivers of children 6–24 months old (Bonvecchio et al., <xref rid="CIT0019" ref-type="bibr">2007</xref>
; Sun et al., <xref rid="CIT0110" ref-type="bibr">2011</xref>
). Radio was used by 79% of the campaigns, television by 57%, and newspapers by 29%. Radio and television spots were the most common format used by 57% and 43% respectively, but television programs (Sun et al., <xref rid="CIT0110" ref-type="bibr">2011</xref>
), radio programs (Huffman et al., <xref rid="CIT0049" ref-type="bibr">1991</xref>
, Monterrosa et al., <xref rid="CIT0081" ref-type="bibr">2013</xref>
), radio dramas (Parvanta et al., <xref rid="CIT0088" ref-type="bibr">1997</xref>
), and radio songs (Huffman et al., <xref rid="CIT0049" ref-type="bibr">1991</xref>
) were also used by some campaigns. In addition, 57% of campaigns used posters and/or pamphlets and a couple used flipcharts (Bonvecchio et al., <xref rid="CIT0019" ref-type="bibr">2007</xref>
; Parvanta et al., <xref rid="CIT0088" ref-type="bibr">1997</xref>
), promotional materials (Sun et al., <xref rid="CIT0111" ref-type="bibr">2007</xref>
; Warnick et al., <xref rid="CIT0126" ref-type="bibr">2004</xref>
), billboards (De Pee et al., <xref rid="CIT0027" ref-type="bibr">1998</xref>
), or mobile loudspeakers and/or videos shown in health care facilities (Bonvecchio et al., <xref rid="CIT0019" ref-type="bibr">2007</xref>
). Of the nutrition campaigns, 71% included an interpersonal communications component in the form of training of service providers or community health workers (Gupta et al., <xref rid="CIT0039" ref-type="bibr">2004</xref>
; Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
; Sun et al., <xref rid="CIT0110" ref-type="bibr">2011</xref>
) and two held community events (Sun et al., <xref rid="CIT0111" ref-type="bibr">2007</xref>
; Warnick et al., <xref rid="CIT0126" ref-type="bibr">2004</xref>
). One of the nutrition campaigns lasted less than a month (Monterrosa et al., <xref rid="CIT0081" ref-type="bibr">2013</xref>
) and two ran, intermittently, for more than 12 months (Ferreira Rea & Berquo, <xref rid="CIT0030" ref-type="bibr">1990</xref>
; Huffman et al., <xref rid="CIT0049" ref-type="bibr">1991</xref>
), but the majority of the campaigns were between 1 and 12 months long. Only three studies mentioned that campaign messages aired daily; the rest provided no frequency information.</p>
</sec>
<sec><title>PMTCT</title>
<p>Only one PMTCT campaign met our inclusion criteria. The study described a twice-weekly serial drama aired on national radio in Botswana between 2001 and 2003 (Kuhlmann et al., <xref rid="CIT0070" ref-type="bibr">2008</xref>
). The drama included characters and storylines that illustrate both the negative consequences of not getting tested for HIV during pregnancy and the benefits of PMTCT services. The study did not describe any formative research or message pretesting but mentioned social cognitive theory and the Modeling and Reinforcement to Combat HIV (MARCH) framework.</p>
</sec>
<sec><title>Respiratory Diseases</title>
<p>Although the search for mass media campaigns addressing respiratory diseases included both pneumonia and tuberculosis, only four tuberculosis campaigns (and no pneumonia campaigns) met our inclusion criteria. The campaigns took place in Colombia, Peru, and Vietnam in the 1990s and in India in 2001. Messages informed the general public about the symptoms of tuberculosis and encouraged anyone with a cough lasting more than 15 days to seek treatment. The messages emphasized the treatability of the disease, often free at local clinics, and the severity if left untreated. Two campaigns also tried to reduce stigma towards people with tuberculosis (Jaramillo, <xref rid="CIT0056" ref-type="bibr">2001</xref>
; Llanos-Zavalaga, Poppe, Tawfik, & Church-Balin, <xref rid="CIT0073" ref-type="bibr">2004</xref>
). One campaign specifically targeted community leaders in addition to the general public (Thuy, Huong, Tawfik, & Church-Balin, <xref rid="CIT0115" ref-type="bibr">2004</xref>
). Three of the four studies described formative research, but only one mentioned theory (Jaramillo, <xref rid="CIT0056" ref-type="bibr">2001</xref>
), and none mentioned pretesting messages. All of the tuberculosis campaigns used radio, television, and newspapers to disseminate campaign messages through a wide variety of formats including spots, talk shows, and dramas. A few campaigns also used videos shown in health care facility waiting areas (Llanos-Zavalaga et al., <xref rid="CIT0073" ref-type="bibr">2004</xref>
), posters (Sharma et al., <xref rid="CIT0102" ref-type="bibr">2005</xref>
; Thuy et al., <xref rid="CIT0115" ref-type="bibr">2004</xref>
), and pamphlets (Thuy et al., <xref rid="CIT0115" ref-type="bibr">2004</xref>
). Three out of the four campaigns supplemented the mass media with interpersonal communication, primarily community events and training of service providers (Llanos-Zavalaga et al., <xref rid="CIT0073" ref-type="bibr">2004</xref>
; Thuy et al., <xref rid="CIT0115" ref-type="bibr">2004</xref>
). The duration of the tuberculosis campaigns varied from 6 weeks (Jaramillo, <xref rid="CIT0056" ref-type="bibr">2001</xref>
) to intermittently over the course of 13 years (Llanos-Zavalaga et al., <xref rid="CIT0073" ref-type="bibr">2004</xref>
) and none of the campaigns provided information about the frequency of emissions.</p>
</sec>
<sec><title>Reproductive Health</title>
<p>Sixty-eight reproductive health studies describing 67 campaigns across the globe between the 1960s and 2013 met our inclusion criteria. For the most part, the campaigns were general family planning/birth spacing campaigns that aimed to increase uptake of modern contraceptive methods and services among men and women of reproductive age. Often campaigns targeted specific sub-groups including women (72%), men (63%), married people (28%), people of low (Bailey, Janowitz, Solis, Machuca, & Sauzo, 1989; Kincaid et al., <xref rid="CIT0065" ref-type="bibr">1996</xref>
; Singhal & Rogers, <xref rid="CIT0104" ref-type="bibr">1999</xref>
), middle (Agha & Beaudoin, <xref rid="CIT0002" ref-type="bibr">2012</xref>
; Agha & Meekers, <xref rid="CIT0003" ref-type="bibr">2010</xref>
), or high (Foreit, de Castro, & Duarte Franco, <xref rid="CIT0032" ref-type="bibr">1989</xref>
) socioeconomic status or people of urban (Agha & Beaudoin, <xref rid="CIT0002" ref-type="bibr">2012</xref>
; Agha & Meekers, <xref rid="CIT0003" ref-type="bibr">2010</xref>
; Babalola & Brown, <xref rid="CIT0005" ref-type="bibr">2001</xref>
; Babalola, Vonrasek, Brown, & Traore, 2001) or rural (Singhal & Rogers, <xref rid="CIT0104" ref-type="bibr">1999</xref>
; Sypher, McKinley, Ventsam, & Valdeaellano, <xref rid="CIT0113" ref-type="bibr">2002</xref>
) residence. A few campaigns also targeted health workers (Basten, <xref rid="CIT0013" ref-type="bibr">2009</xref>
; Boulay, Storey, & Sood, <xref rid="CIT0021" ref-type="bibr">2002</xref>
; Kim, Kols, Nyakauru, Marangwanda, & Chibatamoto, 2001; Palmer & Sood, <xref rid="CIT0086" ref-type="bibr">2004</xref>
; Shefner-Rogers & Sood, <xref rid="CIT0103" ref-type="bibr">2004</xref>
), community leaders (Basten, <xref rid="CIT0013" ref-type="bibr">2009</xref>
; Kim & Marangwanda, <xref rid="CIT0064" ref-type="bibr">1997</xref>
), and religious authorities (Blake & Babalola, <xref rid="CIT0018" ref-type="bibr">2002</xref>
). In addition to general family planning campaigns, there were three vasectomy campaigns, five adolescent/young adult reproductive health campaigns, two maternal mortality campaigns, and a radio program in Nepal that covered a wide range of child survival behaviors. The vasectomy campaigns were designed to improve attitudes towards vasectomy in Brazil and Guatemala and encourage married men with completed families to undergo the procedure (Bertrand, Santiso, Linder, & Pineda, <xref rid="CIT0017" ref-type="bibr">1987</xref>
; Foreit et al., <xref rid="CIT0032" ref-type="bibr">1989</xref>
; Kincaid et al., <xref rid="CIT0065" ref-type="bibr">1996</xref>
). The reproductive health campaigns for adolescents, youth, and young adults each targeted a slightly different age range between 12 and 24 years (Agha, <xref rid="CIT0001" ref-type="bibr">2002</xref>
; Babalola, Folda, & Babayaro, <xref rid="CIT0006" ref-type="bibr">2008</xref>
; Kim et al., <xref rid="CIT0063" ref-type="bibr">2001</xref>
). In general, they aimed to change social norms surrounding the use of reproductive health services and products by young people, encourage young people to frequent family planning clinics, to talk with parents, educators, and service providers about sexual health, and to protect themselves from pregnancy and sexually transmitted infections. The maternal mortality campaigns both took place in Indonesia between 1999 and 2002 in an attempt to increase male and community involvement in preparing for emergencies during pregnancy and delivery (Palmer & Sood, <xref rid="CIT0086" ref-type="bibr">2004</xref>
; Shefner-Rogers & Sood, <xref rid="CIT0103" ref-type="bibr">2004</xref>
). BBC Media Action's radio program, aired in Nepal between 2009 and 2011, addressed a host of child survival topics including antenatal care, safe delivery, postnatal care, newborn care, breastfeeding and complementary feeding, diarrhea, and acute respiratory infection (Basten, <xref rid="CIT0013" ref-type="bibr">2009</xref>
).</p>
<p>Of the studies evaluating reproductive health mass media campaigns, 48% discussed formative research and 21% mentioned message pretesting. Seventy-eight percent mentioned a theoretical framework, most commonly entertainment-education (39%), diffusion theory (24%), social marketing (22%), social cognitive theory (16%), the theory of reasoned action (15%), the health belief model (12%), stages of change (10%), the ideation model (9%), and/or steps to behavior change (9%). Radio was used by 90% of the campaigns, television by 55%, and newspapers by 28%. Although radio and television spots were the most common format, used by 42% and 36% of the campaigns respectively, 27% used radio dramas, 18% used television dramas, and 25% used radio talk shows. In addition, campaigns disseminated messages via pamphlets (33%), posters (30%), films (12%), and promotional materials (10%). Only a few campaigns used music videos (Babalola & Brown, <xref rid="CIT0005" ref-type="bibr">2001</xref>
; Babalola et al., <xref rid="CIT0005" ref-type="bibr">2001</xref>
), television talk shows (Guilkey & Hutchinson, <xref rid="CIT0040" ref-type="bibr">2011</xref>
; Hess, Meekers, & Storey, <xref rid="CIT0045" ref-type="bibr">2012</xref>
; Yassa & Farah, <xref rid="CIT0129" ref-type="bibr">2003</xref>
), radio songs (Babalola & Brown, <xref rid="CIT0005" ref-type="bibr">2001</xref>
; Babalola et al., <xref rid="CIT0005" ref-type="bibr">2001</xref>
; Kane, Gueye, Speizer, Pacque-Margolis, & Baron, 1998), cassette tapes (Blake & Babalola, <xref rid="CIT0018" ref-type="bibr">2002</xref>
; Jato et al., <xref rid="CIT0057" ref-type="bibr">1999</xref>
), mobile sales units (Sweeney, <xref rid="CIT0112" ref-type="bibr">1977</xref>
), mobile cinema (Kabir & Islam, <xref rid="CIT0059" ref-type="bibr">2000</xref>
), mobile loudspeakers (Guilkey & Hutchinson, <xref rid="CIT0040" ref-type="bibr">2011</xref>
; Lieberman, <xref rid="CIT0072" ref-type="bibr">1972</xref>
; Schellstede & Ciszewski, <xref rid="CIT0099" ref-type="bibr">1984</xref>
), billboards (Bailey et al., <xref rid="CIT0010" ref-type="bibr">1989</xref>
; Kabir & Islam, <xref rid="CIT0059" ref-type="bibr">2000</xref>
; Kincaid et al., <xref rid="CIT0065" ref-type="bibr">1996</xref>
; Schellstede & Ciszewski, <xref rid="CIT0099" ref-type="bibr">1984</xref>
; Singhal & Rogers, <xref rid="CIT0104" ref-type="bibr">1999</xref>
; Sweeney, <xref rid="CIT0112" ref-type="bibr">1977</xref>
), or flipcharts (Blake & Babalola, <xref rid="CIT0018" ref-type="bibr">2002</xref>
; Hess et al., <xref rid="CIT0045" ref-type="bibr">2012</xref>
). Several campaigns used authority figures or famous people to bolster their messages including ministers of health in Bolivia and the Philippines (Kincaid & Do, <xref rid="CIT0068" ref-type="bibr">2006</xref>
; Valente & Saba, <xref rid="CIT0119" ref-type="bibr">2001</xref>
; Valente & Saba, <xref rid="CIT0118" ref-type="bibr">1998</xref>
), religious leaders and the royal family in Jordan (Yassa & Farah, <xref rid="CIT0129" ref-type="bibr">2003</xref>
), a popular Indonesian singer (Palmer & Sood, <xref rid="CIT0086" ref-type="bibr">2004</xref>
; Shefner-Rogers & Sood, <xref rid="CIT0103" ref-type="bibr">2004</xref>
), a famous Egyptian actress (Robinson & Lewis, <xref rid="CIT0096" ref-type="bibr">2003</xref>
), famous Nepali artists (Basten, <xref rid="CIT0013" ref-type="bibr">2009</xref>
), and professional Zimbabwean soccer players (Kim & Marangwanda, <xref rid="CIT0064" ref-type="bibr">1997</xref>
). In addition to mass media, 38% of the campaigns included an interpersonal communication component, most commonly in the form of community events (29%) or training of community health workers (11%) or service providers (8%). Of the campaigns, 15% also engaged in franchise development efforts, attempting to associate a logo with quality services at participating clinics (Babalola & Brown, <xref rid="CIT0005" ref-type="bibr">2001</xref>
; Babalola et al., <xref rid="CIT0005" ref-type="bibr">2001</xref>
; Babalola & Vonrasek, <xref rid="CIT0007" ref-type="bibr">2005</xref>
; Do & Kincaid, <xref rid="CIT0004" ref-type="bibr">2006</xref>
; Guilkey & Hutchinson, <xref rid="CIT0040" ref-type="bibr">2011</xref>
; Gupta, Katende, & Bessinger, <xref rid="CIT0038" ref-type="bibr">2003</xref>
; Jato et al., <xref rid="CIT0057" ref-type="bibr">1999</xref>
; Kane et al., <xref rid="CIT0060" ref-type="bibr">1998</xref>
; Kim et al., <xref rid="CIT0008" ref-type="bibr">2001</xref>
; Olaleye & Bankole, <xref rid="CIT0085" ref-type="bibr">1994</xref>
; Robinson & Lewis, <xref rid="CIT0096" ref-type="bibr">2003</xref>
). Only three campaigns explicitly engaged in advocacy efforts (Basten, <xref rid="CIT0013" ref-type="bibr">2009</xref>
; Guilkey & Hutchinson, <xref rid="CIT0040" ref-type="bibr">2011</xref>
; Yassa & Farah, <xref rid="CIT0129" ref-type="bibr">2003</xref>
). Of the campaigns, 40% lasted less than 1 year, 30% lasted between 1 and 2 years, and 12% lasted for more than 2 years. Eighteen percent of the campaigns did not give any information about the duration of the campaign. Of the campaigns, 61% did not provide details on the frequency of message emissions. Of those that did provide frequency information, half aired messages on a weekly basis and half more frequently.</p>
</sec>
</sec>
<sec id="S004-S2002"><title>Evaluation of the Evidence</title>
<p>To draw conclusions about the effectiveness of mass media interventions for child survival, the evaluations were sorted into stronger, moderate, and weak categories on the basis of how thoroughly they addressed threats to inference of mass media effects. Typically, intervention evaluations can be considered as tests of efficacy (does the intervention work under controlled conditions), tests of effectiveness (does the intervention work under realistic conditions or in multiple settings) or tests of sustainability (does the intervention continue to be effective after its early period of introduction; Balster et al., <xref rid="CIT0012" ref-type="bibr">2014</xref>
). Almost all of the evaluations reviewed here fall into the middle category, of effectiveness studies; all included studies were operating under reasonably realistic conditions and almost none of them included longer term implementation or data collection which would permit claims of sustainability. The descriptions below point to any exceptions.</p>
<p>Methods for establishing the validity of claims of mass media effects consist of both design elements and statistical techniques. In this section, we present the criteria for characterizing the primary components of the evaluation method including sampling method, timing of data collection, and use of statistical controls or advanced statistical methods to address threats to inference. Decisions about each of these components affect confidence in the inferences regarding campaign effectiveness.</p>
<sec><title>Sampling Method</title>
<p>We distinguish between samples likely to be biased or unrepresentative of the population to which evaluators wish to generalize, and samples less likely to be biased. Samples considered biased may be very small, homogeneous, have a high nonresponse rate or are in other ways at substantial risk of being unrepresentative of the target population. These samples do not permit generalization to the larger population of interest and therefore are of limited value to this review.</p>
</sec>
<sec><title>Timing of Data Collection</title>
<p>The evaluations included in this review all compare groups either (a)across individuals who have different levels of exposure postintervention, (b) across time before and after the intervention, or (c) across outcomes between treatment and control sites. Each of these comparison approaches has strengths and weaknesses for supporting claims of intervention effects. Some studies use more than one of these comparison strategies to strengthen claims of mass media effects.</p>
<p>In the case of postintervention only designs, analysts use individual exposure data to compare groups who vary in their exposure levels. In most cases, variation in exposure is defined by self-reports of individual respondents. Although useful, this design is threatened by self-selection and causal order challenges. Self-selection, as opposed to random assignment to condition, is a concern because exposure to mass media messages is rarely the only difference between exposed and unexposed groups. Therefore, observed effects may not be due to exposure but rather to confounding variables that affect both exposure and the outcome of interest. This threat can be reduced by controlling statistically for as many known potential determinants of exposure and the outcome behavior as possible. Nevertheless, unmeasured confounders could still pose a threat. Studies that rely entirely on this postintervention comparison of individuals with more or less self-reported exposure, but that do not make statistical adjustments for confounders, are considered to have weak designs.</p>
<p>Ambiguous causal order is also a threat to inference with postintervention only designs. Because both exposure and outcome measures are collected at a single point in time, often both through self-report, it is impossible to know whether exposure drives the behavior or whether the behavior drives recall of exposure. Three ways to address this threat are to show that greater levels of exposure are associated with incrementally greater values on the outcome behavior (dose-response), to observe campaign-related change on the beliefs targeted by the mass media messages and not on other related beliefs, or to trace a pathway from exposure through the theoretically based mediators targeted by the mass media campaign (e.g., attitudes, self-efficacy, social norms, intentions) to the outcome behavior. Researchers may be able to argue that evidence consistent with these elaborations of the basic association will be consistent with one causal order (intervention on outcome) but not the reverse.</p>
<p>Another common method of campaign evaluation, the pre-/postintervention survey design, examines whether outcome measures gathered from similar samples before and after an intervention are changing. This design is particularly threatened by history or other interventions, events or natural (secular) changes that occur simultaneously with the intervention and may be responsible for the observed effects. This simple comparison is generally considered to be a weak design. The value of the evidence from such a design is strengthened if it includes some additional information. For example, the threat of history can be somewhat reduced by also showing that levels on the outcome variable vary across levels of exposure postintervention, thereby linking observed effects to the mass media campaign. Another method for minimizing the threat of history is to collect time-series data (often in the form of clinic service statistics or sales data) that show that outcomes vary in expected ways with the presence or absence of a time-varying mass media intervention. The pre-post intervention survey design is also threatened by the possibility of nonequivalent samples. Using a panel design (with checks for attrition) or randomly selected samples following a consistent sampling method can attenuate this threat.</p>
<p>The third typical design compares treatment versus control geographic areas. When used for evaluating mass media campaigns, this comparison is most often a quasi-experimental design in which the treatment and control sites are not randomly assigned. This design may be threatened by non-comparable baselines and differential natural rates of change over time in addition to history (if other events only in the treatment site could explain observed differences). These threats can be mitigated by increasing the number of matched treatment and control sites to permit analyses using the site, rather than the individual, as the unit of analysis. If that is not possible, it may be helpful to collect multiple pre-intervention measurements to establish comparable baseline trends or to measure exposure and establish differential effects by exposure levels, thus combining the several types of designs. We consider designs that use more than one of these design elements to be stronger than those that use only one.</p>
<p>All of the evaluations that draw conclusions from a substantially biased sample (or that do not report the sampling method) are classified as weak because their findings are not generalizable to the target population. In addition, studies with only one comparison group (before/after, low versus high exposure, or treatment versus control) that do not use statistical controls to adjust for potential a priori differences between the treatment and comparison group are considered weak because no effort is made to address those threats to inference. The evaluations classified as moderate use an unbiased sample and make some effort to address threats to inference either by employing two comparison group approaches (a combination of before/after, low versus high exposure, and/or treatment versus control), or one comparison group and basic statistical controls. Stronger evaluations are those that have an unbiased sample and make a substantial effort to address threats to inference through a combination of multiple comparison groups, statistical controls, and, in some cases, advanced statistical methods like propensity score matching, bivariate probit models, or fixed effects analysis.</p>
<p>Of the 111 evaluations that met the inclusion criteria, 33 were classified as weak, 32 as moderate, and 46 as stronger (see Table <xref rid="T0003" ref-type="table">3</xref>
). Of the weak evaluations, 88% made no attempt to address threats to inference, 30% did not report the sampling method, and 21% suffered from a biased sample. The weak evaluations are not described further because they do not present convincing evidence for the effects of mass media interventions for child survival. The results section describes the 78 campaigns with moderate and stronger evaluations divided into a section for reproductive health (46 campaigns) and a section for all other child survival health topics (32 campaigns). For a summary of the evaluation design for moderate and stronger campaigns, see Table <xref rid="T0004" ref-type="table">4</xref>
.
<table-wrap orientation="portrait" id="T0003" position="float"><label>Table 3.</label>
<caption><title> Summary of assessment of evaluation strength</title>
</caption>
<pmc-comment>OASIS TABLE HERE</pmc-comment>
<table frame="hsides" rules="groups"><colgroup><col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
</colgroup>
<thead valign="bottom"><tr><th rowspan="2" align="left">Child survival health topic</th>
<th colspan="3" align="center">Strength of evaluation<hr></hr>
</th>
</tr>
<tr><th align="center">Weak</th>
<th align="center">Moderate</th>
<th align="center">Stronger</th>
</tr>
</thead>
<tbody><tr><td align="left">Diarrheal disease</td>
<td align="right">2</td>
<td align="right">10</td>
<td align="right">3</td>
</tr>
<tr><td align="left">Immunization</td>
<td align="right">1</td>
<td align="right">3</td>
<td align="right">4</td>
</tr>
<tr><td align="left">Malaria</td>
<td align="right">1</td>
<td align="right">0</td>
<td align="right">1</td>
</tr>
<tr><td align="left">Nutrition</td>
<td align="right">5</td>
<td align="right">3</td>
<td align="right">6</td>
</tr>
<tr><td align="left">Preventing mother-to-child transmission</td>
<td align="right">0</td>
<td align="right">1</td>
<td align="right">0</td>
</tr>
<tr><td align="left">Respiratory disease</td>
<td align="right">3</td>
<td align="right">1</td>
<td align="right">0</td>
</tr>
<tr><td align="left">Reproductive health</td>
<td align="right">21</td>
<td align="right">14</td>
<td align="right">32</td>
</tr>
<tr><td align="left">Total</td>
<td align="right">33</td>
<td align="right">32</td>
<td align="right">46</td>
</tr>
</tbody>
</table>
</table-wrap>
<table-wrap orientation="landscape" id="T0004" position="float"><label>Table 4.</label>
<caption><title> Summary of evaluation design for the moderate and stronger campaign evaluations</title>
</caption>
<pmc-comment>OASIS TABLE HERE</pmc-comment>
<table frame="hsides" rules="groups"><colgroup><col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
<col width="1*"></col>
</colgroup>
<thead valign="bottom"><tr><th align="left">Health topic (number of campaigns per topic)</th>
<th align="center"><italic>n</italic>
</th>
<th align="center">Moderate evaluation</th>
<th align="center">Stronger evaluation</th>
<th align="center">Low exposure: 0–30%</th>
<th align="center">Moderate exposure: 31–60%</th>
<th align="center">High exposure: 61–100%</th>
<th align="center">Probability sample</th>
<th align="center">Sample size: 1,000+</th>
<th align="center">Statistical controls</th>
<th align="center">Advanced statistical methods</th>
<th align="center">Effect of exposure</th>
<th align="center">Change over time</th>
<th align="center">Difference between treatment/control</th>
<th align="center">Observed effect on intermediary outcomes</th>
<th align="center">Observed effect on behavior</th>
<th align="center">Observed effect on health outcome</th>
</tr>
</thead>
<tbody><tr><td align="left">Diarrheal disease</td>
<td align="center">13</td>
<td align="center">10</td>
<td align="center">3</td>
<td align="center">5</td>
<td align="center">2</td>
<td align="center">5</td>
<td align="center">13</td>
<td align="center">11</td>
<td align="center">8</td>
<td align="center">1</td>
<td align="center">3</td>
<td align="center">12</td>
<td align="center">2</td>
<td align="center">6</td>
<td align="center">10</td>
<td align="center">0</td>
</tr>
<tr><td align="left">Immunization</td>
<td align="center">7</td>
<td align="center">3</td>
<td align="center">4</td>
<td align="center">3</td>
<td align="center">2</td>
<td align="center">2</td>
<td align="center">7</td>
<td align="center">6</td>
<td align="center">6</td>
<td align="center">2</td>
<td align="center">2</td>
<td align="center">6</td>
<td align="center">0</td>
<td align="center">2</td>
<td align="center">5</td>
<td align="center">0</td>
</tr>
<tr><td align="left">Malaria</td>
<td align="center">1</td>
<td align="center">0</td>
<td align="center">1</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">1</td>
<td align="center">1</td>
<td align="center">1</td>
<td align="center">1</td>
<td align="center">1</td>
<td align="center">0</td>
<td align="center">1</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">1</td>
<td align="center">0</td>
</tr>
<tr><td align="left">Nutrition</td>
<td align="center">9</td>
<td align="center">3</td>
<td align="center">6</td>
<td align="center">1</td>
<td align="center">5</td>
<td align="center">1</td>
<td align="center">5</td>
<td align="center">3</td>
<td align="center">6</td>
<td align="center">3</td>
<td align="center">3</td>
<td align="center">9</td>
<td align="center">2</td>
<td align="center">5</td>
<td align="center">8</td>
<td align="center">1</td>
</tr>
<tr><td align="left">PMTCT</td>
<td align="center">1</td>
<td align="center">1</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">1</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">1</td>
<td align="center">0</td>
<td align="center">1</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">1</td>
<td align="center">0</td>
</tr>
<tr><td align="left">Respiratory diseases</td>
<td align="center">1</td>
<td align="center">1</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">1</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">0</td>
<td align="center">1</td>
<td align="center">1</td>
<td align="center">0</td>
<td align="center">1</td>
<td align="center">0</td>
</tr>
<tr><td align="left">All child survival</td>
<td align="center">32</td>
<td> </td>
<td align="center">14 44%</td>
<td align="center">9 28%</td>
<td align="center">10 31%</td>
<td align="center">10 31%</td>
<td align="center">26 81%</td>
<td align="center">21 66%</td>
<td align="center">22 69%</td>
<td align="center">7 22%</td>
<td align="center">9 28%</td>
<td align="center">29 91%</td>
<td align="center">5 16%</td>
<td align="center">13 41%</td>
<td align="center">26 81%</td>
<td align="center">1 3%</td>
</tr>
<tr><td align="left">Reproductive health</td>
<td align="center">46</td>
<td align="center">14 30%</td>
<td align="center">32 70%</td>
<td align="center">9 20%</td>
<td align="center">16 35%</td>
<td align="center">20 43%</td>
<td align="center">41 89%</td>
<td align="center">33 72%</td>
<td align="center">36 78%</td>
<td align="center">13 28%</td>
<td align="center">31 67%</td>
<td align="center">28 61%</td>
<td align="center">9 20%</td>
<td align="center">28 61%</td>
<td align="center">41 89%</td>
<td align="center">0 0%</td>
</tr>
<tr><td colspan="5" align="left"><italic>Note.</italic>
PMTCT = preventing mother-to-child transmission.</td>
<td style=""> </td>
<td style=""> </td>
<td style=""> </td>
<td style=""> </td>
<td style=""> </td>
<td style=""> </td>
<td style=""> </td>
<td style=""> </td>
<td style=""> </td>
<td style=""> </td>
<td style=""> </td>
<td style=""> </td>
</tr>
</tbody>
</table>
</table-wrap>
</p>
</sec>
</sec>
<sec id="S004-S2003"><title>What Has Been Successful? Evaluation of the Evidence</title>
<sec><title>Child Survival</title>
<p>Adequate exposure is a key component of campaign success; the campaign must reach substantial proportions of the target audience with enough frequency to be recalled. Of the child survival campaigns, 31% achieved high exposure defined through various techniques for eliciting self-reported exposure (61–100%), 31% moderate exposure (31–60%), 28% low exposure (0–30%), and 9% did not report exposure. Six of the studies asked about exposure by channel (Bowen, <xref rid="CIT0022" ref-type="bibr">2013</xref>
; Curtis et al., <xref rid="CIT0026" ref-type="bibr">2001</xref>
; De Pee et al., <xref rid="CIT0027" ref-type="bibr">1998</xref>
; Gupta et al., <xref rid="CIT0039" ref-type="bibr">2004</xref>
; Quaiyum et al., <xref rid="CIT0094" ref-type="bibr">1997</xref>
; Scott et al., <xref rid="CIT0100" ref-type="bibr">2008</xref>
), but only two provided any sort of indication of frequency of exposure to the campaign (Kuhlmann et al., <xref rid="CIT0070" ref-type="bibr">2008</xref>
; Monterrosa et al., <xref rid="CIT0081" ref-type="bibr">2013</xref>
).</p>
<p>There appears to be a publication bias in the literature toward successful campaign evaluations. Of the 32 child survival evaluations, only 6 found no evidence of effect on a behavioral outcome: two on oral rehydration therapy and two on vaccination coverage (Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
), one on water purification (JHU/CCP, 2008), and one on exclusive breastfeeding (Gupta et al., <xref rid="CIT0039" ref-type="bibr">2004</xref>
). Four of these six evaluations were published as part of a chapter reviewing the effectiveness of 10 HealthCom programs in eight countries. The HealthCom project attributed the failure of diarrheal disease and immunization campaigns in Democratic Republic of the Congo, Lesotho, and Indonesia-West Java to weak mass media interventions and low exposure levels (Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
). Exposure to a marketing campaign in Pakistan to promote the use of water purification tablets was successful initially and then sales decreased because people did not like how the product changed the taste of the water (JHU/CCP, 2008). The evaluation of a mass media campaign to promote exclusive breastfeeding in Uganda found effects of exposure on knowledge of exclusive breastfeeding, but not on behavior, perhaps because the evaluation was conducted prematurely, only 2 months after the campaign began (Gupta et al., <xref rid="CIT0039" ref-type="bibr">2004</xref>
).</p>
<p>Of the 32 child survival evaluations, 26 show positive effects of mass media interventions on a wide range of self-reported behaviors including antenatal care during the most recent pregnancy (Hutchinson, Lance, Guilkey, Shahjahan, & Haque, <xref rid="CIT0052" ref-type="bibr">2006</xref>
), vaccination coverage (Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
; Hutchinson et al., <xref rid="CIT0050" ref-type="bibr">2006</xref>
; Quaiyum et al., <xref rid="CIT0094" ref-type="bibr">1997</xref>
; Zimicki et al., <xref rid="CIT0130" ref-type="bibr">1994</xref>
), last night bed net use (Bowen, <xref rid="CIT0022" ref-type="bibr">2013</xref>
), early initiation of breastfeeding (McDivitt, Zimicki, Hornik, & Abulaban, <xref rid="CIT0074" ref-type="bibr">1993</xref>
; Sun et al., <xref rid="CIT0110" ref-type="bibr">2011</xref>
), minimum dietary diversity (Monterrosa et al., <xref rid="CIT0081" ref-type="bibr">2013</xref>
; Sun et al., <xref rid="CIT0110" ref-type="bibr">2011</xref>
), consumption of iron-rich foods (Sun et al., <xref rid="CIT0110" ref-type="bibr">2011</xref>
) and foods rich in vitamin A (De Pee et al., <xref rid="CIT0027" ref-type="bibr">1998</xref>
; Monterrosa et al., <xref rid="CIT0081" ref-type="bibr">2013</xref>
), handwashing with soap (Scott et al., <xref rid="CIT0100" ref-type="bibr">2008</xref>
), and oral rehydration therapy (Gutiérrez et al., <xref rid="CIT0042" ref-type="bibr">1996</xref>
; Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
; Kassegne et al., <xref rid="CIT0061" ref-type="bibr">2011</xref>
; Kenya et al., <xref rid="CIT0062" ref-type="bibr">1990</xref>
; McDowell & McDivitt, <xref rid="CIT0076" ref-type="bibr">1990</xref>
). Three evaluations show effects on somewhat more objective behavioral outcomes including observed handwashing after cleaning a baby's bottom (Curtis et al., <xref rid="CIT0026" ref-type="bibr">2001</xref>
), number of tuberculosis tests performed (Jaramillo, <xref rid="CIT0047" ref-type="bibr">2001</xref>
), and vitamin A serum status (De Pee et al., <xref rid="CIT0027" ref-type="bibr">1998</xref>
).<xref ref-type="fn" rid="FN0001"><sup>1</sup>
</xref>
<fn id="FN0001"><p><sup>1</sup>
A table summarizing effect sizes, where possible, for each of the moderate and stronger campaigns is available in the online supplemental appendices.</p>
</fn>
</p>
<p>In addition, two campaigns showed dose-response effects on behavior (JHU/CCP, 2008; Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
) and one traced a mediation pathway from exposure to knowledge to vaccination coverage (Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
). In addition to behavioral effects, twelve evaluations found positive effects on awareness/knowledge and less than four each on beliefs/attitudes (JHU/CCP, 2008; Kassegne et al., <xref rid="CIT0061" ref-type="bibr">2011</xref>
; Monterrosa et al., <xref rid="CIT0081" ref-type="bibr">2013</xref>
; Sun et al., <xref rid="CIT0111" ref-type="bibr">2007</xref>
), self-efficacy (Kassegne et al., <xref rid="CIT0061" ref-type="bibr">2011</xref>
), social norms (JHU/CCP, 2008; Monterrosa et al., <xref rid="CIT0081" ref-type="bibr">2013</xref>
), intentions (Monterrosa et al., <xref rid="CIT0081" ref-type="bibr">2013</xref>
; Sun et al., <xref rid="CIT0111" ref-type="bibr">2007</xref>
), and ideation (JHU/CCP, 2008).</p>
<p>All of the moderate and stronger evaluations relied on face-to-face interviews except for one that used clinic service statistics (Jaramillo, <xref rid="CIT0056" ref-type="bibr">2001</xref>
). The majority of the face-to-face interviews were administered to probability samples, most commonly multistage cluster samples, of greater than 1,000 respondents. Used in 88% of the studies, the pre-/postintervention survey design allows campaign evaluators to examine change over time. Seven evaluations gathered data at three or more time points (Curtis et al., <xref rid="CIT0026" ref-type="bibr">2001</xref>
; De Pee et al., <xref rid="CIT0027" ref-type="bibr">1998</xref>
; Gutiérrez et al., <xref rid="CIT0042" ref-type="bibr">1996</xref>
; Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
; Kenya et al., <xref rid="CIT0062" ref-type="bibr">1990</xref>
; McDowell & McDivitt, <xref rid="CIT0076" ref-type="bibr">1990</xref>
), one of which was paired with a quasi-experimental design (Kenya et al., <xref rid="CIT0062" ref-type="bibr">1990</xref>
). The rest of the pre-/postevaluations are single before-/after-measurement designs combined with either statistical controls (Bowen, <xref rid="CIT0022" ref-type="bibr">2013</xref>
; Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
; Sun et al., <xref rid="CIT0110" ref-type="bibr">2011</xref>
), propensity score matching (Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
), a quasi-experimental design (Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
), a panel sample (Bonvecchio et al., <xref rid="CIT0019" ref-type="bibr">2007</xref>
; Quaiyum et al., <xref rid="CIT0094" ref-type="bibr">1997</xref>
; Sun et al., <xref rid="CIT0111" ref-type="bibr">2007</xref>
), a quasi-experimental design and panel sample (Monterrosa et al., <xref rid="CIT0081" ref-type="bibr">2013</xref>
) or additional analyses across levels of exposure (Gupta et al., <xref rid="CIT0039" ref-type="bibr">2004</xref>
; Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
; Kassegne et al., <xref rid="CIT0061" ref-type="bibr">2011</xref>
; Scott et al., <xref rid="CIT0100" ref-type="bibr">2008</xref>
; Warnick et al., <xref rid="CIT0126" ref-type="bibr">2004</xref>
). One quasi-experimental study employed time series data from before, during, and after a tuberculosis mass media campaign (Jaramillo, <xref rid="CIT0047" ref-type="bibr">2001</xref>
). Three evaluations used postintervention-only data across levels of exposure. The evaluators attempted to compensate for the weak after-only design by using extensive statistical controls (Kuhlmann et al., <xref rid="CIT0070" ref-type="bibr">2008</xref>
), propensity score matching (JHU/CCP, 2008), or bivariate probit modeling (Guilkey & Hutchinson, <xref rid="CIT0040" ref-type="bibr">2011</xref>
).</p>
</sec>
<sec><title>Reproductive Health</title>
<p>Exposure to reproductive health campaigns was measured through various self-report techniques by all but one of the campaigns with 43% achieving high exposure levels (61–100%), 35% moderate exposure levels (31–60%), and 20% low exposure levels (0–30%). Thirty-five percent also provided exposure information by channel, but only 7% provided information on frequency of exposure (Do & Kincaid, <xref rid="CIT0028" ref-type="bibr">2006</xref>
; Lettenmaier, Krenn, Morgan, Kols, & Piotrow, 1992; Rogers et al., <xref rid="CIT0097" ref-type="bibr">1999</xref>
).</p>
<p>Four evaluations had mixed results. In Zimbabwe, evaluators found effects of exposure on contraceptive use, but no significant changes between baseline and follow-up (Kim & Marangwanda, <xref rid="CIT0064" ref-type="bibr">1997</xref>
). In St. Lucia, differences in current modern contraceptive use between baseline and endline were not statistically significant, but differences between radio soap opera listeners and nonlisteners were significant at one time point (Vaughan, Regis, & St. Catherine, <xref rid="CIT0121" ref-type="bibr">2000</xref>
). The evaluation of a male motivation campaign in Guinea detected significant effects of exposure on contraceptive ideation and intention to use a modern method within a panel of men and women, but not on contraceptive behavior (Blake & Babalola, <xref rid="CIT0018" ref-type="bibr">2002</xref>
). A campaign to promote midwives and community preparedness for birth emergencies in Indonesia found effects of exposure on the use of a skilled birth attendant, but no significant increases in that indicator over time (Palmer & Sood, <xref rid="CIT0086" ref-type="bibr">2004</xref>
). It is possible that the evaluations were conducted too soon to detect population-level effects on behavior even though campaign exposure influenced intentions and behavior.</p>
<p>Two evaluations found no evidence for effects. In Peru, observed increases in new family planning acceptors at clinics did not exceed predicted levels on the basis of precampaign trends even though exposure to the mass media campaign was high (>60%; Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
). In South Africa, comparisons over time between a treatment and control area registered a negative net effect on condom use for pregnancy prevention among women and no net effect on other contraceptive use behaviors (Agha, <xref rid="CIT0001" ref-type="bibr">2002</xref>
). The authors attributed the result to mass media messages aired on a newly established community radio station with low coverage levels.</p>
<p>Of the 46 evaluations, 40 showed positive effects of mass media-centric reproductive health interventions on a behavioral outcome, most commonly, use of modern contraceptives (30 campaigns). Of the evaluations that found effects on contraceptive use, 28 were based on self-report as were evaluations that found significant effects on number of sexual partners (Agha, <xref rid="CIT0001" ref-type="bibr">2002</xref>
), ever use of condoms (Meekers, Van Rossem, Silva, & Koleros, <xref rid="CIT0077" ref-type="bibr">2007</xref>
), and delivery preparedness (Shefner-Rogers & Sood, <xref rid="CIT0103" ref-type="bibr">2004</xref>
).<xref ref-type="fn" rid="FN0002"><sup>2</sup>
</xref>
On the basis of time series data from clinics, rather than self-report, evaluations found significant effects on number of vasectomies performed (Bertrand et al., <xref rid="CIT0017" ref-type="bibr">1987</xref>
; Foreit et al., <xref rid="CIT0032" ref-type="bibr">1989</xref>
; Kincaid et al., <xref rid="CIT0065" ref-type="bibr">1996</xref>
), number of new family planning acceptors (Bailey, <xref rid="CIT0009" ref-type="bibr">1973</xref>
; Lieberman, <xref rid="CIT0072" ref-type="bibr">1972</xref>
; Piotrow et al., <xref rid="CIT0093" ref-type="bibr">1990</xref>
), and on modern contraceptive use (Agha, <xref rid="CIT0001" ref-type="bibr">2002</xref>
; Boulay et al., <xref rid="CIT0021" ref-type="bibr">2002</xref>
). An evaluation that used condom sales data found a positive effect on condom purchasing behavior (Schellstede & Ciszewski, <xref rid="CIT0099" ref-type="bibr">1984</xref>
).<fn id="FN0002"><p><sup>2</sup>
It is important to note that the HIV/AIDS literature not reviewed here also shows effects of mass media-centric programs on number of sexual partners, ever use of condoms, and condom-purchasing behavior.</p>
</fn>
</p>
<p>In addition, evaluators found positive effects on beliefs/attitudes (41%), interpersonal discussion (26%), awareness/knowledge (24%), intentions (13%), self-efficacy (Agha, <xref rid="CIT0001" ref-type="bibr">2002</xref>
; Sweeney, <xref rid="CIT0112" ref-type="bibr">1977</xref>
), and social norms (Boulay et al., <xref rid="CIT0021" ref-type="bibr">2002</xref>
). Eight campaigns demonstrated dose-response effects (Babalola & Vonrasek, <xref rid="CIT0007" ref-type="bibr">2005</xref>
; Blake & Babalola, <xref rid="CIT0018" ref-type="bibr">2002</xref>
; Gupta et al., <xref rid="CIT0038" ref-type="bibr">2003</xref>
; Hindin, Kincaid, Kuma, Morgan, & Kim, <xref rid="CIT0046" ref-type="bibr">1994</xref>
; Jato et al., <xref rid="CIT0057" ref-type="bibr">1999</xref>
; Kim & Marangwanda, <xref rid="CIT0064" ref-type="bibr">1997</xref>
; Kincaid, <xref rid="CIT0066" ref-type="bibr">2000</xref>
; Lettenmaier et al., <xref rid="CIT0071" ref-type="bibr">1992</xref>
) and one traced a mediation pathway through exposure to ideation to current use of modern contraceptives (Kincaid, <xref rid="CIT0066" ref-type="bibr">2000</xref>
).</p>
<p>Five campaigns relied on clinic statistics (Foreit et al., <xref rid="CIT0032" ref-type="bibr">1989</xref>
; Kincaid et al., <xref rid="CIT0065" ref-type="bibr">1996</xref>
; Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
), distribution data (Schellstede & Ciszewski, <xref rid="CIT0099" ref-type="bibr">1984</xref>
) or a quota sample (Singhal & Rogers, <xref rid="CIT0104" ref-type="bibr">1999</xref>
). The rest administered face-to-face interviews to probability samples, most commonly multistage probability samples, of greater than 1,000 respondents. The evaluators used a wide range of evaluation designs that permit comparisons across levels of exposure (67%), across time (61%), and across treatment and control sites (20%). The most common designs were the single pre-/postintervention survey (46%) and the postintervention across levels of exposure design (41%). Of the evaluations, 78% used at least some statistical controls and 20% or less used panel data, a quasi-experimental design, time series data from clinic/sales statistics, propensity score matching, or bivariate probit models.</p>
</sec>
</sec>
<sec id="S004-S2004"><title>What Knowledge Gaps Remain?</title>
<p>In general, the existing evaluations of health topics related to child survival fail to consistently provide all the details about the campaign design, exposure, and evaluation that are necessary to conduct a meta-analysis and to better understand what features of the campaign are most associated with success. Future campaign evaluations should be sure to include explicit information about formative research, use of theory in the campaign design and the evaluation, audience segmentation, message development and pretesting, channels used, duration and intensity of the campaign, population exposure levels broken down by channel and detailing how exposure was measured, frequency of exposure, sampling method, sample size and population, and analyses performed, including control variables and statistical significance of differences between comparison groups.</p>
<p>More specifically, with the exception of reproductive health, there are relatively few evaluations of mass media campaigns for child survival that permit conclusions to be drawn about the effectiveness of mass media as an intervention strategy. More rigorous and recent evaluations across a more diverse range of target behaviors are needed for all of the child survival health topics, but especially in the areas of malaria, PMTCT, and respiratory diseases (which each only have one rigorous evaluation, to date). Studies evaluating the cost-effectiveness of mass media would also be useful. Only two of the moderate and stronger studies provided cost-effectiveness data, concluding that mass media interventions can be very cost-effective: $0.05 per additional antenatal care user, $0.30 and $0.36 for each additional child vaccinated for measles and diphtheria, pertussis, and tetanus, respectively, and $1.62 per additional person protected by a mosquito net (Bowen, <xref rid="CIT0022" ref-type="bibr">2013</xref>
; Guilkey & Hutchinson, <xref rid="CIT0040" ref-type="bibr">2011</xref>
). It is also important to better understand the duration of mass media effects. Only one study examined whether or not the positive effects of mass media on behavior persisted over time (McDowell & McDivitt, <xref rid="CIT0076" ref-type="bibr">1990</xref>
). The evaluators found that 3 years after a campaign to promote the use of a homemade water-sugar-salt solution in The Gambia, both knowledge and use had decreased sharply.</p>
<p>With respect to reproductive health, the evaluations reviewed here suggest that mass media-centric reproductive health interventions can affect the use of modern contraceptive methods in a variety of contexts. Nevertheless, more research is necessary on a wider range of reproductive health outcomes that are important to child survival, for example, antenatal and perinatal service utilization. Cost-effectiveness studies would also be valuable as none of the studies provided cost-effectiveness data. In addition, evaluators should test theoretical mechanisms of effect. Often, the proximate determinants of behavior (beliefs, attitudes, intentions) are measured, but mediation analyses are not performed. These additional analyses can both help strengthen claims of effect and contribute to the theoretical understanding of how mass media campaigns change behavior. More long-term evaluations should be conducted to better understand how quickly the effects of mass media interventions dissipate across different behaviors.</p>
</sec>
</sec>
<sec id="S005"><title>Discussion and Conclusions</title>
<p>There are three classes of conclusions that can be drawn from this systematic review of the evidence for the effects of mass media campaigns on child survival. Although overlapping, it is useful to distinguish between conclusions about the available literature, substantive conclusions about mass media effects, and conclusions about the quality of existing evaluations.</p>
<p>First, the 111 evaluations reviewed here describe mass media campaigns for child survival that took place between 1960 and 2013. Of the moderate and stronger campaign evaluations, 34 (52%) took place before the year 2000, so truncating the search within the past ten or even 20 years would neglect a large part of the relevant literature. In addition, there are surprisingly few rigorous evaluations of communications campaigns for most of the focal child survival health topics with the exception of reproductive health. Furthermore, the evaluations that are available reflect a publication bias: Weaker campaigns are less likely to be evaluated at all, and evaluations of campaigns that show poor results are less likely to be written up and to find publication. As a result, the high proportion of successful campaigns reviewed here (81%) surely overestimates the proportion of all mass media campaigns that are successful.</p>
<p>This publication bias makes it difficult to draw substantive conclusions about mass media effects because we lack information about failed communications campaigns. From the few unsuccessful campaigns that have been published, we can glean several insights. First, there must be room to move the population on the target behavior. In Democratic Republic of the Congo and Lesotho, for example, where baseline vaccination rates were already high, it was difficult to detect effects of the mass media campaign (Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
). In addition, exposure 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 (Hornik et al., <xref rid="CIT0048" ref-type="bibr">2002</xref>
). 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 (Gupta et al., <xref rid="CIT0038" ref-type="bibr">2003</xref>
).</p>
<p>From the successful campaigns with moderate and stronger evaluations, we conclude that interventions 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.</p>
<p>The quality of the evaluations reviewed here leaves room for improvement. Of the evaluations that met our inclusion criteria, 33 were too weak to draw conclusions about the effectiveness of mass media. Many of the weak evaluations did not provide enough information to inspire confidence in the results, omitting essential details about sampling method, sample size, statistical controls, analyses performed, and the statistical significance of differences between groups. Others used biased samples and/or did not make any effort to address threats to inference.</p>
<p>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.</p>
<p>In sum, there is evidence that mass media interventions can be effective for addressing a wide range of health behaviors related to child survival. There is further evidence that a number of approaches can be effective. The publication of additional rigorous evaluations of both successful and unsuccessful communications campaigns is necessary to better understand which components of campaign design are associated with successful campaigns. Studies should strive to better understand the duration of mass media effects and to evaluate the cost-effectiveness of mass media campaigns as compared with other types of health interventions.</p>
</sec>
<sec id="S006"><title>Supplemental Material</title>
<p>Supplemental data for this article (Appendix: Descriptive Tables and Spreadsheets Summarizing Studies Reviewed) can be accessed on the publisher's website at <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1080/10810730.2014.918217">http://dx.doi.org/10.1080/10810730.2014.918217</ext-link>
.</p>
</sec>
</body>
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