The Reach and Impact of Religious Leaders Preaching about Family. Health and Family Planning: An Evaluation of the Family Health.

Transcription

1 The Reach and Impact of Religious Leaders Preaching about Family Health and Family Planning: An Evaluation of the Family Health Program in Jordan, 2012 Jordan Health Communication Partnership Johns Hopkins Bloomberg School of Public Health Center for Communication Programs, JHU CCP October 2012

2 Acknowledgements This study was conducted under the auspices of the Ministry of Interior and supported by the Jordan Health Communication Partnership (JHCP) / Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (JHU CCP). Special thanks and appreciation go to Dr. Abdel Rahman Ebdah, Assistant Secretary General and Director for Preaching and Guidance at the MAIAHP for his enlightened vision and support and to Mr. Yousef Al Shibly, Head of the Preaching and Guidance Department at the MAIAHP, Ms. Itidal Al Abbadi, Director of Women s Affairs at the MAIAHP. Sincere thanks also to the former MAIAHP Directors Dr. Marwan Al Rayahneh and Mr. Mohammad Al Ameri, all of who played a key role in the implementation of the Family Health Program in. We would like to acknowledge the generous support of the United States Agency for International Development (USAID) for funding this research. Sarah Kamhawi, MPH, Monitoring and Evaluation Program Officer and Carol Underwood, PhD, Senior Research Advisor, wrote this report. Overall, the JHU CCP provided technical assistance and coordination of the study. Dr. Carol Underwood, Principal Investigator, led the technical assistance, analysis, and report writing. Accurate Opinion for Public Opinion Measurements, Co. was subcontracted to field the study and enter the data. Thanks are extended to Mr. Yaser Sa ad Edin, Executive Manager. Special thanks are due to all JHCP staff who cooperated with and supported the research team throughout various stages of the study, including Mr. Edson Whitney, JHCP Chief of Party; Ms. Rula Dajani, JHCP Deputy Chief of Party and Ms. Lina Qardan, Senior Technical and Advocacy Advisor. 1

3 Table of Contents Acknowledgements... 1 Executive Summary... 3 Introduction... 5 Background and Rationale... 5 Conceptual Framework... 5 Study Objectives and Hypotheses... 6 Methods... 6 Sample Design... 6 Sample Size... 7 Questionnaire... 7 Data Collection, Entry, and Analyses... 7 Results... 8 Sample Characteristics... 8 Message Recall... 9 Actions Taken after Exposure Attitudes Relating to Program Topics Dose-effect Conclusions Recommendations

4 Executive Summary Background The Jordan Health Communication Partnership (JHCP) Program seeks to enhance health outcomes in Jordan through health communication programs and interventions. Islamic Religious Leaders (RLs) are important opinion leaders in Jordan and, as such, are among JHCP s key audiences. JHCP joined forces with the Higher Population Council/General Secretariat to expand RLs involvement in Islamic advocacy for population issues including RH/FP. During , the JHCP trained 32 RLs to be workshop facilitators. The trainers then conducted workshops for 776 RLs, who then reached 162,099 community members through 1,167 lessons/sermons. Methods The primary objective of this study is to determine the proportion of mosques congregants in city who report having heard a message relating to RLs Family Health Program topics in the mosques during the previous 6 months as compared to regular attendees in, a control. The secondary objective of this study is to determine whether there is a relation between having been exposed to messages about the RLs Family Health Program topics and holding positive attitudes and intentions relating to these topics. A total of 431 and 426 interviews were successfully completed in City and, respectively. Fieldwork commenced on the 12 th of July 2012 and lasted one week. Key Findings Mosque congregants in were younger and less educated than congregants in city. They also scored higher on the RL influence scale when compared with city congregants. Recall of messages relating to the Family Health Program was higher among those in as compared to those in city. This difference was maintained even after stratifying by RL influence. It is worth noting the Total Fertility Rate in, according to the 2009 Jordan Population and Family Health Survey, is 4.5 births per woman (the highest in the country) while it is 3.8 in. Therefore, as there is a greater need for FP in, it is possible the s religious leaders preach more about this topic as compared to RLs. Congregants in city were more likely to take action relating to RL Family Health Program topics that they were exposed to as compared to those in, suggesting that the training of RLs in enhanced their effectiveness as preachers on these topics. This finding is affirmed when tying the recalled messages to the relevant actions taken. Exposure to messages did not appear to affect congregants attitudes. It is important to note that most congregants held positive attitudes (>80% agreement) with all topics. 3

5 Conclusions and Recommendations In assessing a program s effects, reach is an important but not sufficient measure of impact. As the data demonstrate, RLs in appear to disseminate topics relating to family health and family planning at a greater rate than those in city; however, mosque congregants in city are more likely to take relevant actions after exposure to such messages, which could indicate that the trained Imams, when they do disseminate information on the topics, convey the messages more clearly and with greater effect due to their training. 4

6 Introduction Background and Rationale In 2009, as a result of the religious leaders (RLs) needs assessment, the Jordan Health Communication Partnership (JHCP) joined forces with the Higher Population Council/General Secretariat (HPC/GS) to involve RLs in Islamic advocacy for population issues including reproductive health / family planning (RH/FP) in a more in depth and sustainable fashion. To that end, JHCP and HPC designed the Religious Leaders Training Package on Family Health to use during training sessions designed to provide male and female RLs with accurate and credible information on family health, especially RH/FP. The guiding hypothesis of that study was that increased knowledge and deeper understanding of family health matters would lead to more frequent preaching about these topics. The training was implemented in Zarqa Governorate in March-April 2010 and in in the spring of 2011 and in the spring of As a result, 372 and 776 religious leaders in Zarqa and, respectively, were trained. Studies of RLs in both Zarqa and found that RLs reported higher levels of preaching about a broader range of topics in the post-intervention survey compared with the pre-intervention survey (see JHCP s reports: Religious leaders knowledge, attitudes, practices and public speaking about family planning and reproductive health: Results from Baseline and Endline Surveys in Zarqa Governorate, Jordan, 2010 and Religious leaders knowledge, attitudes, practices and public speaking about family planning and reproductive health: Results from Baseline and Endline Surveys in Governorate, Jordan, 2011). While these findings were important and heartening JHCP recognized that it would also be important to interview individuals who attend mosque services, listen to RLs homilies, and/or are counseled by RLs. Mosque congregants are, therefore, the secondary audience of the RL program. Monitoring data from the field indicated that the 776 RLs in reached 162,099 community members through 1,167 lessons or Friday sermons during To date, JHCP has not evaluated the secondary or indirect effects of the RL program on mosque congregants. This is important as the ultimate goal of the program is to reach the broader Jordanian population with FP/RH messages that will enable or encourage them to use modern contraceptives so as to reduce the total fertility rate. This report contains the results of a study designed to compare message exposure and RH/FP knowledge, attitudes and practices among individuals who regularly attend mosques led by trained RLs with those who attend mosques led by RLs who have not been trained by JHCP. Conceptual Framework Cleland and Wilson (1987) introduced the notion of ideation when referring to the constellation of cognitive, emotional and social factors associated with behavioral change or the propensity to take action. Their key idea is that a shared language and geographic proximity allow changing perceptions, ideas, and aspirations to be communicated with members of any given community 5

7 (Cleland & Wilson, 1987). While communication may serve to reinforce normative beliefs, communication interventions can also bring individuals to together to rethink and reconstruct their ways of thinking and, ultimately, their actions. Indeed, research has demonstrated that communication programs can introduce and promote new ways of thinking, strengthen intentions to take related action, and that participation in or exposure to communication interventions is statistically and significantly correlated with taking action. For example, there is evidence that theory-based programs can influence contraceptive practices (Kincaid, 2000) and gender equity (Underwood et al., 2011), among others. Study Objectives and Hypotheses The primary objective of this study is to determine the proportion of regular attendees of sermons and religious lessons in mosques in governorate, who report having heard a message relating to Religious Leaders (RLs) Family Health Program topics during sermons and/or lessons during the previous 6 months as compared to regular attendees in a comparable control governorate. The secondary objective of this study is to determine whether there is a relation between having been exposed to messages about the RLs Family Health Program topics and holding positive attitudes and intentions relating to these topics. The guiding hypothesis of the study is that individuals who recall hearing their religious leaders talk positively about family planning, gender equity, and other family health matters compared with mosque-goers who did not hear such messages from their RLs will be significantly more likely to approve the messages and take actions related to those messages. Methods Sample Design For purposes of this study, was the intervention study site and the control site. is spatially larger and more populated than Governorate and is divided into 9 administrative districts. Governorate is considerably smaller and more homogeneous, so did not need to be divided into districts. In order to have a more proper comparison between mosques in and governorates, only one of the 9 districts of was included in the study ( City directorate). The sampling unit was the randomly selected mosque. A list of mosques in and City was provided to the JHCP by the MAIAHP. This list was then verified with Google Maps. The list of mosques in included 34 mosques without addresses and, since they could not be identified on Google Maps, were not included in the sampling for. A total of 187 and 134 mosques were located in city and, respectively. The sample was proportionally distributed among these areas. 6

8 Once a mosque was selected, household visits were then made within its catchment area, with dimensions matching the residential blocks utilized by the Department of Statistic when fielding the Jordan Family Health and Population Surveys (Jordan DHS). All household members aged 18 and older for men and aged between 18 and 49 years for women were screened for eligibility. Women and men who visited the mosque at least 5 and 10 times over the previous month,respectively, for prayers or religious lessons were designated as regular mosque congregants and were therefore eligible for the study. A Kish grid was utilized in order to randomly select a respondent within one household when more than one individual was found to be eligible. Another visit was arranged if the selected individual was not available at the time of screening. Sample Size In order to detect an odds ratio of 1.5 for the odds of a respondent having heard a sermon and/or attended a religious lesson about family planning/spacing, modern family planning methods, gender equity, or reproductive health when comparing respondents from city and the, with a power of 80% and =0.05, the sample size needs to exceed 407 respondents from each region. The sample size calculation accounts for clustering. Thus, the target sample size was 420 from each governorate, yielding a total of 840 respondents. A total of 20 individuals were to be interviewed in the catchment areas of each randomly selected mosque. Thus, in order to obtain a sample of 420 respondents, 21 mosques were randomly selected from City as well as from. This represents 11% of the eligible mosques in City, and nearly 16% of the mosques in. Questionnaire The interviewer-administered questionnaire included questions to gage mosque congregants recall of Family Health Program topics and the impact of exposure to such messages. The questionnaire also included questions to gage respondents attitudes towards gender equity and family planning. Data Collection, Entry, and Analyses Accurate Opinion for Public Opinion Measurements, Co. conducted the data collection and data entry. The data set was entered, cleaned and edited for inconsistencies using CSPro 4.0. Missing data were not statistically imputed. Data analysis was completed using STATA version 11 statistical software. A total of 431 and 426 interviews were successfully completed in City and, respectively. Fieldwork commenced on the 12 th of July 2012 and lasted one week. To determine statistical significance in bivariate analyses (e.g., comparisons between City and mosque congregants), the researchers used Chi-square tests of differences in proportions and one-way ANOVA and Student's t-tests for the difference in means. The bivariate analyses are disaggregated by sex. When needed, regression analysis was conducted to determine whether confounding accounted for significant differences in the bivariate analyses. 7

9 Results Sample Characteristics As shown in Table 1, female congregants represented a larger proportion of the sample in as compared to (12% and 6%, respectively). Congregants in were generally younger and less educated than those from. Nearly one-third of congregants in attained an intermediate diploma or higher as compared to nearly one-fifth of congregants in. Roughly three-quarters of respondents were married; no differences in marital status were noted when comparing the two regions. Three statements (shown in Table 2) were used to gage the influence RLs have on respondents. Congregants in reported higher agreement scores with all three statements as compared to those in. A RL influence scale was generated utilizing these three statements (Cronbach s = Table 1: Sample characteristics n=431 n=426 Sex* Men (%) Women (%) Age* (%) (%) (%) (%) (%) Mean age (yrs) 43.8* 40.3* Marital status Married (%) Engaged (%) Single (%) Separated/divorced/widowed (%) Education* Less than secondary (%) Secondary (%) Intermediate diploma and higher (%) * Statistically significant difference (p<0.05) between governorates when utilizing chi2 test for proportions and Student s t test for means Table 2: Influence of RLs on congregants Agrees or strongly agrees with: n=431 n=426 Hearing messages from religious leaders about family planning influences your intentions to space between pregnancies, or asking your sons / 71.0* 78.2* daughters to do so ( if the respondent has sons or daughters) (%) Hearing messages from religious leaders about gender equity influences your intentions to be equitable (%) 71.5* 82.6* The opinions of religious leaders affect how you live your life (%) 52.9* 62.9* Mean number of agreements

10 0.70). There s a statistically significant difference between the mean RL influence in (2.0) and (2.2). This does not seem to confound the findings for recall of messages, as when you stratify by RLs influence, most of the significant differences between and are maintained. Message Recall Respondents were asked to specify whether they had heard sermons or attended religious lessons in the mosque about the topics listed in Table 3. Nearly half of all respondents did not recall hearing messages about any of the mentioned topics. Forty-three percent recalled hearing messages about Islam s stance on gender equity. Less than one-fifth of respondents recalled hearing any of the remaining topics. Overall, recall of messages relating to the Family Health Program was greater among congregants as compared to those in, where respondents recalled hearing 1.8 messages during the previous 6 months as compared to 1.4 message in. Significantly more respondents in said that they did not recall hearing any of the messages as compared to (53% and 42%, respectively). Congregants in had significantly great recall than those in with records to Islam s approval of FP, Islam s stance on gender equity and population. No significant differences were noted for all remaining topics. Table 3: Recall of messages discussed during religious sermons or lessons during the previous 6 months n=431 n=426 Total n=857 Islam s approval of modern family planning methods (%) Islam s approval of family planning (%) 13.0* 17.8* 15.4 Islam s approval of spacing pregnancies for at least three years (%) Islam and family Health (%) Islam and motherhood /Maternal health (%) Islam and childhood/ Infant and child health (%) Islam s stance on gender equity (%) 36.4* 48.8* 42.6 Islam s stance on the abundance of children (quality over quantity) (%) Reproductive health (%) Population (%) 5.3* 10.8* 8.1 None of these topics (%) 52.9* 41.6* 47.3 Does not recall (%) Mean number of topics 1.4* 1.8* 1.6 * Statistically significant difference (p<0.05) between governorates when utilizing chi2 test for proportions and Student s t test for means To examine RL influence more closely, the level of influence was dichotomized; high RL influence is defined as those who agreed or strongly agreed with greater than the mean number of statements on the RL influence scale (greater than 2 statements) and low RL influence as all others. Even after stratifying congregants by RL influence, those in recalled more topics than those in, as is shown in Table 4. The difference in recall was more pronounced among those with low RL influence, for 57% of those in did not recall any topics as compared to 42% in. The difference noted among those of high RL influence was not as pronounced, with congregants recalling messages about the stance of Islam on gender equity more so that those in. 9

11 Recall of messages is not associated with RL influence while stratifying by governorate; that is, no significant differences were noted with regards to recall when comparing those with low and high RL influence within the same region. Table 4: Recall of messages discussed during religious sermons or lessons during the previous 6 months stratified by RL influence Low RL Influence High RL influence n=247 n=191 n=184 n=235 Islam s approval of modern family planning methods (%) Islam s approval of family planning (%) 11.7* 18.9* Islam s approval of spacing pregnancies for at least three years (%) Islam and family Health (%) Islam and motherhood /Maternal health (%) Islam and childhood/ Infant and child health (%) Islam s stance on gender equity (%) 33.2* 46.6* 40.8* 50.6* Islam s stance on the abundance of children (quality over quantity) (%) 12.2* 19.9* Reproductive health (%) Population (%) 4.5* 11.0* None of these topics (%) 56.7* 42.4* Does not recall (%) Mean number of topics 1.3* 1.8* * Statistically significant difference (p<0.05) between and among those with high or low RL influence when utilizing chi2 for proportions and Student s t test for means Actions Taken after Exposure Respondents who recalled any of the topics were asked whether they had taken any action as a result of their exposure to the messages relating to that topic. As depicted in Table 5, nearly half of respondents answered positively in ; a significantly greater proportion as compared to (36%). Those who did take an action were asked to specify what that action was without being prompted. Self-reported actions that are related to the topics of interest are listed in Table 5. Interestingly, a significantly higher proportion of respondents in as compared to discussed the messages positively with other (66% and 44%, respectively), decided to treat both male and female children equitable (40% and 25%, respectively) and encouraged their sons/ daughters to use modern contraceptives (13% and 4%, respectively) and to space between pregnancies (15% and 3%, respectively). 10

12 Table 5: Actions taken after hearing the messages n=187 n=236 Took action after hearing the messages (%) 35.8* 50.0* Actions n=67 n=118 Discussed messages positively with spouse/relatives/ friends/ neighbors / colleagues family (%) 65.7* 44.1* Decided to use modern contraceptives (%) Decided to space births at least 3 years (%) Decided to treat both male and female children equitably (%) 40.3* 25.4* Encouraged their sons/ daughters to use modern contraceptives (%) 13.4* 4.2* Encouraged their sons/ daughters to space between pregnancies (%) 14.9* 2.5* Encouraged their sons/ daughters to treat both male and female children equitably (%) Convinced spouse to use modern contraceptives (%) Convinced spouse to visit the health provider / Health center for family planning counseling (%) Decided to have lesser number of children Or decided to avoid having a big number of children (%) Encouraged sons and daughters to plan their family for a better quality of life (%) Convinced spouse to space pregnancies for at least three years (%) Convinced spouse to treat both male and female children equitably (%) Started using modern contraceptives (%) Reviewed the Islamic literature on the topics discussed (%) Asked other RLs. or Mufti about the Islam point of view on the issues discussed (%) Mean number of taken actions Took at least 3 actions Took at least 2 actions * Statistically significant difference (p<0.05) between governorates when utilizing chi2 test for proportions and Student s t test for means Table 6: Association between message recall and actions taken Family planning No recall n=36 Recall 1 n=31 No recall n=55 Recall 1 n=63 Took any FP action 30.6* 80.7* 21.8* 57.1* Gender equity No recall n=7 Recall 2 n=60 No recall n=14 Recall 2 n=104 Took any gender equity action 14.3* 58.3* Recalled hearing about Islam s approval of modern family planning methods, family planning or spacing at least 3 years between pregnancies 2 Recalled hearing about Islam s stance on gender equity * Statistically significant difference (p<0.05) between those with recall and those without recall when utilizing chi2 test for proportions and Student s t test for means Statistically significant difference (p<0.05) between and, stratified by recall Actions taken are clearly associated with the topics recalled by congregants. As shown in Table 6, 81% in and 57% of respondents in who recalled any FP messages took actions relating to FP; significantly greater than 31% and 22% of respondents who took such action even though they did not recall FP messages. Similarly, in, significantly more respondents who recalled a gender equity message took action relating to that topic as compared to those who did not recall that message (58% and 14%, respectively). This trend was noted in, but did not reach statistical significance. This stratification also demonstrates that those who 11

13 recalled either FP or gender equity messages were more likely to take relevant actions in as compared to, as significantly more exposed respondents in than took FP and gender equity actions. When stratified by RL influence, no significant differences by area were noted with regards to having taken any FP action (Table 7). It is maintained that more congregants in as compared to took actions relating to gender equity among those with high RL influence. This is of interest since more congregants in as compared to recalled hearing gender equity messages regardless of their RL influence (Table 7). This indicates that RLs in were more effective in their message dissemination possibly because they were well trained Table 7: Association between taking action after exposure and RL influence Low RL Influence High RL influence Family planning n=27 n=34 n=40 n=84 Took any FP action Gender equity n=27 n=191 n=40 n=84 Took any gender equity action * 35.7* * Statistically significant difference (p<0.05) between those in and with high RL influence when utilizing chi2 test for proportions Attitudes Relating to Program Topics All respondents, whether they recalled hearing messages about the topics of interest or not, where presented with a number of statements relating to the topics of interest. Respondents specified whether they strongly agreed, agreed, disagreed, or strongly disagreed to each statement. Statements with a negative tone were recorded for analysis purposes. As shown in Table 8, agreement with positive statements relating to family planning was generally positive (>80% agreed or strongly agreed) and no differences were noted by recall in either area. On average, respondents agreed with more than 4 of the 5 statements regardless of area or exposure. Respondents in were more likely to agree with the statement that religious leaders should address gender equity in their religious lessons or sermons to increase public awareness if they recalled hearing messages about gender equity in the mosque. This difference was lost after conducting further analysis controlling for age, sex and educational attainment. Nearly all respondents in agreed with this statement regardless of their exposure. Once again, on average, respondents agreed with more than 4 of the 5 statements regardless of area or exposure. Agreement with the statement that a large number of children does not give higher social status was moderately low (<50%) regardless of area or exposure. 12

14 Table 8: Association between message recall and positive attitudes by topics Family planning No recall Recall 1 Agrees or strongly agrees with: n=347 n=84 Islamic Shari a approves of spacing at least 3 years between pregnancies (%) Modern contraceptives use is the best way to plan your family / Space between pregnancies (%) A small family leads to a better quality of life rather than big family (%) Couples should space their pregnancies for at least 3 years (%) Religious leaders should address family planning in their religious lessons or sermons to promote family health (%) No recall n=317 Recall 1 n= Mean number of positive FP opinions Gender equity Agrees or strongly agrees with: No recall Recall 2 No recall Recall 2 n=274 n=157 n=218 n=208 Families should not give preference to males over females (%) Having at least one son is NOT better for a couple than having only daughters (%) The gender of the child does not matter (%) Islam does not distinguish between genders in rights (%) Religious leaders should address gender equity in their religious lessons or sermons 95.3* 99.4* to increase public awareness (%) Mean number of positive GE opinions Social status Agrees or strongly agrees with: No recall Recall 3 No recall Recall 3 n=376 n=55 n=354 n=72 A large number of children DOES NOT GIVE higher social status (%) Recalled hearing about Islam s approval of modern family planning methods, family planning or spacing at least 3 years between pregnancies 2 Recalled hearing about Islam s stance on gender equity 3 Recalled hearing about Islam s stance on the abundance of children (quality over quantity) * Statistically significant difference (p<0.05) between those with recall and those without recall when utilizing chi2 test for proportions and Student s t test for means Statistically significant difference (p<0.05) between and, stratified by recall BOLDED words indicate when a statement was reversed from a negative statement to a positive statement for analysis purposes As shown in Table 9, for various opinions, those of high RL influence reported higher agreement as compared to those with low RL influence in both and. The mean number of positive FP opinions was significantly higher among those with high RL influence in and (4.7 and 4.6, respectively) as compared to those with low RL influence (4.2 for both and ). No differences were noted between and. 13

15 Table 9: Attitudes stratified by RL influence Agrees or strongly agrees with: Low RL influence Family planning n=247 n=191 High RL influence n=184 n=235 Islamic Shari a approves of spacing at least 3 years between pregnancies (%) Modern contraceptives use is the best way to plan your family / Space between pregnancies (%) A small family leads to a better quality of life rather than big family (%) Couples should space their pregnancies for at least 3 years (%) Religious leaders should address family planning in their religious lessons or 85.4* 93.2* sermons to promote family health (%) Mean number of positive FP opinions (Cronbach s alpha 0.64) Gender equity Families should not give preference to males over females (%) Having at least one son is NOT better for a couple than having only daughters (%) The gender of the child does not matter (%) Islam does not distinguish between genders in rights (%) Religious leaders should address gender equity in their religious lessons or sermons to increase public awareness (%) Mean number of positive gender equity opinions (Cronbach s alpha 0.31) Social status A large number of children DOES NOT GIVE higher social status (%) All topics Mean number of positive statements agreed or strongly agreed with (Cronbach s alpha 0.57) Statistically significant difference (p<0.05) between those with low RL influence and those with high RL influence when utilizing chi2 test for proportions and Student s t test for means * Statistically significant difference (p<0.05) between and among those with high or low RL influence when utilizing Student s t test for means BOLDED words indicate when a statement was reversed from a negative statement to a positive statement for analysis purposes Dose-effect A significant dose effect was only noted in governorate when regressing the number of actions taken onto the number of recalled messages. In, on average, the number of reported actions taken increases by 0.12 with every increase in the number of messages recalled (p<0.05). This finding was maintained after controlling for sex, age and educational attainment. A similar but statistically insignificant finding was noted in. 14

16 : # of actions taken vs. # of recalled messages Number of recalled messages Number of actions taken Fitted values : # of actions taken vs. # of recalled messages Number of recalled messages Number of actions taken Fitted values 15

17 Conclusions Mosque congregants in were younger and less educated than congregants in city. Congregants in scored higher on the RL influence scale when compared with city congregants. Recall of messages relating to the Family Health Program was higher among those in as compared to those in city. This difference was maintained even after stratifying by RL influence. Therefore, it would be safe to conclude that RLs in disseminated messages at a greater rate than those in. It is worth noting the Total Fertility Rate in, according to the 2009 Jordan Population and Family Health Survey, is 4.5 births per woman (the highest in the country) while it is 3.8 in. Therefore, as there is a greater need for FP in, it is possible the s religious leaders preach more about this topic as compared to RLs. Even though nearly half of congregants in reported taking action after being exposed to the listed messages, a significantly higher proportion than those in city (36%), congregants in city were more likely to take action relating to the topics that they were exposed to, suggesting that the training of RLs in enhanced their effectiveness as preachers on these topics. This finding is affirmed when tying the recalled messages to the relevant actions taken. Nearly 81% and 58% of those from city who recalled any FP or gender equity message took a FP or gender equity action, respectively; significantly greater than those in (57% and 36%, respectively). Moreover, in city, recall of messages was significantly related to taking a relevant action relating to both FP and gender equity, while this was only observed with relation to the FP topic in. When stratifying by RL influence, among those with high RL influence significant difference is noted only with regards to actions taken relating to gender equity when comparing and. Exposure to messages did not appear to affect congregants attitudes. It is important to note that most congregants held positive attitudes (>80% agreement) with all topics. RL influence is clearly associated with congregants attitudes, for the mean number of positive statements with which respondents agreed was consistently higher among those with higher RL influence as compared to those with low RL influence, while stratifying by region. On average, congregants with high RL influence in both city and agreed with 10 statements as compared to agreement with an average of 9 statements among those with low RLs. A significant dose effect between number of recalled topics and the number of actions taken was noted only in. One must keep in mind that while a greater proportion of congregants reported taking action, those in took more message-relevant actions compared to congregants. 16

18 Recommendations RL influence appears to play a key role in the extent to which mosque congregants will take action and hold positive attitudes. It appears that, regardless of region, those with low RL influence are more likely to take action related to family planning (but not to gender equity) after exposure to messages. This finding is counterintuitive, but could possibly be due to the fact that, overall, they tend to have less positive attitudes compared to those with high RL influence so when RLs talk with them about this topic, they are more likely to act. This is something that requires further inquiry. In assessing a program s effects, reach is an important but not sufficient measure of impact. As the data demonstrate, RLs in appear to disseminate topics relating to family health and family planning at a greater rate than those in city; however, mosque congregants in city are more likely to take relevant actions after exposure to such messages, which could indicate that the trained RLs, when they do disseminate information on the topics, convey the messages more clearly and with greater effect due to their training. Future efforts of behavior change communication through religious leaders ought to be evaluated through a cohort study where the impact of preaching and counseling can be assessed in a longitudinal fashion. 17