Impact of Mass Media Exposure on Family Planning: Ethiopian Demography and Health Survey

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1 Journal of Public Health in Developing Countries Vol. 3, No. 2, pp ISSN Original Contribution Open Access Impact of Mass Media Exposure on Family Planning: Analysis of the Ethiopian Demography and Health Survey Asmamaw K. Tsehay 1, Desalegn T. Zegeye 2, Tesfahun M. Yilma 3 1 Public Health Informatics, West Gojjam Zonal Health Department, Amhara Regional State Health Bureau, Ethiopia 2 University of Gondar Hospital, Gondar, Ethiopia 3 Department of Health Informatics, Institute of Public Health, University of Gondar, Ethiopia Correspondence to: Asmamaw Tsehay, Public Health Informatics, West Gojjam Zonal Health Department, Amhara Regional State Health Bureau, Ethiopia. asme1917@gmail.com ARTICLE INFO Article history: Received: 1 Dec 2016 Accepted: 25 Apr 2017 Published: 22 Aug 2017 Keywords: Mass media Family planning Demographic health survey Ethiopia ABSTRACT Background: Mass media is a basic element of transferring valuable information on health services. As family planning is influenced by mass media, there is a need to study the impact of mass media exposure on family planning. Methods: Three rounds of Ethiopian Demographic Health Survey (EDHS) (2000, 2005, and 2011) datasets were analysed by bivariate and multivariate techniques. Results: A weighted sample of 28,161 individuals was analysed. The mean age of the study participants was 31 years. A higher number of participants were from Oromiya regional state (33%) and 87% were from rural. Married women who watched television (TV) at least once a week were two times more likely to use family planning methods than those who did not watch TV at all (AOR: 2.5, p <0.001). The odds of listening to a radio at least once a week was 1.35 (95% CI 1.179, 1.547; p <0.001). The multivariate analysis also showed that married women who had radio in the household were 1.6 times more likely to use family planning methods than women who did not possess one (p <0.001). Conclusions: Mass media had a positive impact on family planning in Ethiopia. Exposures to TV, radio, and newspaper were positively associated with the use of family planning; and negatively associated with the number of desired children. Citation: Tsehay AK, Zegeye DT, Yilma TM. Impact of Mass Media Exposure on Family Planning: Analysis of the Ethiopian Demography and Health Survey. J Public Health Dev Ctries. 2017; 3(2): The Authors All rights reserved, JPHDC. This is an Open Access article distributed d under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 405

2 INTRODUCTION Mass media, such as television (TV), radio, and newspapers, are widely used to reach a large proportion of population. Over the past two decades the world has evolved in dramatic ways with regard to mass communication and public health [1]. Typical campaigns have placed messages in media that reached large audiences, most frequently via TV or radio, but also outdoor media, such as billboards and posters, and print media, such as magazines and newspapers. Exposure to such messages is generally passive, resulting from an incidental effect of routine use of media. The great promise of mass media campaigns lies in their ability to disseminate well-defined behaviorally-focused messages to large audiences repeatedly, over time and at a low cost per head [1,2]. One of the uses of mass media is to support family planning programs, which provide services that help people to achieve the number of children they desire, to reduce the number of unwanted pregnancies, to reduce the risk of sexually transmitted infections, and to improve the health of women and children by spacing birth [3,4]. The influence and pervasiveness of the mass media can be found everywhere around us today [5,6]. Increasing contraceptive use and reducing unmet need for family planning are central to improving maternal health. In lessdeveloped regions of the world, especially Sub- Saharan Africa and South Asia, human and financial resources are limited, modern contraceptive use is relatively low, unmet need for modern contraception is high, and consequently maternal morbidity and mortality are high [7]. All available channels and outlets should be used to ensure that coordinated behavioral change communication messages and activities reach the desired population. The channel of choice for these activities should be based on the target audience and the local availability and acceptability of the channel [4]. An analytical study from 48 developing countries shows that women who watch TV some times are 1.6 times more likely to use family planning methods than women who do not watch TV at all [8]. Negative association was seen between watching TV and the number of children desired. The average number of children desired ranges from 5.2 children for women who do not watch TV to 3.2 children for those who are the daily viewers [8,9]. In Kenya 28% of the married women reported that their household possessed a working radio and only 8.6% reported that they had a working TV in the Ethiopian Demographic Health Survey (EDHS), The survey also found that 68.4% of married women listened to radio at least once a week and radios were owned by 60.7% while only 4.5% report owning a TV set [10]. Another study in Bangladesh found that the probability of being a current user of modern contraceptive methods is increased by 26% if women are exposed to family planning TV messages and by 37% if women are exposed to family planning poster messages compared with those who were not exposed [11,12]. Married women who were exposed to family planning messages in TV were 2.4 times more likely to use the family planning methods than those who were not exposed in India [13]. But the proportion was lower in Pakistan where women who were regularly exposed to TV was 1.6 times more likely to use family planning methods than the non-exposed group [14]. Despite widespread knowledge about family planning among married women of reproductive age, there is still a substantial proportion of women with an unmet need for family planning. Many women do not want more children, but are exposed to the risk of pregnancy and are not practicing family planning methods. This leads to the conclusion that mere knowledge of family planning is not enough, and that there is a need for strong motivation and taking practical steps about family planning methods. High population growth, unmet need for family planning rate and low contraceptive prevalence rate can lead to high rates of infant, child and maternal mortality as well as abortions. One way of addressing these issues is mass media [10,15,16]. Hence, there is a need to study the impact of mass media on family planning. Therefore, this study sought to describe the influence of mass media exposure on family planning in Ethiopia. 406

3 MATERIALS AND METHODS Study Design and Setting A survey-based study was designed using the three EDHS datasets of the years 2000, 2005 and The surveys were conducted in February-June 2000, April-August 2005, and December 2010-June 2011, respectively. Ethiopia, officially known as the Federal Democratic Republic of Ethiopia, is located in the horn of Africa. Ethiopia is the most populous landlocked country in the world and the secondmost populated nation on the African continent, with over 84 million inhabitants (2013 estimates). It occupies a total area of 1,104,300 km 2 and has Addis Ababa as its capital city [17,18]. The country is divided into 11 administrative divisions - 9 regional states and 2 city administrations (Addis Ababa & Dire Dawa). The latest recorded population growth rate was 2.6 percent [18]. Study Population The source population for this study was all married women in the age range of in Ethiopia. The study population was all married women of age who were registered at the three EDHS from 2000 to The women with no record of family planning methods were excluded from the study. Ethiopian Demographic Health Survey The 2000 EDHS is a nationally representative survey comprising of 15,367 women aged in which 4,543 urban and 10,824 rural and 2,607 men aged The second 2005 EDHS took nationally representative samples of 14,070 women aged that consisted of 4,423 urban and 9,647 rural women and 6,033 men aged The 2011 EDHS included 16,515 households in which 5,329 urban and 11,186 rural women aged 15-49, and all men age in these households were included. A two-stage stratified-cluster sampling was used for the three surveys [17]. Data Collation The three EDHS datasets were downloaded from MEASURE DHS (Demographic and Health Survey) website after obtaining the necessary permissions for their download and further analyses. Thirty appropriate variables were selected from 3,665 variables. The variables were then merged into one dataset for analyses. The total number of women from the three EDHS was 45,952 from which married women were selected, n 1 = 9,203 (2000 EDHS), n 2 = 8,438 (2005 EDHS) and n 3 = 9,478 (2011 EDHS). The total number of unweighted women was 27,119. When these datasets were weighted with women s individual sample weight, the weighted sample became n 1 = 9,653 (2000 EDHS), n 2 = 8,914 (2005 EDHS), n 3 = 9,594 (2011 EDHS) and the total number was 28,161 from the three surveys. Some variables were further edited by combining some of their groups in one or two groups either because of the small number of observations in some categories or to make the analysis and the interpretation more meaningful. Statistical Analyses Three levels of analysis were deployed. The first was the descriptive analysis to examine the distribution of the respondents in terms of the explanatory variables used in the study. This was achieved by conducting distribution tables and calculating the frequencies and proportions of contraceptive use in each category within the selected explanatory variables. The second was the binary logistic regression analysis to examine the relationship between the selected mass media variables (independent variable or covariate) and the use of contraceptives as proxy for utilization of family planning (dependent variable). This was done through the calculation of the odd ratios (OR). Then multivariate logistic regression models were used, which mainly gave an elaborated explanation and estimation of the probability of the outcome with respect to the effects of the different determinant factor. RESULTS Characteristics of the Participants The mean age of the participants was 31 year (SD +8.6) and was similar for the three EDHS. About half of the respondents were under 30 years. The highest proportion of respondents was from the Oromoyaa region (33%), and the lowest was from the Harari region (0.2%). The 407

4 majority of married women participated in the study were Orthodox Christians and Muslims, 46% and 31%, respectively in the three EDHS. Protestants, traditional and other religions accounted for the remaining 23% of the religious groups in Ethiopia. Over eight out of 10 respondents (87%) lived in rural areas. More than three quarter of married women aged had no education. The proportion of uneducated women decreased from the first to the third EDHS and was 83%, 79% and 67% in EDHS 2000, 2005 and 2011, respectively. Married women enrolled for higher education increased from 0.5% in EDHS 2000 to 2.8% in EDHS Electricity coverage for married women in the three EDHS was still limited, with a very large disparity between urban and rural residents. In urban areas, the married women with electricity access from 74% in 2000 to 84% in 2005, but then decreased in 2011 to 79%. In rural areas the proportion increased from 0.3% in 2000 to 1.9% in 2005 and to 4.1% in Wealth quintiles were divided into five scores as poorest, poorer, middle, richer, and richest. There were not much differences on wealth quintiles within each EDHS, where the lowest wealth quintiles were between 15-20% and the highest were between 18-19% of respondents. From all the respondents of the three EDHS, only 10.2% of rural residents were in the highest quintiles where as in urban dwellers it was 74.8%. From the 11 regions, 94% of women from Addis Ababa were within highest wealth quintiles. Highest wealth quintile was lower in Amhara in which only 13% of women in the region were in the highest wealth quintile. Exposure to Mass Media The three EDHS assessed ownership of radio and television and exposure to the media by asking how often a respondent watched TV, listened to the radio, or read any newspaper. Table 1 gives the breakdown of exposure of married women to the media in the three surveys. Generally radio exposure was higher among married women as compared to TV and the print media. From all the married women who owned a radio, about a quarter ( 27.3%) used family planning methods. However, among the women who owned TV, 54.2% used family planning methods as shown in Table 2. Table 1. Exposure of Married Women to the Mass Media Features Ownership % Radio ownership TV ownership Frequency of exposure (at least once a week) Listening to radio Watching TV Reading newspaper Table 2. Ownership of Media and Family Planning Utilization among Married Women in EDHS (2000, 2005 and 2011) Ownership Has radio Use of Family Planning n (%) Yes No No 2,087 (11.4) 16,167 (88.6) Yes 2,498 (27.3) 6,639 (72.7) Has TV No 3,827 (14.7) 22,197 (85.3) Yes 754 (54.2) 637 (45.8) Exposure to Family Planning Messages In the 2011 s EDHS, amongst the married women aged 15-49, community events were the most common source of family planning messages at 37.3% and the radio was the second most common at 30.3%. These figures were lower in the previous EDHS in which 14.4% in 2000 and 24.9% women in 2005 listened to family planning messages through radio. Another common source was TV with 14% of 408

5 women reporting exposure to family planning messages via television. The women did not have high exposure to written sources of family planning messages. Only 2%, 4% and 5% of the women reported seeing family planning messages in a newspaper or magazine in 2000, 2005 and 2011, respectively. There was a slight variation in exposure to printed family planning messages by the background characteristics. Women in the two youngest age categories, aged 15-24, had higher levels of exposure to family planning messages in a newspaper, magazine, pamphlets, posters, or leaflets than women in the older categories. A higher proportion of urban women than rural women were exposed to the messages from each of the above-mentioned sources. The number of children desired ranged from an average of 6.2 for women who did not watch TV to 4.3 for those who did watch for at least once a week as shown in Table 3. Table 3. Frequency of Mass Media Exposure and Desired Number of Children in EDHS (2000, 2005 and 2011) Frequency Listening to radio Average Desired Number of Children Not at all 6.14 Less than once a week 5.58 At least once a week 4.81 Watching TV Not at all 6.23 Less than once a week 5.25 At least once a week 4.28 Impact of Mass Media on Family Planning Table 4 shows that married women who had radio in the household were 1.6 times more likely to use family planning than women who did not have one ( AOR: 1.64; 95% CI: 1.50, 1.79; p <0.001). However the influence of radio ownership on the use of family planning decreased from the first EDHS in contrary to the frequency of ownership - AOR: 2.1; 95% CI: 1.72, 2.62; p <0.001 in EDHS 2000 to AOR: 1.4; 95% CI: 1.26, 1.59; p <0.001) in EDHS Similarly, women who had TV in their household were 1.4 times more likely to use family planning. The impact of watching TV was higher than listening to radio and reading newspaper. Women who watched TV at least once a week were two times more likely to use family planning than who did not watch TV at all with AOR: 2.5; 95% CI: 2.13, 2.94; p <0.001), although most of the respondents heard about family planning through radio. DISCUSSION The mass media has an impact on the prevention and control of many public health problems. This study focused on the impact of mass media on the use of family planning among married women (aged 15-49) in Ethiopia from the three demographic health surveys. The highest proportion of survey participants were from Oromiya region (33%) and the lowest were from Harari region (0.2%). Over eight out of 10 respondents lived in rural areas. This shows that there were proportional allocations of study participants throughout the Ethiopian region and place of residence. Although mass media exposure increased in each installment of the EDHS, but the increase was lower than most of the other developing countries. In 2011, 37% of women were exposed to TV which was lower than other developing countries where it was 49%. In EDHS of % of married women were exposed to radio and 7% to TV which was lower than Pakistan where 33% were exposed to radio and 46% to TV in a similar DHS [8,14]. In 2005 s EDHS, exposure to mass media among married women increased to 47% for radio and 11% for TV and to 54% and 47% in 2011, respectively. The increase in mass media exposure can be due to the increase in availability of mass media technology as shown by the ownership statistics and women s awareness of mass media. Radio and television are two important media for disseminating information about family 409

6 Table 4. Family Planning Use by Mass Media Coverage and Exposure of Married Women, Aged Years, in EDHS (2000, 2005 and 2011) Mass Media Variables Has radio Use of Family Planning Yes No Adjusted Odds Ratio (95% Confidence Interval) No 14,916 1, Yes 6,876 2, (1.50, 1.79)** Has TV No 20,531 3, Yes 1,262 1, (1.21, 1.61)** Frequency of newspaper reading Not at all 20,928 3, Less than once a week 1,172 1, (1.62, 2.049)** At least once a week (1.30, 2.09)** Almost daily (0.90, 1.91) Frequency of listening to radio Not at all 14,768 1, Less than once a week 5,027 1, (1.21, 1.47)** At least once a week 1, (1.18, 1.55)** Almost daily 1, (1.21, 1.63)** Frequency of watching TV Not at all 18,915 2, Less than once a week 2,141 1, (2.06, 2.52)** At least once a week (2.13, 2.94)** Almost daily (1.70, 2.56)** Heard about family planning on radio during previous month No 18,027 2, Yes 4,332 2, (1.32, 1.59)** Heard about family planning on TV during previous month No 20,802 3, Yes 1,556 1, (1.13, 1.47)** Read about family planning in newspaper during previous month No 21, Yes (0.90, 1.21) ** - p <0.001; * - p <

7 planning. However, access to these media and exposure to family planning through them are still limited in Kenya particularly for TV. In 2011 s EDHS, 42% of married women owned radio and 9.3% owned TV which is higher than Bangladesh where 28% of the respondents reported that their household possessed a working radio and only 8.6% reported that they had a working TV [10]. In this study it was found that there were some differences between possession of radio or TV and the exposure status of mass media. From all the married women, 32.5% had radio and 4.9% had TV in their households but 39.1% were exposed to radio and 18.5% to TV. In 2000 s EDHS the gap between ownership and exposure to TV was 5.2%, in 2005 s EDHS it increased to 7%, and became even wider to 28% in The difference with ownership of mass media elements and exposure status may be due to two possible reasons. First, there may be more than one married woman in the household, and second, women may be exposed to mass media at their neighbours. The increase in ownership and exposure through the three EDHS may be due to socio-economic development. Although the number of married women who owned radio was higher than the women with TV, but the impact on family planning was greater for TV owners where 54.2% of TV owners used family planning which is similar to a study from India where 54.4% of TV owners used family planning [13]. The possible explanation for this finding is that mostly TVs were owned by women in the urban area who had better living status. These factors can shift the use of family planning upwards for TV owners than radio owners. The other possible reason would be that TV messages were more interesting and can easily get into individual s mind than other media. We mostly believe what we see rather than what we hear. Frequency of listening to radio amongst married women in this study was lower than other developing countries, in Kenya 54% of women listened to radio on daily basis whereas a study from 48 developing countries showed that 68% of married women listened on daily basis in the same DHS year. Similarly, watching TV was 37% in Kenya for daily or monthly viewers, which is lower than Asia and northern Africa (85%) but higher than eastern and southern Africa which is 25% [8,14]. We found a negative association between watching TV and the number of children desired. The average number of children desired ranged from 6.2 for women who did not watch TV to 4.3 for those who watched at least once a week, and this was similar to west and middle Africa [8]. Community events were the most common source of family planning messages in 2011 at 37.3%. Radio was the second most common at 30.3%, lower than Bangladesh where 42% of women received family planning messages via radio, 17% via TV and 14% via print media [10]. Only 14% of women reported exposure to family planning messages via TV. Married women in this study did not have high exposure to written sources of family planning messages. Only up to 5% of women reported seeing family planning messages in a newspaper or magazine. This may be due to educational status of women, where above three quarters of married women (76%) had no education and also due to inaccessibility of print media to the rural community. The impact of watching TV was higher than listening to radio and reading newspaper. Women who watched TV at least once a week were two times more likely to use family planning methods than who did not watch at all with AOR of 2.5. This is similar to studies from other developing countries. In India, for instance, women who were exposed to TV were 2.14 times more likely to use family planning [8,10,13]. CONCLUSIONS Mass media had a positive impact on the use of family planning in Ethiopia among married women aged Exposures to TV, radio and newspaper were found positively associated with the use of family planning and negatively with the number of desired children. Ownership of radio and TV also influenced family planning. Although the electronic and print media have an impact on family planning, exposure to TV shows greater influence on the use of family planning methods. AUTHORS CONTRIBUTIONS All authors contributed equally in the proposal development. AKT handled the data collection 411

8 process. All authors were involved in data analysis. AKT prepared the manuscript and TMY and DTZ revised the paper. All authors have read and approved the final manuscript. ACKNOWLEDGEMENTS The authors would like to thank Measure DHS Corporation, Calverton, Maryland, USA for providing the datasets for this study. Our gratitude also goes to the Institute of Public Health, University of Gondar and Amhara Regional State Health Bureau for their technical and financial support. CONFLICT OF INTEREST Authors have declared that no competing interests exist. REFERENCES 1. Abroms LC, Maibach E. The Effectiveness of Mass Communication to Change Public Behavior. Annu Rev Public Health. 2008; 29: Wakefield MA, Loken B, Hornik RC. Use of mass media campaigns to change health behaviour. Lancet. 2010; 376: Federal Ministry of Health, Reproductive health for health science students lecture note: In collaboration with The Carter Canter (EPHTI) and The Federal Democratic Republic of Ethiopia Ministry of Education and Ministry of Health; Federal Ministry of Health [Ethiopia], National Guideline For Family Planning Services In Ethiopia. February Shane VM, Fred A, Noureddine A. Contraceptive trends in developing countries. DHS comparative reports, December Jimi K, Adewole A. The Mass Media and Behavioural Change: Lesson from Family Planning and Health Communication Campaigns in Nigeria Jacobstein R, Curtis C, Spieler J, Radloff S. Meeting the need for modern contraception: effective solutions to a pressing global challenge. Int J Gyna Obst. 2013; 5 S Charles F, Westoff D, Caroline M. The Impact of Television and Radio on Reproductive Behavior and on HIV/AIDS knowledge and behavior. DHS analytical studies 24. November Retherford RD, Mishra V. Media exposure increases contraceptive use. Natl Fam Health Surv Bull. 1997: 7: Islam MM, Hasan AH. Mass media exposure and its impact on family planning in Bangladesh. J Biosoc Sci. 2000; 32: Goni A, Rahman M. The impact of education and media on contraceptive use in Bangladesh: a multivariate analysis. Int J Nurs Pract. 2012; 18: Parr DN. Mass Media Promotion of Family Planning and the Use of Modern Contraception in Ghana. August Kulkarni MS. Exposure to mass media and its impact on the use of family planning methods by women in Goa, India. Health and Population. 2003; Guttmacher Institute. Women's Exposure to Mass Media Is Linked to Attitudes Toward Contraception in Pakistan, India and Bangladesh. International Family Planning Perspectives. March Fantahun M. Comparative study of the characteristics of family planning service users and non-users in Northwest Ethiopia. Afr J Reprod Health. 2006; 10: Federal Ministry of health [Ethiopia]. National guidelines for family planning services in Ethiopia. February Central statistics agency [Ethiopia]. Ethiopian demographic and health survey Addis Ababa, Ethiopia and Calverton, Maryland, USA: Federal Ministry of Health [Ethiopia]. International conference on family planning, Addis Ababa, Ethiopia. November