1. Exposure to Family Planning Messages through Mass Media and Interpersonal Communication and Current Contraceptive Use in Ghana Claire Bailey ceb504@soton.ac.uk Supervisors: Dr J.W. McDonald & Dr Zoë Matthews

2. Outline of Presentation  Rationale for study - The Ghanaian context  Aims of study  Theoretical background  Introduction to data – Ghana 2003 DHS  Methodology  Definition of study variables  Results  Conclusions

3. The Ghanaian Context  Estimated population in 2005 of 21 million  Population growth rate in 2005 was 1.25%.  The 2005 Total Fertility Rate is 3.02  GDP per capita (ppp) was estimated in 2004 as $2,300

4. Trends in Contraceptive Use in Ghana

5. Ghana’s Poverty Reduction Strategy Vision 2020 Plan of Action  Aim to have contraceptive prevalence of modern methods of 15% by 2000 and 50% by 2020  Strategy to decentralize service delivery and support national campaign on fertility regulation including comprehensive Information, Education and Communication (IEC) programme to promote the use of family planning

6. Aims of Study  The aims of my study were to determine if there is any association between current use of modern contraceptives among Ghanaian women and:  exposure to family planning messages through a range of different mass media channels  exposure to interpersonal communication regarding the use of family planning

7. Theoretical Background  The appeal of using mass media communication channels to promote family planning messages is the wide spread coverage and cost effectiveness.  Some debate about its effectiveness and two primary competing theories:  Ideational Hypothesis - media effects are universal and each individual may be prompted to change their attitude and behaviour by exposure to modern ideas  Diffusion of Innovation Theory - mass media is effective at creating awareness and knowledge of innovations, but interpersonal communication is necessary for actual behaviour change

8. Data  2003 Ghana Demographic Health Survey (GDHS)  Sub-sample drawn to include all women who are potentially at risk of pregnancy and therefore potential contraceptive users:  All women aged 15-49 currently in union (married or living with a man) AND  All unmarried women aged 15-49 who are currently sexually active (within past month of survey date) – unmarried includes, never married, separated, widowed and divorced

9. From this subset cases were excluded where the women is one or more of the following:  Currently pregnant  Amenorrheic  Infecund  Menopausal  Currently abstaining The final data set contains 2065 cases

10. Methodology  Binary logistic regression modelling with current use of a modern contraceptive as the response variable.  Multi-level modelling was used, to allow for random variation at the group as well as the individual levels, to account for the hierarchical clustered data structure which is a function of the sampling of the survey and could lead to dependence among the observations.

11. Study Variables Binary response variable: 0 = not currently using a modern contraceptive method 1 = currently using a contraceptive method Explanatory variables: Exposure to Mass Media - Respondent has heard a family planning message in the few months prior to survey from: Radio – yes/no Television – yes/no Newspaper/magazine – yes/no

12. Explanatory variables – Interpersonal communication:  Respondent has heard a family planning message from a Health worker  Respondent has heard a family planning message at a community Meeting  Respondent has discussed family planning with someone other than partner Control variables:  Age  Education  Occupation  Religion  Ethnicity  Region  Urban/rural  Number of living children  Marital status

13. Results – Respondent Characteristics Variable % of respondents (n) Total n=2065 Response Current use No71 (1461) Yes29 (604) FP exposure- mass media fpnews No81.1 (1675) Yes18.9 (390) Fptv No49.3 (1018) Yes50.7 (1047) Fpradio No19.2 (396) Yes80.2 (1669) Variable% of respondents (n) Total n=2065 Interpersonal Communication Fphealthworker No43.7 (903) Yes56.3 (1162) Fpcommunity No63.0 (1301) Yes27.0 (764) Discussedothers No69.9 (1443) Yes30.1 (622)

14. Results- Simple Logistic Regression βSE (β)Exp (β)95% CI fpnews0.34**0.121.40(1.12,1.76) fptv0.36***0.101.44(1.19,1.74) fpradio0.43***0.131.54(1.19,1.99) discuss0.67***0.101.96(1.61,2.40) fphealth0.62***0.101.85(1.52,2.26) fpcomm0.180.101.20(0.99,1.46) ***p<0.001; **p<0.01; *p<0.05 NB: The intercepts and the baseline categories are omitted from this table, all baselines are β=0 and Exp (β) = 1

15. Results- Multiple Logistic Regression βSE (β)exp (β)95% CI Discussed FP with someone other than partner No (RC)0.001.00 Yes0.91***0.162.48(1.82,3.38) FP message from health worker No (RC)0.001.00 Yes0.54***0.121.72(1.34,2.19) FP message from community meeting No (RC)0.001.00 Yes0.46*0.231.58(1.01,2.52) ***p<0.001; **p<0.01; *p<0.05 RC = Reference Category

16. What next? – Model 2  To explore the possible indirect effect of exposure to messages in the mass media a new model is fitted with discussed family planning with others as the response variable.  Discussing family planning with others was chosen as the response as literature suggests it is an intermediate behaviour change variable and part of the mechanism through which receiving family planning information from mass media influences contraceptive behaviour.  All other variables and model specification remain the same

17. Results- Simple Logistic Regression βSE (β)Exp (β)95% CI fpnews1.18***0.113.25(2.59,4.08) fptv0.82***0.102.28(1.88,2.77) fpradio1.16***0.153.19(2.37,4.29) ***p<0.001; **p<0.01; *p<0.05 NB: The intercepts and the baseline categories are omitted from this table, all baselines are β=0 and Exp (β) = 1

18. Results- Multiple Logistic Regression βSE (β)Exp (β)95% CI FP message from radio No (RC)0.001.00 Yes0.56**0.181.76(1.24,2.48) FP message from Television No (RC)0.001.00 Yes0.29*0.131.34(1.04,1.73) FP message from Newspaper No (RC)0.001.00 Yes0.53***0.141.70(1.26,2.28) ***p<0.001; **p<0.01; *p<0.05 RC = reference category Other variables in the model are: Number of living children, Education, Region FP message from health worker & FP message from community meeting

19. Random effects  Both final models were tested for the inclusion of random effects components at the household and cluster level.  The models were re-fitted with the same fixed effects and adjusted to allow the intercept to vary first at household then at cluster level.  In all cases it was concluded that there is no significant clustering effect and all of the observations in the data can be treated as independent. The fixed effects models are a valid and adequate approach to analysing this data.

20. Conclusions  Exposure to mass media family planning messages does not have a direct association with current use of modern contraceptives after controlling for socio-economic factors.  There is evidence that it does have indirect influence through its strong positive association with interpersonal communication which in turn is strongly and positively associated with contraceptive use.  Results support the diffusion of innovation hypothesis where mass media works as part of a two-step flow process where knowledge disseminated through the media prompts interpersonal discussions, which then diffuses through social networks and prompts behaviour change.

21. Thank-you very much. Claire Bailey ceb504@soton.ac.uk