Mass media and interpersonal influence in a reproductive health communication campaign in Bolivia.

Communication campaign research represents a core enterprise in the communication discipline. Numerous frameworks have been developed to describe the campaign process, and many theories have been developed that inform campaign evaluation (Rice & Atkin, 1989). This is particularly evident in the field of health communication, in which billions of dollars are spent annually trying to change health-related behaviors (Atkin & Arkin, 1990). Health communication campaigns have been developed to address a wide variety of needs defined by policy makers, constituent groups, activists, and stakeholders, among others. Health communication programs designed to increase access to contraceptives and reproductive health services in developing countries have been in existence for over 30 years (Berelson & Freedman, 1964; Lapham & Mauldin, 1985) and have continued to raise one fundamental question: How can we encourage people to practice family planning so that they may reduce their risk of unwanted childbearing?

Although there is no clear answer to this question, different schools offer different perspectives (Cleland & Wilson, 1987; Pollack & Watkins, 1993). Some schools argue that economic development will lead to a naturally arising desire for lower fertility because the costs of numerous children will outweigh the benefits (e.g., Schultz, 1976). Others argue that improving health service delivery will satisfy an already existing demand for family planning services (Bruce, 1990). A third school argues that communication campaigns that disseminate information about family planning options and services will increase the demand for family planning services and eventually lead to reduced fertility (Palmore, 1968; Piotrow, Kincaid, Rimon, & Rinehart, 1997; Rogers, 1973, 1995; also see Bongaarts & Watkins, 1996).

Although these perspectives are compatible, the purpose of this article is to describe research undertaken in Bolivia intended to evaluate a communication campaign that follows a communication perspective. Our orientation is that economic and quality of service factors are important influences on contraceptive behavior, but that communication of these factors helps to accelerate the fertility transition process. Although we focus here on Bolivia and one particular health issue, our theoretical developments and study procedures have implications for communication theory and social change in general.

The Bolivian Situation

In 1971, the Bolivian government evicted Peace Corps volunteers from the country under suspicion that these volunteers were sterilizing women against their will. In 1975, the Catholic Church in Bolivia denounced the importation of contraceptives by the United Nations as "massive birth control" and forced the cancellation of UN population activities in Bolivia for 15 years. A strong pronatalist policy was maintained by the Bolivian government throughout the 1970s and early to mid-1980s (Wickham, France de Bravo, Lawrence, & Macias, 1992).

After strong lobbying by private nongovernmental organizations (NGOs) and increasing international pressure, the Bolivian government reversed its policy in 1987 by allowing some contraceptive methods to enter the country and be distributed. In 1989, the United States Agency for International Development (USAID) assisted the Bolivian government in the creation of a National Reproductive Health Program (NRHP) designed to increase information and access to reproductive health services nationwide as a key component in a strategy to promote infant health and reduce maternal mortality.(2) In addition to creating the NRHP, the Bolivian government allowed international health and development agencies such as USAID, the World Bank, the United Nations, and the Centers for Disease Control to help the government and local organizations distribute and promote contraceptives and launch programs designed to improve reproductive health.(3)

The NRHP was a mandate to improve reproductive services in Bolivia, which at that time were the worst in South America (Demographic and Health Survey [DHS], 1989). Indeed, rates of infant mortality, maternal death due to abortion and childbirth complications, and unwanted fertility were among the highest in South America. Currently, the total fertility rate in Bolivia is 4.8 ("Bolivia 1994," 1996; DHS, 1994) and is the highest in South America. For women who have elementary school education or less, the fertility rate is greater than 6.0. So while the birthrate has been declining in Bolivia for the past four decades, this decline is highly stratified by socioeconomic status, primarily indicated by education. In Bolivia, as in many developing countries, individuals with relatively high education have fewer children, whereas those with low education have many children and suffer adverse economic and health consequences.

The high fertility rate in Bolivia is primarily a consequence of lack of information about and access to modern methods of contraception. Women who have not used contraceptives in Bolivia have cited "lack of knowledge" as the most frequent reason for why they do not use them (DHS, 1994). On average, Bolivian women feel that the ideal number of children to have is 2.5, and a majority state that they desired that their most recent birth would have occurred later or not at all. About 80% of Bolivian women would like to limit their number of children after the second child, regardless of SES, residence, or age (DHS, 1994). Additionally, Bolivia has the highest infant and maternal mortality rates in South America. These high mortality rates are primarily a consequence of inadequate access to and use of pre- and postnatal care facilities. Thus, there is a clear demand for contraceptive and reproductive health information in Bolivia, and room to measure improvement in reproductive health indicators.

The positioning of family planning within the context of reproductive health appeared to be an effective strategy for reaching the audience and encouraging acceptance of campaign messages. The reproductive health approach received political support. The campaign was personally launched by Bolivia's President Sanchez de Lozada and the secretary of health who appeared in the first television and radio spots. Unlike family planning, reproductive health is not a controversial topic in Bolivia. Instead, it is at the heart of the government's strategy to reduce maternal mortality and improve child survival.

This combination of political, historical, and demographic factors led the Bolivian government to create the NRHP. The NRHP was accompanied by a mass media campaign first launched in 1994 to inform Bolivians of reproductive health services available in their country.(4) The campaign's main objective was to educate Bolivians about where to obtain reproductive health services and to help them make informed decisions about reproductive health matters.

Campaigns

Early studies on communication campaign effects provided results of both successes (Cartwright, 1949; Mendolsohn, 1973; Rogers & Storey, 1989) and failures (Hymen & Sheatsley, 1947; National Public Radio, 1996; Udry, Clark, Chase, & Levy, 1972). Many studies were conducted by Lazarsfeld and colleagues (Berelson, Lazarsfeld, & McPhee, 1954; Katz & Lazarsfeld, 1955; Lazarsfeld, Berelson, & Gaudet, 1948; and see Eulau, 1980, for a review). One theoretical outcome was the classic two-step flow model (Katz, 1957, 1987; see Gitlin, 1978, for a critique) which posits that opinion leaders use the mass media for information more than opinion followers, and these leaders pass on their opinions to these followers. No other models have been presented to integrate mass and interpersonal communication processes within the context of campaign effects, and the communication field remains Balkanized today (Barrett & Danowski, 1992; Chaffee, 1982; Hawkins, Wiemann, & Pingree, 1988; Reardon & Rogers, 1988; Rice, Borgman, & Reeves, 1988).

Many scholars have argued that the mass media are effective at disseminating information, but that interpersonal communication is necessary for behavior change (Chaffee, 1982; Hornik, 1989; Valente, 1993; Valente, Poppe, & Merritt, 1996). This adage has directed many projects to use the mass media to advertise new ideas and products, and then to rely on outreach and peer education programs for adoption. Few studies, however, have tested the relative influences of mass and interpersonal communication within a particular study (Hornik, 1989; Valente et al., 1996). Consequently, there are few models that integrate mass and interpersonal communication influences, and there is confusion about which is more influential and which is more amenable to programmatic implementation (Chaffee & Mutz, 1988).

The most common model used to understand campaign effects has been the diffusion of innovations that specifies five stages in the behavior change process: knowledge, persuasion, decision, trial, and adoption (Rogers, 1995; Valente & Rogers, 1995). Diffusion of innovations is a specific incarnation of a hierarchy model (Ray, 1975; Thorson, 1989), and the principles of the hierarchy approach have been expanded (McGuire, 1989) and adapted specifically to the case of family planning (Piotrow et al., 1997; Rogers, 1973, 1995; Valente et al., 1996).

In this study, we use diffusion principles to specify the behavior change steps and reproductive health indicators expected to be influenced by the mass media campaign. We then compare the relative influences of mass media and personal networks on these steps. The study is designed to determine how well a specific media campaign disseminated information about reproductive health and whether the campaign influenced adoption of contraceptives. We consider the influences of mass and interpersonal communication both separately and jointly in the contraceptive adoption process.

It has been noted that using hierarchy models can be problematic given the number of variables and complexity of the models (Thorson, 1989). Additionally, behavior change may take a considerable amount of time to occur, and most communication Campaign studies collect postcampaign data immediately following the broadcast to capitalize on higher recall levels. Fortunately, we were able to collect data at multiple time points, and the original campaign was rebroadcast a second time. The second broadcast enabled us to capture information about behavior change that might otherwise have been missed. Thus, the initial campaign may have primed the audience (Berkowitz & Rogers, 1986; Iyengar & Simon, 1993) for later behavior change. The rebroadcast had the second advantage in that we used a panel design to test for selectivity effects in the results (Yoder, Hornik, & Chirwa, 1996; Zillman & Bryant, 1985).

Specific Hypotheses

Many authors have commented on the relationship between mass media coverage and health-related behaviors (e.g., see Jones, Beniger, & Westoff, 1980; Maccoby & Farquhar, 1975; Udry et al., 1972; Westoff & Rodriguez, 1995). Since the influential Ryan and Gross (1943) study on the diffusion of innovations, most researchers have relied on the mass media to disseminate information about new ideas and have left it to interpersonal communication and peer education programs to persuade individuals to adopt innovations. In the present study, we expect exposure to the campaign to be …