A Theory-Based Framework for Media Selection in Demand Generation Programs

"Theories are often used to guide the design of messaging content aimed at increasing demand for health services and commodities. However, it not always the case that theories are used to guide the selection of the media through which those messages are conveyed; especially in modern demand generation initiatives that leverage new technologies and media."

This guide is a resource for anyone seeking to use communication strategically to help increase the demand for the 13 reproductive, maternal, newborn, and child health (RMNCH) commodities identified as underutilised by the UN [United Nations] Commission on Life-Saving Commodities (UNCoLSC) for Women's and Children's Health. It provides step-by-step information and practical tools to guide media selection (i.e., communication channels) for demand generation activities using the theory-informed media selection (TIMS) framework. The guide has a focus on information and communication technology (ICT) and new media channels, commonly referred to as e- and m-health. The ultimate goal is to increase the demand for and utilisation of the commodities, which include:

• In the category of reproductive health: (1) female condom, (2) contraceptive implants, and (3) emergency contraception.
• In the category of maternal health: (4) oxytocin, (5) misoprostol, (6) magnesium sulfate.
• In the category of child health: (7) amoxicillin, (8) oral rehydration salts (ORS), (9) zinc.
• In the category of newborn health: (10) injectable antibiotics, (11) antenatal corticosteroids, (12) chlorhexidine, (13) resuscitation.

(For additional background information on the Commission, please click here.)

Having outlined the commodities, the resource begins with an overview of demand generation, which draws on social and behaviour change communication (SBCC) and social marketing (SM) techniques in order to:

• Convince members of the intended audience to adopt new behaviours, products, or services;
• Convince current users to increase or sustain the practice of the promoted behaviour and/or to increase or sustain the use of promoted products and services; and
• Take market share from competing behaviours (e.g., convince caregivers to seek health care immediately, instead of not seeking care until their health situation has severely deteriorated or has been compromised) and products or services (e.g., convince caregivers to use ORS and zinc instead of other anti-diarrhoeal medicines).

It is noted that coordination and collaboration with appropriate partners is important when forming demand generation communication strategies and programmes because they should be matched with efforts to improve logistics and expand services, increase access to commodities, and train and equip providers in order to meet increased demand for products and/or services.

Next, the report outlines key concepts and definitions in demand generation, describing what is involved in SBCC campaigns and interventions as well as in SM. Specifically, channels and approaches defined here include: advocacy, community mobilisation, entertainment-education (EE), information and communication technologies (ICTs), interpersonal communication (IPC), and mass and traditional media.

That said, behavioural theories are described here as less helpful on providing guidance as to whether the content should be delivered via print materials, radio, the internet, or some combination of media. This is where the TIMS framework comes in.

It involves 2 theories:

1. Media Richness Theory, described in Annex 1 in detail. In short: "Rich media are those that can transmit messages with high cue (verbal and visual) and language variety, allow for timely feedback and tailoring for the recipient (including the infusion of affect), and are able to transmit messages that are ambiguous, complex and non-directive." (See Figure 3 on page 10.) For example, a text message "is a fairly lean medium when compared to face-to-face, interpersonal communication that allows for the transmission of both verbal and visual cues, instantaneous feedback and high degrees of tailoring and affect." Yet, "if the provider does not allow for interactivity, or does not vary his or her language or tailor the message to the individual client, then the effective richness of the medium is reduced." Thus, if the message is relatively simple, SMS (text) or print - lean media - might be the more effective use of resources. Another lesson is that a combination of media (e.g., text messaging combined with radio to provide a feedback mechanism) can increach the richness of communication, which is consistent with best practice in SBCC.
2. Uses and Gratifications Theory, described in Annex 2 in detail. In short, this theory focuses on why and how people use different media, seeking to identify the channels that people rely on for different types of information and to satisfy clusters of perceived needs in these categories: staying informed, escaping daily realities, enhancing social interaction, identifying with media characters, and being entertained.

Grounded in these two theories, TIMS is next outlined in detail in order to guide programme managers in making informed decisions about selection of media for demand generation programmes. In brief, the process involves 3 steps:

1. Use the Media Richness criteria to identify which medium or combination of media can support the necessary level of communication richness.
2. Use the Uses and Gratifications criteria to identify which medium or media members of the intended audience use for the type of communication necessary to affect desired behaviours.
3. Select the medium or combination of media that is/are identified as a result of Step 1 and Step 2 (i.e., the overlapping media from each step). "If after completing Step 1 and Step 2 there are no overlapping options or the resources necessary to implement them are not available, consider using a less-rich medium or combination of media, knowing that reach or effectiveness may be reduced."

Each step in this process is illustrated using two hypothetical scenarios as guidance. For example, in Step 3 of TIMS, here is the kind of thinking that might inform programme managers:

• Scenario A: Increasing demand for contraceptive implants among women in Ethiopia: "In Step 1, using the Media Richness criteria, face-to-face counseling, videoconferencing and/or social media were identified as potentially the most effective media. In Step 2, the Uses and Gratifications framework suggests that radio and television would be the most appropriate media for staying informed and communicating about social norms, myths and misconceptions. In this scenario, there is no overlap in the media identified; therefore, a choice needs to be made as to which media is the most appropriate for the demand generation project....By combining radio or television programming with a mobile call- or text-in service, the necessary richness could be established; however, it is still possible that women would not be reached because their ICT use is limited and mainly for social and entertainment purposes."
• Scenario B: Increasing demand for chlorhexidine among providers in India: "In Step 1, using the Media Richness criteria, text messages and video were identified as potentially the most effective media. In Step 2, the Uses and Gratifications framework suggests that mobile media would be the most appropriate for staying current on clinical practice. In this scenario, there is a clear overlap in mobile media, suggesting that its use would be the most effective and acceptable approach for reaching the providers, as mobile media has the capacity to support the necessary richness of communication and is currently being used in a similar manner by the intended audience."

As noted here, the point of these scenarios is that cases vary greatly, so programme managers seeking to generate demand for underutilised RMNCH commodities should give careful consideration to the type and abilities of the message and communication necessary to reach the intended audience through a variety of media/channels, the project timeline, associated cost, and available resources.

The Demand Generation for Reproductive, Maternal, Newborn, and Child Health Commodities activities are implemented by the Health Communication Capacity Collaborative (HC3) at Johns Hopkins Bloomberg School of Public Health Center for Communication Programs (JHU-CCP), with support from the RMNCH Trust Fund and the United States Agency for International Development (USAID), in partnership with Demand Generation sub-group of the UNCoLSC Demand, Access and Performance Technical Resource Team, including Population Services International (PSI), International Consortium on Emergency Contraception (ICEC), Jhpiego, and other partners.