Impact of the SIAGA Maternal and Neonatal Communication Campaign on Knowledge of Danger Signs and...

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JOURNAL OF HEALTH & MASS COMMUNICATION

Volume 1, Numbers 1/2 Winter/Spring 2009

INAUGURAL EDITORIAL

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Build It and (S)he Will Come

ESSAY

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Health Communication as Interdisciplinary Intersection Rather than Separate

Field

ARTICLES

11 Paula M. Frew, Wendy Macias, Kayshin Chan, and Ashley C. Harding

In “Step” with HIV Vaccines? A Content Analysis of Local Recruitment

Campaigns for an International HIV Vaccine Study

40 Suruchi Sood, Manisha Sengupta, Corinne L. Shefner-Rogers and Anne Palmer

Impact of the Siaga Maternal and Neonatal Communication Campaign on

Knowledge of Danger Signs and Birth Preparedness in West Java, Indonesia

58 Amanda Hinnant

Getting the Science Right: An Experiment on How Readers Evaluate Medical

News Coverage in Magazine Health Journalism

77 Karyn Ogata Jones and Renee Pelton

Attribute Agenda Setting and Breast Cancer in Newspapers

90 Randy M. Page, Rosemary Thackeray, Brad Neiger and Marissa Black

Analysis of Food and Beverage Brand Websites Targeting Children: Internet

Marketing Strategies, Content, and Features

109 Cynthia-Lou Coleman, L. David Ritchie and Heather Hartley

Assessing Frames and Metaphors in News Coverage of Prescription Drug

Advertising

129 Cory L. Armstrong

Examining the Blame Frame: Portrayals of Women in Newspaper Content

about Dieting

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Suruchi Sood is an assistant professor in the Department of Health, Behavior and Society at the Johns

Hopkins Bloomberg School of Public Health ([email protected]); Manisha Sengupta is an

independent consultant in the Bloomberg School; Corinne L. Shefner-Rogers is an independent

consultant with the Bloomberg School and adjunct professor in the Department of Family and

Community Medicine, School of Medicine, at the University of New Mexico; and Anne Palmer is

senior program officer at the Center for Communication Program in the Bloomberg School.

40 Journal of Health & Mass Communication, Vol. 1, Nos. 1/2 (Winter/Spring 2009)

IMPACT OF THE SIAGA MATERNAL AND

NEONATAL COMMUNICATION CAMPAIGN

ON KNOWLEDGE OF DANGER SIGNS

AND BIRTH PREPAREDNESS IN

WEST JAVA, INDONESIA

SURUCHI SOOD, MANISHA SENGUPTA,

CORINNE L. SHEFNER-ROGERS AND ANNE PALMER4

In 2004, an impact assessment of the SIAGA Maternal and Neonatal

Communication Campaign was conducted in West Java, Indonesia. This paper

examines the impact of the SIAGA campaign on knowledge about pregnancy danger

signs and birth preparedness behaviors in women of childbearing age in three study

districts of West Java. A total of 891 women was surveyed about maternal health

knowledge and behaviors. Analyses included logistic regression modeling of the

impact of exposure to the SIAGA campaign on several dependent variables.

Overall, there was evidence of a strong relationship between different levels of

exposure to the SIAGA campaign and increased awareness about severe bleeding

as a danger sign, increased knowledge about community-based life-saving services,

increased birth preparedness and antenatal care behaviors. Education and

residence emerged as significant control variables associated with these outcomes.

Keywords: maternal and neonatal health, mass media campaign, community

mobilization, birth preparedness

IMPACT OF THE SIAGA MATERNAL AND NEONATAL COMMUNICATION CAMPAIGN Suruchi Sood et al.

Journal of Health & Mass Communication, Vol. 1, Nos. 1/2 (Winter/Spring 2009) 41

Mass media public health campaigns can be effective in changing knowledge, attitudes,

and behaviors for a variety of health issues including family planning, HIV/AIDS, drug use,

tobacco use, heart disease, and drunk driving (Piotrow et al., 1997; Dearing, 2001; Cappella

et al., 2001; Worden & Flynn, 2002; Flora, 2001; Winsten & DeJong, 2001; Lederman et

al., 2001). Health communication messages may be more effective when linked with

community-level programs, and when they encourage interpersonal dialogue (Rogers &

Storey, 1987; Wallack & Dorfmann, 2001; Papa et al., 2000; Rogers et al., 1999; Sharan &

Valente, 2002; Sood et al., 2004). The germinal work by Farquhar et al, (1977) — the

Stanford Heart Disease Prevention Program — utilized a quasi-experimental design and

compared the effects of media and intensive interpersonal counseling on physiological risk

indicators as well as knowledge and behaviors related to cardiovascular disease, and serves

as a heuristic model for this specific paper.

Very few behavior change interventions have focused on improving maternal and

neonatal health by changing health-seeking behaviors, for example using a skilled healthcare

provider for delivery (Koblinsky, 2004). Since the 1990s, safe motherhood programs have

focused on promoting the use of a skilled attendant for childbirth as a primary means for

preventing maternal death. The presence of a skilled attendant at delivery is the most valid

indicator of the impact of safe motherhood programs (Starrs, 1998). Skilled healthcare

providers can recognize life threatening complications during childbirth and postpartum, and

either treat the complication or refer the woman to a higher level of care as necessary.

Different studies report a wide range of estimates of maternal mortality ratio (MMR)

for Indonesia, but a range of estimates of 300 — 400 maternal deaths per 100,000 live births

has been generally accepted as the prevailing level (UNFPA, 2007). In other South-east

Asian countries, the MMR is lower than Indonesia’s. In Burma, this ratio is 230;

Philippines, 170; Vietnam, 160; Thailand, 44; Malaysia, 39; and Singapore, six (UNICEF,

2004). The issue of high maternal mortality remains at the top of the health care agenda in

Indonesia, in order to meet the Millennium Development Goals (MDGs) # 5 “improve

maternal health,” Indonesia will have to ensure a reduction in maternal mortality to nearly

100 / 100,000 live births by 2015 (UNFPA, 2007)

In Indonesia a woman dies every hour from pregnancy, complications during delivery,

late referral to hospital services and poor emergency obstetric care (UNFPA, 2007). The

majority of deaths result from severe bleeding (World Health Organization, 2004a). In 1991,

the Government of Indonesia trained and deployed 54,000 village midwives (bidan di desa),

one per village, throughout the nation. Despite the presence of these community-based

bidan, pregnant women continued to use traditional providers (dukun) for delivery. Dukun

are preferred because they are older, married women who are long-standing members of the

village community, compared to bidan who were young, unmarried women from another

village. In 2003-2004, 50 percent of all home births were delivered by nurses or bidan, and

32 percent were delivered by dukun (Badan Pusat Statistik, 2003).

Suruchi Sood et al. IMPACT OF THE SIAGA MATERNAL AND NEONATAL COMMUNICATION CAMPAIGN


The SIAGA Campaign in West Java, Indonesia combined mass communication

messages with community mobilization activities and had four major components: (1) Suami

SIAGA (Alert husband), (2) Warga SIAGA (Alert citizen), (3) Bidan SIAGA (Alert

midwife), (4) Desa SIAGA (Alert village). The word SIAGA is both a concept and an

acronym. SIAGA translates as “alert” or “ready” in Bahasa Indonesia (the Indonesian

language). The SIAGA concept embodies the Indonesian value of shared responsibility and

community help (gotong royong). The acronym, SIAGA, stands for Siap (ready), Antar (take

or transport), jaGA (stand by or guard). A SIAGA community, husband, or midwife, is one

who protects a pregnant woman and is ready to transport her to a healthcare facility when

needed. See Table 1 for the SIAGA Communication Campaign Components.

The present study was designed to evaluate the impact of the SIAGA campaign.

Specifically, we examined the dose-response relationship between exposure to a

combination of mass media and intensive community mobilization activities, and levels of

awareness, knowledge, and birth preparedness behaviors regarding pregnancy, childbirth,

and postpartum care.

Methods

Sources of Data

In 2004, Johns Hopkins University’s Center for Communication Programs, in

collaboration with the University of Indonesia’s Center for Health Research, conducted an

impact assessment of the SIAGA Communication Campaign. The objective of the

assessment was to determine the impact of the SIAGA campaign on (1) awareness about

severe bleeding as a danger sign during pregnancy, delivery, and postpartum, (2) knowledge

about community life-saving services, (3) birth preparedness, (4) use of antenatal care, (5)

use of a skilled healthcare provider for antenatal care, (6) use of a skilled attendant for

delivery, (7) obtaining postpartum care for the mother, and (8) obtaining postpartum care

for the child.

The research design for the impact assessment was a post-test non equivalent quasi field

experiment with four campaign exposure groups (no exposure, low, medium and high

exposure) to the SIAGA communication campaign. The sample included 865 married

women who had a live birth in the past 15 months. Approximately 10 women per village

were systematically randomly sampled from a total of 96 villages and municipalities drawn

from three study districts in West Java where both mass media and community mobilization

activities were implemented: Kabupaten Kuningan, Kabupaten Cirebon, and Kota Cirebon.

Initially, a stratified cluster sample was used to randomly select 35 villages from the 55

where mass media and intensive community mobilization activities were implemented (high

exposure). Next, 31 out of 62 villages with mass media and general community mobilization



activities (medium exposure) and finally 30 villages that received only mass media messages

(low exposure) were sampled. Women who were not exposed to any of the messages or

activities conducted by the SIAGA communication campaign were considered as the “no

exposure” group during analysis. Some 26 women who were exposed only to the

TABLE 1DESCRIPTION OF THE SIAGA COMMUNICATION CAMPAIGN COMPONENTS



mobilization activities were excluded from the analyses leaving a total of 865 women in the

study sample.

Ethical approval for this study was obtained from the Johns Hopkins University

Bloomberg School of Public Health Committee on Human Research.

Measures

The independent measure of exposure to the SIAGA communication campaign, as

described above, was calculated as a four-level variable. These four categories were, to

some extent, a function of the area in which the respondents resided. For example, women

who lived in areas in which community mobilization activities were not conducted were

only eligible to belong to either the “no exposure” or the “low exposure” group.

The dependent variables for this study included several topics pertaining to knowledge

and behaviors. The knowledge level variables included: awareness about severe bleeding

as a danger sign and knowledge about community life-saving services. The specific

behaviors included actions undertaken to prepare for child birth and use of specific services

during pregnancy, childbirth and in postpartum. The knowledge and behavior related

variables were measured as follows:

Awareness of severe bleeding as a danger sign. This variable was measured as a

dichotomous variable (0=not aware, 1=aware). Awareness was assessed separately for the

pregnancy, delivery, and postpartum periods.

Knowledge of community-based life-saving services. Four dichotomous variables were used

to measure knowledge about life-saving services in the community. Respondents were asked

whether they knew about notifying the community, transportation services, blood donation

services, and available funds that could be used in the event of an obstetric emergency.

Birth preparedness. Five variables were used to measure birth preparedness. Questions

included asking respondents whether they had notified others in their community, arranged

for a skilled attendant to be present for delivery, and arranged transportation, funds, and a

blood donor in case of an obstetric emergency. In Indonesia, healthcare facilities may not

have adequate blood supplies in the event of an obstetric emergency. Pregnant women are

encouraged to identify a potential blood donor (with matching blood type) that will

accompany her to the healthcare facility when needed. These birth preparedness items are

central to the concept of birth preparedness, and to preventing delays in receiving treatment

for pregnancy-related complications (Stanton, 2004). Each question yielded a dichotomous

answer (0=no; 1=yes).

Use of antenatal care. Respondents were asked whether they received antenatal care at least

four times during their pregnancy. The World Health Organization guidelines for adequate



antenatal care (World Health Organization, 2001) calls for a minimum of four antenatal care

visits. This variable was dichotomous (0=no; 1=yes).

Use of a skilled attendant for delivery. The survey questionnaire included a question about

whether a woman used a skilled attendant for delivery. The presence of a skilled healthcare

provider during childbirth contributes to improved maternal health outcomes, and to a

reduction in maternal deaths (Starrs, 1998; World Health Organization, 2004b). Possible

responses included “no” (coded as “0”) or “yes” (coded as “1).

Obtaining postpartum care for the mother. This variable was measured using a dichotomous

question that asked women whether they had received postpartum care within the first four

hours following delivery.

Obtaining postpartum care for the child. Women respondents were asked if their newborn

had received postpartum care (i.e., care in the first four hours following delivery). Postpartum

care contributes to improved neonatal outcomes (Koblinsky, 2004; Starrs, 1998). This

variable was dichotomous (0=no; 1=yes).

The following potential confounding variables were included in the analyses: (1) Age

of the respondent (mean years), (2) residence (urban or rural), (3) education (at least some

primary school or junior high school and above), and (4) socioeconomic status (household

expenditures in the amount of Rupiahs (Rps). 300,000 or less, Rps. 301,000 to 700,000, or

Rps. 700,001 or more; one US Dollar is approximately. 8,000 Indonesian Rupiahs). In

addition to these commonly used control variables, we included “duration at current

residence” (measured as “two years or less,” or “more than two years”) as a potential

confounder. An individual’s familiarity with her community may contribute to her

knowledge and use of community-based resources.

Statistical Analysis

Statistical analysis included descriptive statistics for exposure and the dependent

variables. In addition, a series of multivariate logistic regression analyses were conducted.

A first set of analyses used “no exposure” as a reference category and examined the impact

of mass media (low) exposure. A second set of analyses used the exposure to mass media

alone (low) as the reference category and compared it to medium and high exposure

separately, so as to distinguish between specific groups. All analyses were conducted using

STATA version 9.0. Probability levels were set at p<.05



RESULTS

Descriptive Analysis

Table 2 shows the descriptive characteristics of the respondents by level of exposure to

the SIAGA Communication Campaign. The mean age of respondents was 28 years. Some

25 percent (N=217) of respondents were not exposed to the SIAGA campaign message. At

least 38 percent (N=331) of women in the study sample were exposed to only mass media

messages, and 23 percent (N=200) were presented with mass media messages and general

community mobilization activities. Fourteen percent (N=117) of respondents were exposed

TABLE 2PERCENTAGE DISTRIBUTION OF RESPONDENTS’

CHARACTERISTICS BY LEVEL OF EXPOSURE



to mass media message and intensive community mobilization activities. The majority of

respondents lived at their current residence for more than two years.

The levels of education, socioeconomic status, and residences differed significantly

among the four exposure groups. Respondents that were not exposed to the SIAGA

campaign were least likely to live in urban areas (13.8%) and most likely to have a primary

school education (82%). The majority (62%) of women in the “no exposure” category were

also most likely to have monthly household expenditures of Rps. 300,001-700,000. We were

able to make valid comparisons across the four exposure groups by controlling for these

potential confounders using multiple logistic regression analyses.

Table 3 presents the dependent variables by level of exposure. These data suggest a

strong dose-response effect of exposure to the SIAGA campaign on awareness of bleeding

as a danger sign during pregnancy, delivery, and postpartum, and on knowledge of

community-based life-saving services. Birth preparedness activities were highest for

respondents that were exposed to both the mass media messages and intensive community

mobilization activities. The results for antenatal care visits and use of a skilled provider for

delivery indicated that these behaviors increased with exposure to a combination of mass

media and community mobilization activities. The majority of women in the study sample

received postpartum care for themselves and for their child regardless of exposure status.

Awareness about Bleeding

Awareness of severe bleeding as a danger sign during pregnancy, childbirth, and the

postpartum period varied significantly among the women with no exposure (reference

category) and those exposed to the mass media campaign (Table 4). The second set of

multivariate analyses revealed that awareness of severe bleeding did not vary significantly

among women with low exposure (mass media only) when compared to the medium

exposure category (mass media and general community mobilization) and the high exposure

category (mass media and intensive community mobilization. The only exception was that

women with a high level of exposure (i.e., exposure to both the mass media component and

the intensive community mobilization activities) were two times more likely (AOR=2.04;

CI= 1.28,3.26; p<.05) to recognize severe bleeding during childbirth as a danger sign than

women with low exposure to the SIAGA campaign (Table 4). Among the control variables,

age and education were associated with significantly higher awareness levels of bleeding

as a danger sign during pregnancy, childbirth, and postpartum.

Knowledge about Life-Saving Services

The findings presented in Figure 1 indicate that women in the low exposure category

were significantly more likely to be aware of transportation schemes (AOR=2.77; CI= 1.45,



5.33; p<.05) and community notification (AOR=1.89; CI= 1.28,2.80; p<.05) in comparison

to women who had not been exposed to the mass media component of the SIAGA campaign.

Further, Figure 1 also shows the adjusted odds ratios for knowledge of community-based

life-saving services by different levels of exposure to the SIAGA campaign. Women with

TABLE 3PERCENTAGE DISTRIBUTION OF RESPONDENTS’ AWARENESS

AND BEHAVIORS BY LEVEL OF EXPOSURE



both medium and high levels of exposure were significantly more likely to know about the

various community bases life saving services in comparison to women who were only

exposed to the mass media campaign. A strong dose response relationship was also

suggested.

Residence in a rural area was associated with significantly higher awareness of

community-based life-saving services.

TABLE 4RELATIONSHIP BETWEEN LEVELS OF EXPOSURE TO THE SIAGA COMMUNICATION

CAMPAIGN AND AWARENESS OF SEVERE BLEEDING AS A DANGER SIGN



Birth Preparedness

The results pertaining to birth preparedness activities indicate that women exposed to

the mass media campaign were significantly more likely to report arranging for

transportation (AOR=1.87; CI=1.19,2.93; p<.01), community notification (AOR=1.73;

CI=1.12,2.66; p<.01) and preparing to use a skilled provider (AOR=1.99; CI=1.22, 3.25;

p<.01) in comparison to their counterparts with no exposure to the SIAGA campaign.

Comparisons among women with low exposure (mass media only) and those who were

exposed to the mass media and general community mobilization activities revealed few

significant differences. The only exception was with regards to making arrangements for

blood donation. Women exposed to both mass media and general community mobilization

activities were significantly more likely to report arranging for blood donation (AOR=2.01;

CI=1.12,3.59; p<.01). However, as the results from Table 5 indicate women who were

exposed to both mass media messages and intensive community mobilization activities were

FIGURE 1RELATIONSHIP BETWEEN LEVEL OF EXPOSURE TO THE SIAGA

COMMUNICATION CAMPAIGN AND KNOWLEDGE ABOUT COMMUNITY SCHEMES



significantly more likely to undertake birth preparedness activities, such as prepare

transportation, notify their community about their pregnancy, prepare emergency funds and

TABLE 5RELATIONSHIP BETWEEN LEVEL OF EXPOSURE TO THE

SIAGA COMMUNICATION CAMPAIGN AND BIRTH PREPAREDNESS ACTIVITIES



prepare for emergency blood donation than women who were only exposed to the mass

media campaign.

Among those exposed to the SIAGA campaign, regardless of the level of exposure,

urban residence was associated with significantly lower likelihood of making preparations

in case of an obstetric emergency and notifying the community about a woman’s pregnancy.

However, urban residence was also associated with significantly greater levels of

preparation to deliver with a skilled provider across of levels of exposure. At the same time,

regardless of the level of exposure to the SIAGA campaign, education was associated with

higher levels of birth preparedness activities, specifically preparing transportation, prepare

money for emergency obstetric care and prepare to use a skilled provider for delivery.

Use of Antenatal Care

Women who were exposed to the mass media component of the SIAGA campaign were

significantly more likely than those not exposed to the SIAGA campaign to report having

received four or more antenatal care visits (AOR=1.89; CI=1.15, 3.08; p<.001). However,

there were no significant differences among the antenatal care visits with increasing levels

of exposure to the SIAGA campaign.

Skilled Attendance at Delivery

There was no significant difference among those not exposed to the SIAGA

communication campaign and those exposed to the mass media component, with regards to

the use of a skilled provider for delivery. Use of a skilled attendant for delivery did not vary

significantly with increasing levels of exposure to the SIAGA campaign (Table 6).

Postpartum care for the mother or the newborn did not vary significantly with increasing

levels of exposure to the SIAGA campaign. Interestingly, women who were exposed to the

mass media and general community mobilization activities were significantly less likely to

report having received post partum care for themselves, than women who were exposed only

to the mass media campaign (AOR=0.49; CI=0.30, 0.80; p<.01) (Table 6).

DISCUSSION

The SIAGA campaign in West Java, Indonesia was designed to increase awareness,

knowledge, and behaviors associated with positive maternal health outcomes. The aim of

the present study was to assess the influences of exposure to SIAGA campaign messages

and activities promoting maternal health knowledge and behaviors. The results of the

present study showed that exposure to the mass media component of the SIAGA campaign



TABLE 6. RELATIONSHIP BETWEEN LEVEL OF EXPOSURE TO THE

SIAGA COMMUNICATION CAMPAIGN AND ANTENATAL CARE, USE OF SKILLED ATTENDANT AND POSTPARTUM CARE



was associated with increased awareness about severe bleeding as a danger sign. Exposure

to the mass media in combination with intensive community mobilization activities was

associated with increased birth preparedness. A strong dose-response effect of exposure to

the campaign on knowledge of community based life saving schemes was observed.

The consistency of the findings related to the impact of high levels of exposure to the

campaign underscores the effectiveness of using intensive community mobilization activities

to encourage behavior change. Program planners, however, must weigh the costs (i.e.,

human and material resources) of implementing such time and cost intensive activities.

We failed to find significant associations between level of exposure to the SIAGA

campaign and (1) use of a skilled attendant for delivery, or (2) use of postpartum care for

the mother and newborns. These results are especially important since skilled attendance at

delivery is considered a key indicator for maternal mortality reduction. Despite these non-

significant results, it would be premature to conclude that the SIAGA campaign itself was

unsuccessful in increasing the use of skilled healthcare providers for childbirth, given that

actual use of skilled attendants for delivery was relatively high for the study sample

regardless of their exposure status. The SIAGA messages and activities may have focused

more directly on preparing for obstetric emergencies than on the importance of using a

skilled provider for delivery, or on the value of postpartum care. Also, time from campaign

end to evaluation and the fact that births are a rare event may have affected these findings.

A number of socio-demographic characteristics were considered to control for the

differences among the respondents not exposed to the SIAGA campaign in comparison to

those with low exposure (mass media only), as well as, comparisons between those exposed

to the mass media component only and those who were exposed to medium (mass media

plus general community mobilization), and high (mass media plus intensive community

mobilization) levels of the SIAGA campaign that may help to explain certain birth

preparedness and delivery behaviors. Urban residents were (1) significantly less likely to

know about community-based life-saving services, (2) significantly less likely to prepare

funds for the birth of their child or notify the community about the pending birth, and (3)

significantly more likely to prepare for a skilled provider for delivery and (4) significantly

more likely to use a skilled provider at delivery. It may be that the establishment of

community-based life-saving services was weaker in urban areas than in rural areas. Urban

residents may not have the same sense of community as rural dwellers, thus urban residents

may not be as knowledgeable about community activities, and may be less inclined to notify

their community members about a pregnancy. Residents in urban areas may also have better

access to various levels of medical care and therefore do not feel the need to prepare for the

birth of a child in the same way as residents in rural areas.

Not surprisingly, education was significantly correlated with a number of outcome

indicators. Women who were better educated were more likely (1) to be aware of severe

bleeding as a danger sign during the pregnancy, delivery, and postpartum periods



(specifically those exposed to the mass media campaign (low exposure) and those exposed

to the mass media campaign and intensive community activities (high exposure), (2) to

prepare money, transportation, and a skilled healthcare provider in case of an obstetric

emergency regardless of the level of exposure, and (3) to have four or more antenatal care

visits using a skilled antenatal care provider (specifically those exposed to the mass media

campaign (low exposure) and use a skilled provider at delivery, regardless of the level of

exposure to the SIAGA campaign. Finnegan and Viswanath (1999) suggested that unlike the

mass media, community mobilization activities span educational boundaries and reduce the

“knowledge gap” that might exist in a given community. Our findings showed that the

SIAGA campaign reached more women with higher education levels via mass media and

general community mobilization activities than with intensive community mobilization

activities. Prior research indicates that maternal mortality is higher among poor women with

lower levels of education (Abou-Zahr & Royston, 1991; Thaddeus & Maine, 1994). It is

critical to make specific efforts to reach a wider cross-section of women, especially low-

literate and illiterate women, with maternal mortality reduction messages and activities

through community and social mobilization activities.

This study had several limitations that need to be addressed in future research. The study

only included women with a live birth. It is possible that the selection of women with a live

birth was correlated to the presence of a skilled attendant independent of campaign

exposure. Future research could include statistics pertaining to both live and non-live births.

The use of cross-sectional data limited our ability to identify causal relationships between

exposure to the intervention and maternal health awareness and behaviors. Another

limitation was that we were unable to examine the impact of community mobilization

activities independently of mass media exposure. A fourth limitation of this study was that

we were unable to conduct a cost-effectiveness analysis to determine the relative impact of

community mobilization activities. Cost effectiveness is an important factor providing

accountability for campaign spending and might serve as a focus for further analysis. One

of the research challenges in the field of public health communication is the lack of adequate

scholarly investigation of the impact of behavior change communication strategies that

integrate mass media campaigns with community-based health promotion activities. A future

research agenda could include the collection of longitudinal data that would allow for

estimating time trends, and the availability of cost estimates for cost-benefit analysis.

Despite these limitations, the overall findings were encouraging, showing strong effects

of exposure on indicators associated with positive maternal outcomes. A key implication

from these findings is the importance of integrating mass media and intensive community

mobilization activities to improve preparation for obstetric emergencies, thus contributing

to reducing maternal mortality.



ACKNOWLEDGMENTS

We gratefully acknowledge the women participants in West Java, Indonesia who completed the survey

questionnaires. We sincerely thank the Maternal and Neonatal Health Program managed by JHPIEGO

Corporation. Funding for this research was provided by the United States Agency for International

Development (Cooperative Agreement HRN-A-00-98-0043-00). Some of the results shown here were

presented at the 55 International Communication Association Conference, New York, May 26-30,th

2005.

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