You could be forgiven for thinking (as I did) that coalition-building is a field of media development where international organisations can play only a modest role.

However, the experiences of local stakeholders who have been involved in long-running advocacy initiatives suggest otherwise. The “Coalitions for Change” workshop held by the PRIMED (Protecting Independent Media for Effective Development) programme, led by 成人论坛 Media Action, in autumn 2021 offered a unique insight into the potential for balanced partnerships between international and local actors to bring about systemic change.

Success requires understanding and political savvy

The challenges are daunting. Coalition-building is a complex set of moving parts that is, to a large extent, hostage to the vagaries of the political, economic and social landscape – and multiple factors over which international organisations have limited influence or control. There are no shrink-wrapped solutions or off-the-shelf frameworks. Success relies on an in-depth understanding of the local operating environment, trust-based relationships with key stakeholders and plenty of political dexterity.

At first glance, it is difficult to see how international organisations can bring added value to what the French would call “an internal kitchen”. It could even be argued that external support is counter-productive since there is a danger that it will be perceived as interventionist or agenda-driven. Furthermore, top-down approaches can damage the sense of ownership and buy-in which are crucial to locally driven initiatives.

Yet the PRIMED workshop showcased several examples of successful coalitions which have been steered – and, in two cases, initiated – by international partners. The mutual benefits of these relationships were clearly articulated. First and foremost, such partners can provide unique access to experience and expertise from comparable environments. The value of these peer-to-peer exchanges is self-evident. Local stakeholders are given the chance to see how similar challenges have been addressed and overcome by their counterparts in other countries. This approach works well when it comes to developing new legislation, regulatory structures or ethical codes.

The PRIMED team in Bangladesh is mentoring journalists from a regional newspaper, Daily Gramer Kagoj, among other outlets, to produce accurate and engaging online content. Credit: 成人论坛 Media Action Bangladesh

As World Health Day approaches, and as we look towards the first-ever later this year, we’re sharing insights from 成人论坛 Media Action’s work to help health workers and communities work better together to build a healthier world.

In low-income countries in Africa and Asia, many health systems are staffed by community health workers. In Nepal they are known as Female Community Health Volunteers, in Ethiopia, Health Extension Workers, while in India and Bangladesh they are generally known as Frontline Health Workers.

Whilst the names may differ, most are women, most work in remote areas, and many are volunteers. They play a vital role connecting people to, and sometimes providing, basic primary care; referring patients to clinical services and motivating families to adopt heathier practices.

All are tasked with communicating about health, but often they lack sufficient training or engaging communication tools that would help them do this more effectively.

This is where 成人论坛 Media Action comes in. Over the last 10 years we’ve been supporting community health workers to better meet the needs of their communities. These are five important things we have learned in the process:

First, understand the world health workers live and work in

In Nepal, access to communities can be extremely challenging for Female Community Health Volunteers (FCHVs) due to large distances and difficult terrain between communities and health centres in rural areas. What’s more, FCHVs are often balancing their responsibilities with looking after family and, as many of them are volunteers, trying to earn an income.

Whilst access to mobile networks and internet is increasing, literacy rates remain low in rural areas and our research shows that some communities feel FCHVs should know more than they currently do. It became evident that updated training and tools that fit with the practicalities of FCHVs’ day-to-day lives and the changing community needs would help.

Most FCHVs have access to a basic mobile phone and mobile network, so we’re now working with our partners to explore how training and tools for basic mobile phones will help them to carry out their duties in remote areas. We’re also developing creative printed materials to support their interaction with people of all literacy levels in their communities.

In a similar project in Bangladesh, we discovered that health workers were using heavy, cumbersome flip charts to visit their clients in urban slums, so we developed a mobile app to help them undertake their roles more effectively. 

“Now I’m getting all the topics by using one app which is not possible with other tools (flash cards, flip charts, leaflets). I can deliver all relevant information by the app which was difficult for me before” said one community health worker who frequently used the app.

Second, use human centred design and build partnerships

In rural India, the catalyst for the development of our highly successful Mobile Kunji and Mobile Academy projects was women’s lack of access to traditional mass media platforms. At the start of this work, our formative research showed that only a few women watched television or listened to the radio, however 82% had access to some form of basic mobile phone. So, rather than setting up a parallel system, 成人论坛 Media Action leveraged the one available.

Using human centred design, our India team created content that worked on basic mobile phones and suited how health workers used them – to make and receive calls only. We created Mobile Academy, a training course for health workers, which is delivered through mobile audio messages, whilst Mobile Kunji is a set of visual cards and accompanying mobile audio messages that health workers can use during visits with families. Using these services and tools, our research has shown that health workers are able to better reach, engage, and influence families to improve their health.

Working in the development sector I am aware that, particularly over the last few years, donors and others expect project results to be quantifiable. Numbers talk.

This was apparent at the in Cape Town in January when we looked at how the SDGs will be measured, and it was discussed again at the in Amsterdam this week. Donors want statistics to demonstrate impact and show a project is value for money, but aren’t as confident using insights from qualitative research.

In my team we crunch a lot of numbers. In 2016, for example, we surveyed more than 20,000 people, which yielded strong results. For example, a statistical analysis of governance data across seven countries (which controlled for confounders such as people’s age, education levels and existing interests) shows that people who listened to or watched our programmes know more about politics and get more involved in civic life. In our health work, we used quantitative data to understand .

But we have increasingly come to appreciate the need for qualitative research to contextualise our data and explain why we are having an impact. We’re not alone.

At the Esomar conference I took part in a panel with colleagues from My Choices Foundation, StreetInvest, and Save the Children to showcase how qualitative research can provide greater value to the development sector. I summarised what we had learned from our recent projects.

Story behind the numbers

Qualitative research helps us to explain the story behind quantitative data.

Our radio health shows in Ethiopia, Jember (Maternal Light) and Biiftuu Jireenya (Dawn of Life) aim to help women have safer pregnancies and deliveries, and improve the health of newborn babies. Our surveys showed they were reaching a huge audience – around 21 million people across three states - more than a third of the adult population.

However, analysis of our data showed it was difficult to isolate the impact of our programmes. The health sector in Ethiopia was changing fast the government and donor investment leading to local health workers being trained across the country. This investment was reaping benefits; data from the showed the percentage of women going for antenatal care had jumped from 27 % to 62 % between 2011 and 2016. But what impact were we having?

To understand, we designed qualitative research, whereby we spoke to women and those they felt influenced their decisions (such as their local health extension worker, their husbands and close family members).

Women told us how health services and social norms had changed since they had given birth to their older children. Things that had been unthinkable, such as giving birth at a health facility, were now possible. They were also able to identify storylines and items in the shows that made them think differently about what was “normal” during pregnancy and birth. The shows were reinforcing the advice that health workers were giving – and health workers also felt women trusted them more because they were saying the same information that they had heard on the radio.

Reaching vulnerable people

A limitation of quantitative research is that it’s hard to reach vulnerable groups such as refugees or survivors of gender-based violence. They are less likely to agree to a face-to-face survey or might not have a fixed address. In this situation, it helps to use qualitative research techniques that put respondents at ease.

Last year, we spoke to Syrian refugees travelling from Greece to Germany to understand how humanitarian agencies could best communicate with them. We employed Arabic-speaking researchers and trained them to use a narrative approach, where they sat with a refugee for at least an hour, hearing about their journey and the part communication had played in it. Being listened to, rather than asked a series of fixed questions, helped the respondents feel comfortable and more likely to share information.

Qualitative research can also help us understand sensitive issues. In Syria, we assessed our radio drama Hay el Matar. To understand issues around the conflict we asked a trusted, local NGO to use projective techniques. This involved asking respondents to discuss the feelings of others – either people in their community or an “extremist” character in the drama. People felt more comfortable talking about how others view violence, or explaining the motives of a fictional character, than talking about themselves.

We discovered that Syrians interpreted people’s accents as a strong signal for which side of the conflict they were on. We relayed this to our radio producers who took greater care with the accents of the actors. We could not have grasped these nuances with quantitative data alone.

Insights on a budget

There’s another cold, hard fact to take into account. Conducting quantitative research, on the scale needed to measure media interventions, is expensive. Project budgets often don’t stretch to this so we need to gain qualitative insights in the absence of large-scale, representative surveys.

At the end of the panel discussion in Amsterdam this week, the Esomar Foundation’s Phyllis MacFarlane asked a crucial question: “What does the development sector need to do for qualitative research to be taken more seriously? Steve Kretschmer from Surgo Foundation summed it up nicely.Quantitative data needs to be used to explain the “what” he said, but when it comes to the “why”, well-designed qualitative research is invaluable. He added that the development sector could work with the commercial sector to adopt practices such as using video to capture emotions (rather than relying on what people say) to make the most of audience insight and – most importantly – to make a difference.

More on that another time …

Sonia Whitehead is Head of Research at 成人论坛 Media Action.

We use the word ‘partnership’ a lot in the development world. At a global level, we’re all ‘partners’ – a giant family of policymakers, donors, practitioners, academics and companies working together to advance a shared vision of a world free from poverty, hunger and violent conflict.

We come together for mutual benefit, bringing our different skills, experiences and resources to the table, to solve deeply rooted problems. But because we’re human, partnerships – as with any relationship – can be fraught with friction and misunderstanding. 

At Media Action, we build partnerships so media and communication can make as positive a difference to people’s lives as possible. Our natural partners are, of course, other media organisations, often the local and national broadcasters in the countries where we work. We share a common interest in using media to provide a public service to enrich and enhance the lives of citizens.

But we have other, less obvious companions in our journey to make life better for people in the Global South. We also collaborate with governments and NGOs that don’t specialise in communication in order to . Like us, they share the belief that, when rooted in evidence, media and communication have a key role to play in maternal and child health.

What’s everyone bringing to the table?

And what can a media organisation like us bring to these ? Editorial acumen, technical know-how and tangible products. We provide high-quality media content that educates and entertains. Our programmes are custom-built to encourage social and behaviour change, creating demand for the maternal and child health services provided by our partners.

Of course, simply handing over a stack of DVDs does not a partnership make. So we also work with our partners to facilitate community discussions, which use our content to spark conversations about the kinds of issues addressed on TV and the radio. With some partners, this work goes further, with , skills they could then go on to use day in and day out.

Bringing their loyal audiences and in-depth knowledge of local people, our media partners are invaluable to us. They help us spread the benefits of media and communication further, to reach .  

We in turn can offer programmes that draw audiences in, , to help pique the interest of those who aren’t normally interested in health matters but make decisions within families. There aren’t many people who reject entertainment after all. Dramas can sway ‘’, who were previously somewhat ambivalent about maternal and child health, into pushing for their loved ones to take advantage of the services our partners offer.

What makes for a long and prosperous partnership?

Over the course of all this collaboration, we’ve learnt a few things about how to be a better partner and how to get the most out of working together. In many ways, it’s like a marriage or long-term relationship: if one side expects their meals to be cooked and the laundry to be done, but the other has no intention of doing that, there’s bound to be trouble! So it’s important to be about the relationship from the start.

This last piece of guidance has been particularly helpful to us, as we’ve found that partners have high expectations of us because of the 成人论坛 brand. Clarity from the outset and a joint plan can help smooth out problems that may arise if those expectations are unrealistic.

We’ve also discovered that involving partners in content creation elevates projects into genuinely joint ventures that everyone has a stake in. Similarly, it’s worth providing ongoing support to partners so they can adapt to different scenarios and to ease the burden of carrying out outreach, which can be time-consuming and complex.

Ultimately, and at the risk of sounding obvious, it’s all about communication: listening and talking to each other…solving problems together…working for a common goal. That’s how sustainable change happens.

If you’d like to find out more about how 成人论坛 Media Action used media and communication to improve maternal, newborn and child health, go to our digital platform, .

Sophia Wilkinson is 成人论坛 Media Action’s Acting Head of Health and Resilience; she was previously the organisation’s Senior Health Adviser. Sophia’s most recent publication is , which reflects on 成人论坛 Media Action’s maternal and child health partnerships with governmental and NGOs in Bangladesh, India and Ethiopia.  Sophia tweets as .

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How we view our role and relationships within our communities shapes how we behave – . When widespread, these views constitute ‘social norms’, which people tend to follow because they believe that others do and because they think it’s expected of them. Media Action’s programmes aim to challenge social norms that can lead to people risking their health and reinforce those that support people to make healthier choices.

Donors increasingly want proof that we’re changing norms at scale. But it’s not easy either to or to identify exactly how media influences desired outcomes, such as children getting vaccinated or .

These are some of the challenges we face as Media Action’s research team. How do we design research to measure social norms and track whether they’re changing? We came up against this question when evaluating whether our had changed social norms in Ethiopia.

We set out to understand whether our programmes had convinced families to by, for example, saving money and planning how to travel to the hospital. In Ethiopia, preparing for a baby’s arrival typically means planning the important post-birth thanksgiving ceremonies. Women are judged negatively if they don’t put on a good spread but the costs of hosting this celebration mean that there’s less money to get a woman to a facility when the time comes.

We primarily used qualitative methods to understand social norms but we also undertook large-scale surveys to understand how we were shaping social norms at a population level.

To highlight challenges around researching social norms with surveys – and how they might be overcome – here are five common responses heard in the field in Ethiopia: 

1. ‘How would I know what other people think?’

Though intuitive in English, it’s not always obvious in other languages that asking someone ‘what would your neighbour think?’ really means ‘what do you think your neighbour would think?’. Respondents sometimes take the question very literally and reply that they ‘didn’t know the minds of other people’.   

, where interviewees reflect on what they understand by a question, and careful piloting of questions can reveal when something isn’t interpreted as intended. To get the wording of a question right, it’s essential to take the time to test and refine translations into local languages and carefully train field interviewers.

2. ‘Which people?’

When asked about ‘other people in the community’, interviewees often weren’t sure who they were meant to be thinking about. We consequently explained what we meant to respondents, to help them move from an amorphous sense of ‘other people’ to something more meaningful. For example: ‘If you think of five women you know, how many of them would start going for check-ups in the first three months of pregnancy?’  

3. ‘It’s none of my business!’

Our team found people in Amhara (a region in northern Ethiopia where the research took place) to be quite reserved. It’s an area where it seemed to be impolite to speculate on the lives of others, not least to an outsider with a clipboard.

Surveying was as much an art as a science, with proving to be as important as good survey design.

When it comes to rapport the ordering of questions is important. First of all, you can turn people off a survey by leading with potentially sensitive questions. How willing would you be to tell someone what you earn or weigh when you just met them?

Second, it’s easier to get good answers to tricky questions (like those around social norms) if they’re asked some way into the survey after rapport has been built. But these questions can’t be left too late. People often find talking about things like community dynamics tiring, so you have to broach these topics while people still have enough energy to discuss them.

Finally, it’s important to brief interviewers well so they’re confident of the research aims. They’ll also be better at reassuring participants they’re not trying to probe into their private lives, but rather uncover the practices and perceptions of their community as a whole.

4. ’I don’t know’   

Respondents are often stumped by questions – particularly by those that ask to what extent they agree with a given statement. However, presenting them with a range of simple and concrete options can help elicit answers.

For example, to determine whether respondents believe their community sees something as appropriate or expected, we presented them with options such as: ‘they would think it’s OK’, ‘they would think it’s not OK’ and ‘they wouldn’t care’.

To determine what respondents think people in the community are actually doing, we presented them with choices like ‘none or a few do it’ and ‘almost all do it’.

We found that listing these options helped increase understanding and made the surveys less demanding of participants, resulting in fewer ‘don’t knows’.

5. ‘Let me tell you what happened to me during my last pregnancy…’

When a respondent has to choose from a limited number of options, there’s no way of recording the rich detail someone might provide through sharing their experiences in a more narrative form. Within the context of a survey, personal stories become conundrums (how do I classify this?) rather than goldmines of information. This tension demonstrates why qualitative research remains invaluable.

Illustrating this, we recently used a to allow mothers to tell us the journey of their pregnancy. Asking questions like ‘Would you say that your story of pregnancy is the same as most of the mothers in your community?’ helped us understand whether or not interviewees were conforming to norms.

We’re continually exploring ways to improve our surveys to pinpoint what social norms are and how they’re changing, always with the aim of truly reflecting people’s perceptions and helping them improve their health.

Hilina Assefa is a Senior Research Officer with 成人论坛 Media Action’s Ethiopia team; Lois Aspinall is a Research Manager with the UK office.

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Following the launch of our  site, Emebet Wuhib-Mutungi explains how influencing mothers-in-law and husbands can help improve the health of mothers and their babies. 

 because of complications caused by pregnancy or giving birth. Almost all of these women live in the Global South. And most could be saved through simple precautions, like going for regular antenatal check-ups.

But as we discovered through  (watch the video below for more background), expectant mothers often don’t go for check-ups early enough. Our research into people’s beliefs suggests this is because Bangladeshis view pregnancy as a ‘natural process that doesn’t need special attention’, while in Ethiopia, going for a check-up is seen as inviting ‘bad luck’. .

To mark the launch of our site, Sophia Wilkinson explains how health communication can make a big difference at scale – for less than the cost of a can of coke per person.

“But what about the impact?”

This is the question I'm asked the most after I’ve told an audience that, quite literally, millions of people listen to our radio shows and watch our TV programmes about . The other question I routinely get is:

“I don’t care how big your audience is! What I want to know is whether anything has changed?”

What people often don’t realise is that the more people you reach, the bigger the difference you can make. You don’t have to choose between the two.

Skilfully designed and well-executed media and communication projects can not only change behaviour and norms, they can do so at scale. Offering both quality and quantity, such interventions should be immensely attractive to those working to solve the world’s costliest and most widespread health challenges.  

I’m going to brag. In Ethiopia alone, some listened to our radio shows about different aspects of pregnancy, birth and newborn health over the course of just one year – and 14 million did so regularly. This means in the three states where we surveyed – Amhara, Oromia and SNNPR (Southern Nations, Nationalities, and Peoples' Region) – almost half of all adults listened to our shows.

But aside from professional pride, why does this box office success matter when you’re not looking to drive up profits from ticket sales? 

It matters because of the scale of the challenges we’re trying to solve.

In Ethiopia, , 29 will die before they’re even a month old and 48 won’t make it to their first birthday. And every year, due to pregnancy-related complications.

Of course, we all know that the death of many of these mothers and newborns could be avoided. But it’s not just about providing good quality, accessible health services. It also requires lots of people to do things differently in their day-to-day lives. Millions. Not just hundreds.

The Ethiopian women who listened to our shows did just that. They were more likely to have: one, received antenatal care, two, made arrangements for having their baby in a health facility and, three, given birth in a facility or with a skilled attendant looking after them.