Spring 2015
Working Project papers
Evaluating the Impact of Radio-Based EntertainmentEducation in Douentza, Mali
Prepared by
Uttara Dukkipati, Kathleen Fischer, Ariel Moser and Megan Schliep
Submitted March 27, 2015 to Professor Juliet Sorensen as part of the
Spring 2015 Health and Human Rights Seminar at Northwestern University
Author’s Biographies
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Uttara Dukkipati is a graduating JDMBA from Northwestern School of Law and the Kellogg School of
Management. Prior to graduate school, she worked in Washington, DC at a foreign policy think tank,
where she covered issues of global development. Uttara had the opportunity to travel to Mali with
NAHP in March.
Katie Fischer is a graduating law student at Northwestern University. Katie is a registered nurse in Illinois,
and before attending law school, she worked at the University of Chicago Medicine. Katie plans to focus
her legal career in health care and practice in the Chicago area.
Ariel Moser is a Clinical Researcher at Northwestern University in the department of Maternal Fetal
Medicine. She is also a second-year student in the MPH program interested in maternal and child health as
well as global health. Ariel had the opportunity to visit Mali with NAHP in March.
Megan Schliep is a Speech-Language Pathologist at Northwestern University specializing in acute care. She
is also a second-year student in the MPH program and is particularly interested in health policy and access
to care.
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EXECUTIVE SUMMARY ......................................................................................................................................... 4
INTRODUCTION ...................................................................................................................................................... 4
I. THE INTERVENTION CONTEXT: MALI ......................................................................................................... 6
A. AN OVERVIEW OF MALI AND ITS RECENT CONFLICT .................................................................................................. 6
B. ECONOMIC DEVELOPMENT, HEALTH INDICATORS, AND EDUCATION FOR SCHOOL-AGED CHILDREN................ 7
1. Economic Development....................................................................................................................................................7
2. Health Indicators ................................................................................................................................................................8
3. Education for School-Aged Children ..........................................................................................................................9
C. CULTURE: MUSIC, LANGUAGE, AND THE RADIO.......................................................................................................... 10
II. DOUENTZA ....................................................................................................................................................... 11
A. REGIONAL OVERVIEW ..................................................................................................................................................... 11
B. IMPACT OF RECENT CONFLICTS ON DOUENTZA AND ITS RESIDENTS ..................................................................... 12
C. HEALTH CARE IN DOUENTZA AND THE MOPTI REGION ............................................................................................ 13
D. EDUCATION IN DOUENTZA ............................................................................................................................................. 14
III. THE ALBUM INTERVENTION: ORGANIZATIONAL PARTNERSHIPS CRITICAL TO THE
ALBUM’S SUCCESS ............................................................................................................................................... 16
A. NORTHWESTERN ACCESS TO HEALTH PROJECT (NAHP) ........................................................................................ 16
B. NEAR EAST FOUNDATION (NEF) ................................................................................................................................. 16
C. RADIO DAANDE DUWANSA............................................................................................................................................. 17
D. THE ALBUM: LYRICS AND LOGISTICS ........................................................................................................................... 19
IV. PRIOR STUDIES: SUBSTANTIATING THE SURVEY METHOD ......................................................... 20
1. RADIO AS A VIABLE METHOD FOR HEALTH EDUCATION INTERVENTIONS ............................................................ 20
2. USING SURVEYS TO MEASURE THE IMPACT OF RADIO-BASED INTERVENTIONS .................................................. 22
V. CONSIDERATIONS IN SURVEY DESIGN ................................................................................................... 24
A. THE ALBUM AS ENTERTAINMENT-EDUCATION.......................................................................................................... 24
B. RADIO DAANDE AND THE FLOW OF INFORMATION ................................................................................................... 26
C. THE POTENTIAL DRAWBACKS OF USING A SURVEY METHOD.................................................................................. 26
D. THE IMPORTANCE OF THEORY ...................................................................................................................................... 27
E. THE HEALTH BELIEF MODEL ......................................................................................................................................... 28
F. EFFECT OF MULTIPLE COMMUNICATION INTERVENTIONS ....................................................................................... 29
VI. THE SURVEY ................................................................................................................................................... 30
A. SURVEY DESIGN ................................................................................................................................................................ 30
B. EXPERT ADVICE CONSIDERED IN OUR SURVEY DESIGN ............................................................................................ 31
C. SUGGESTIONS FOR POST-QUALITATIVE ANALYSIS ..................................................................................................... 33
CONCLUSION ......................................................................................................................................................... 35
APPENDICES ......................................................................................................................................................... 36
A. THE SURVEY...................................................................................................................................................................... 36
1. Demographic Questions:............................................................................................................................................... 36
2
2. Malaria: ................................................................................................................................................................................ 36
3. HIV/AIDS: ............................................................................................................................................................................ 36
5. Education: ........................................................................................................................................................................... 37
6. Breastfeeding:.................................................................................................................................................................... 37
7. Hygiene and Sanitation: ............................................................................................................................................... 37
8. Radio Questions ................................................................................................................................................................ 37
9. Album Questions: ............................................................................................................................................................. 37
B. THE ALBUM AND ITS LYRICS (TRANSLATED FROM FRENCH) ................................................................................... 38
1. Malaria ................................................................................................................................................................................. 38
2. AIDS ........................................................................................................................................................................................ 38
3. No to Female Genital Cutting ..................................................................................................................................... 39
4. Girls’ Education................................................................................................................................................................. 39
5. Breastfeeding ..................................................................................................................................................................... 40
6. Hygiene and Sanitation................................................................................................................................................. 40
BIBLIOGRAPHY .................................................................................................................................................... 41
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Executive Summary
This intervention evaluation assesses the implementation of a public health education initiative in
the Douentza region of Mali through a partnership between the Near East Foundation (“NEF”)
and the Northwestern Access to Health Project (“NAHP”). The partnership between these two
organizations focuses on the PONI model, which describes a specific approach taken to promote
successful development initiatives in high-need areas. In 2014, NAHP capitalized on NEF’s
longstanding relationship with Douentza’s local musicians and radio stations to commission a
music album that addresses six key health and development issues in Douentza. The album has
played regularly on local radio in Douentza since 2014.
The purpose of this intervention evaluation is twofold: first, to assess the album’s impact on
community members’ knowledge and perception of the six topics, and secondly, to evaluate the
effectiveness of this type of public health album as a teaching tool. We propose that conducting a
qualitative survey of local residents will provide the most meaningful feedback to best answer
these two key questions and inform further research on health communication efforts and their
impact in the Douentza area. We plan to work closely with NEF staff to execute this survey in
an effective manner, remaining mindful of both current resource constraints and the potential for
NAHP to engage in future quantitative research in this area.
Introduction
In 2014, the Northwestern Access to Health Project (NAHP) initiated two health interventions in
Douentza, a small town in the Mopti region of Mali. This paper assesses the impact of one of the
two parallel interventions, a six-topic album designed to educate radio listeners about the
following health and development issues: malaria, AIDS, FGM, girls’ education, breastfeeding
and hygiene and sanitation (the “six topics”), which represent some of Mali’s most acute health
challenges. The second intervention was a microfinance program designed to eliminate financial
incentives for traditional practitioners of female genital mutilation (FGM) in the Douentza area,
thereby cutting off the “source” of the demand for such services. Given that each intervention
addresses community teaching needs regarding FGM, there may be some overlap in the effects
of these related interventions. However, this paper specifically focuses on the album and its
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impact; our NAHP colleagues are evaluating the microfinance initiative in a separate research
effort.
NAHP’s goal in commissioning the album was not only to educate the community about these
issues but also promote local residents’ utilization of health care resources and education
services, particularly for school-age girls. A group of popular local musicians, known
collectively as “Troupe de Haire,” 1 proposed the six topics but NAHP approved them before the
album’s production commenced. For maximal impact, the album was recorded in Peulh,
Douentza’s local language, and the music was arranged in forms popular with local listeners.
NAHP provided financial support for the album’s production, and retained ownership of the
album once the project was completed. The album has been played regularly on local radio.
Based on extensive research and expert interviews, the paper sets forth the best method for
assessing the efficacy of this intervention: a survey conducted with the help of NEF in the cercle
of Douentza. 2 In support of this claim, this paper is organized into five sections. The first section
provides background information on Mali. The second section provides background on the cercle
of Douentza. Both sections familiarize the reader with the context of the album intervention.
The third section describes the album and the partnership underpinning its production. The fourth
section draws upon past social science studies to demonstrate why the survey method constitutes
the best means of evaluating the album’s impact in the community. The fifth section also outlines
several considerations, including the importance of theory, in deciding to use and design the
survey. The sixth and final section explains the survey process and outlines why it will provide
NAHP with the most robust and useful results in evaluating the impact of the album.
1
2
In English, Troupe de Haire means “Troup of the Douentza Hills” (Tambouré 2015).
Additional information on Douentza cercle appears below in Section II(A).
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I. The Intervention Context: Mali
A. An Overview of Mali and its Recent Conflict
The landlocked West African country of Mali is the size of Texas but home to a total population
just half that size –16.5 million. Mali is one of the poorest countries in the world; over half of its
population lives in poverty (PMI 2015). A former French colony until 1960, Mali experienced
sustained economic growth in the late 1990s and the early 2000s, coupled with relative political
stability. As a result, Mali was regarded as a model of African democracy until March 2012
(BBC Country Profile 2015).
Unfortunately, since 2012, Mali has faced a multi-dimensional and interconnected crisis; facing
armed conflict, political instability, food shortages, and flooding. The country also experienced a
cholera outbreak, which primarily affected women and children. Mali’s armed conflict arose
from factors such as uneven governance, the “corrosive impact of drug trafficking and other
illicit commerce”, and military fragmentation (Arieff 2012). In 2012, Tuareg rebels attacked
government positions throughout northern Mali, a vast region—roughly the size of France—
comprised of semi-arid and desert sub-regions. As a result of these attacks, the Tuareg rebels
temporarily seized control of a large portion of the north, declaring it an independent state named
Azawad (Goldhammer 2015).
Public corruption—reportedly tied to the aforementioned criminal networks—contributed to
general dissatisfaction among Malians with the government of former President Amadou
Toumani Touré and lent itself to initial support for a 2012 coup orchestrated by the Tuaregs
(Arieff 2013, 1). However, an uptick in regional arms and combatant flows due to the overthrow
of Muammar Gaddafi in nearby Libya, as well as the power vacuum created by the coup,
allowed Islamist militants to seize control of large swaths of the north. After several months of
“an uneasy power-sharing arrangement,” the Tuaregs were pushed out and the northern part of
the country fell under Islamist control (France24 2015).
The Islamist rebels, including elements of Al Qaeda in the Islamic Maghreb, were intent on
imposing Sharia law and possibly establishing a base for terrorist activity (Dreazen 2013). As the
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Islamist rebels began pushing south, U.N. action was planned; however, France felt compelled to
act sooner to prevent further damaging gains by the Islamist rebels. After France intervened in
January 2013—using fighter jets and attack helicopters in coordination with Malian forces—the
Islamist rebels have largely receded to remote mountain ranges, near Kidal, in the far northeast
of the country (France24 2015).
The crisis affected 2.8 million people across the country. More than 100,000 Malians were
refugees in neighboring countries during the period of the conflict; many have yet to return. As
of September 2014, it was believed that sustainable peace still required the presence of 10,200
military and police personnel from the United Nations. In addition, there were at least 1,500
French troops remaining in the country at that time (Duval Smith 2014).
Now, with the conflict largely under control, Mali is trying to return to a path of economic
growth and political stability. President Ibrahim Boubacar Keita was elected as President
towards the end of 2013, returning democracy to the country. As of the end of March 2015, the
Malian government was still negotiating a peace agreement with Tuareg-led rebels. The “Algiers
Agreement”, as it has been named, has undergone five rounds of negotiations since Fall 2014.
Tuareg rebel leaders assert the nomadic Tuareg people have been marginalized and consequently
impoverished for decades. As such, they are seeking “a form of local government, including
some form of federalism, with local parliament and security” (Markey 2015). Regardless of the
outcome of these negotiations, peace has largely to returned to Mali.
B. Economic Development, Health Indicators, and Education for School-Aged Children
1. Economic Development
Before the crisis began, despite its relative stability, Mali was ranked among the lowest twelve
countries on the United Nation’s Development Programme’s (UNDP) World Development
Index. The low UNDP ranking was largely due to Mali’s fledgling economy. Despite its role as
one of Africa’s major cotton producers, Mali has faced a chronic trade deficit, rendering it
heavily dependent on foreign aid and remittances from émigré Malians (BBC Country Profile
2015). Its development challenges are acute: education, malnutrition and sanitation are all key
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issues throughout the country. Mali’s failure to reach seven of its eight Millennium Development
Goals (MDGs) illustrates the severity of these issues.
The MDGs are eight international development goals that were established following the
Millennium Summit of the United Nations in 2000. The goals range from halving extreme
poverty rates to halting the spread of HIV/AIDS with a 15-year deadline for achievement. They
“form a blueprint” for global development and are agreed to by all the world’s nations and
development institutions (UN Website 2015).
According one.org, an international campaigning and advocacy organization committed to
ending extreme poverty and preventable diseases in Africa, sub-Saharan Africa remains the
region furthest from meeting its MDGs. Yet while some individual African nations are making
significant progress towards their MDGs, Mali is not. Mali will achieve only one of its eight
Millennium Development Goals—improving citizens’ access to water—by the 2015 deadline.
By contrast, neighboring Burkina Faso and Ghana are simultaneously making strides towards
multiple goals (UN Website 2015).
2. Health Indicators
The current health system in Mali is decentralized and composed of three levels: community
health centers, primary referral facilities and regional hospitals (Galvin 2015). At the community
level, Mali’s health system involves an integrated community case management package. Every
level, however, suffers from a critical shortage of personnel (Touhouri 2009, 1). In addition to
personnel shortages, there may be other factors, such as an inability to pay for services or family
influences on decision-making, that impact access to health care services, particularly for women
(White 2013, 58). Furthermore, there is a wide disparity in the doctor-to-population ratio in
urban versus rural areas (PMI 2015). In Mali, 40 percent of the population lives more than five
kilometers from a health center (Duval-Smith 2014). As of 2006, Mali had invested 5.8 percent
of its annual gross domestic product (equivalent to US$ 5.31 billion) in health. This amounts to
$60 per capita.
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UNICEF reports that neonatal problems, malaria, pneumonia and diarrhea still account for 70
percent of deaths of children under age five. Malaria is the primary cause of death for children
under five; in addition, 27 percent of children in this age group experience malnutrition as well.
For this reason, the Government of Mali provides free malaria medication for pregnant mothers
and children under five (Traoré 2015). According to UNICEF, early initiation of breastfeeding,
the safest mode of nutrition for infants, occurred in only 57.1 percent of the population from
2008–2012 (UNICEF 2015). However, it is important to note that despite a brief trend in the
increased use of bottles and formula, it is customary for Malian women to breastfeed their
children until they reach 2 years of age (Ongoiba 2015). It is estimated that in the cercle of
Douentza, where the album intervention took place, approximately 90 percent of women
breastfeed their children (Traoré 2015).
Malaria is a primary cause of mortality in Mali. Transmission varies across the country. The
disease is epidemic in the northern part of the country, whereas it is endemic in the central and
southern regions (where more than 90 percent of Malians live). In 2011, the national health
information system reported that suspected malaria accounted for 42 percent of all outpatient
visits for all age groups (PMI 2015). Internally displaced persons migrating from the north, due
to the conflict, are especially at risk given their lack of immunity to infection (PMI 2015). The
percentage of people ages 15–49 in Mali who are infected with HIV constitute 0.9 percent of the
total population (UNICEF 2015). 89 percent of girls and women have had some experience with
FGM. FGM can be a significant risk factor during pregnancy and childbirth as well as
increasing the likelihood of a host of other negative health outcomes (WHO 2001, 10).
3. Education for School-Aged Children
Mali’s education indicators are as weak as its health indicators. It is has been proven that
education, and specifically women’s education, can have a positive impact on health outcomes
(see UNESCO 2011, 6). Yet Mali’s low rates of childhood education, particularly for girls,
demonstrate a potential area for improvement in health teaching and outcomes in the country.
According to the United Nations, 70 percent of boys are enrolled in primary school, while only
56 percent of girls are enrolled (Voice of America 2015). The Malian government has stated its
commitment to providing access to quality education for all children. In its pursuit of this goal,
the government has created a ten-year program focused on Access to Quality Education known
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as PRODEC. UNICEF in Mali works with the Ministry of Education to develop and implement
policies on increased access, improved quality of education and enhanced quality of the
education management system. As a result of UN efforts, Mali has adopted the ‘Fast Track
Initiative’ to accelerate the process to reach universal primary education by 2015 (UNICEF 2015
(b)).
C. Culture: Music, Language, and the Radio
Culturally, music and the radio are of great social and political import to the desert state of Mali.
Globally, Mali is known for its musical heritage. The country is home to several world-renowned
music festivals, and music is popular with Malians nationwide. Music is so central to Malian
culture that many cercle administrative centers, such as Douentza, have state-supported arts
centers and programming. The arts centers are hubs for musicians to practice and compete in
nationally supported, semi-regional and regional competitions (Bocoum 2015).
Like many nations in Africa, Mali is a multilingual country; over 50 languages are spoken within
its borders. While French is Mali’s official language, Bambara is the “lingua franca” of the
country (Troupe de Haire 2015). Overall, 13 of the native languages of Mali have the legal status
of “national language”.
The multitude of languages and dialects spoken are reflective of ancient settlements, migrations,
ethnic groups and cohabiting tribes. In Mali, Bambara represent the biggest ethnic group with 33
percent of the population; among other ethnic groups, Fulani (or Puelh) constitute 10 percent,
Senoufo—9 percent, Songhay—7 percent, Malinke—6 percent, Tuareg—5 percent, and
Dogon—4 percent of the population (João Leitão 2012).
Despite its linguistic diversity, Mali has one of the lowest literacy rates in the world. The United
Nations estimates the average literacy rate between 2008 and 2012 as 33.4 percent, and the CIA
estimates the literacy rate for women at 39.6 percent and the literacy rate for men at 46 percent
(CIA-World Factbook 2009).
Mali’s literacy rate makes the spread of information in written form difficult. Further
complicating the issue, many literate Malians cannot read or speak French, the language most
commonly used in written materials (Tower 2008, 25). Spoken communication is therefore of
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critical importance. The radio provides an efficient, alternative means of spreading information
within the country; it not only “provid[es] information, opinion, and entertainment . . . [and]
circulat[es] social norms and mores” (Tower 2008, 21), but also serves as “an attractive medium
in reaching groups for whom there are significant social and structural impediments to accessing
education, particularly women, rural residents, and the elderly” (Tower 2008, 25).
Despite these disheartening development indicators and the conflict, and perhaps because of
these factors, NAHP intervened in Mali. The next section of this paper will address Douentza,
the region in which the album was played.
II. Douentza
Figure 1: the location of Douentza Cercle in Mali (Reproduced from Sperling 2006, 14).
A. Regional Overview
Mali is divided into eight regions, which are further subdivided into 49 cercles. NAHP’s
interventions have been implemented in the town of Douentza, which is part of Douentza cercle,
the largest administrative district in the greater Mopti region (see Fig. 1 above). As of 2006, the
Cercle’s population was estimated between 160–170,000 residents (Sperling 2006, 14).
Douentza cercle is a predominantly agricultural region, and most of its residents work as crop
and livestock farmers (Sperling 2006, 15–16). It has a short growing season, and with limited
exceptions, most of the Cercle’s residents face significant challenges in farming (Ibid.). As a
result of natural shocks, such as droughts or pest infestations, or man-made shocks, such as
armed conflict, Douentza Cercle’s residents often face huge risks to their food supply and
livelihood (Aker and Coulibaly 2009, 16–17).
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While multiple ethnic groups populate the larger Douentza Cercle, members of the Puelh ethnic
group constitute the largest group in the town of Douentza. Puelhs were traditionally a nomadic
group and also are referred to as the Fula, Fulani, Fulbe, Haalpulaar, or Fellata (de Bruijn 2003,
288). As members of the Puelh community, a majority of residents in Douentza speak Puelh in
their homes (Pelckmans 2011, 75).
Douentza faces many of the same development challenges as the Malian nation overall, but the
rural and isolated nature of the Douentza cercle and its proximity to the north have compounded
the region’s difficulties. While far from the nation’s capital, Bamako, Douentza is only 120 miles
from the regional capital of Mopti, which marked the line-of-control held by the Malian military
during the conflict. Given its northern location, Douentza was particularly susceptible to
occupation—first, by the Tuareg separatists and then by Islamist rebels.
B. Impact of Recent Conflicts on Douentza and its Residents
As a result of the conflict and two occupations during 2012–13, Douentza’s economic activities
were negatively impacted. The road was closed and the town lost many of its productive assets,
including fences, business supplies, and other items of value to plundering by the Islamist rebels.
When the Islamist rebels entered the town in March 2013, they enforced Sharia law. According
to Dr. Benjamin, chairman of the Near East Foundation (“NEF”), the Islamists were utilizing
Sharia law as a means to implement “social control” over the local population. Women were
suddenly no longer allowed to leave their homes and participate in public activities, such as the
local market. Smoking was forbidden. These strict rules were intended to assert control over the
activities of the town and indirectly aid the Islamists in trafficking narcotics through the region
for profit, rather than any real effort at Islamizing the town (Benjamin 2015; Tambouré 2015).
In order to defeat the occupying Islamist rebels, the French bombed Douentza once during the
conflict. The bombing campaign destroyed the middle school, the high school and one hotel. The
high school is in the process of being rebuilt. The middle school is expected to be repaired next
year (Tambouré 2015).
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Prior to 2012, the town of Douentza had roughly 28,005 residents (Pelckmans 2011, 72; RPGH
2009) and was growing rapidly. Tourism, as well as residential and commercial development,
had appeared to increase in recent years (Pelckmans 2011, 74–75). Douentza had benefitted from
its position as a major stopping point on the road from Bamako to Gao, a regional center
(Benjamin 2015), and trading close to the roadside had become a viable career option for local
merchants (Pelckmans 2011, 75). Both tourism as well as residential and commercial
development had rapidly increased in the years preceding the conflict (Pelckmans 2011, 74–75).
As a result of the 2012 conflict, all trading and development activities came to a halt, the roads
became nearly impassible, and the cercle’s population declined significantly as residents fled the
conflict (Benjamin 2015). Now that peace has returned, Douentza is slowly on the road to
rebuilding its population and infrastructure, but its exact number of residents is difficult to
determine today (Ibid.).
After the conflict ended, France24 wrote that in Douentza, “the markets once again bustle with
life and music, and even cigarettes are once again on offer at the town’s vibrant stalls,”
(France24 2015). Yet in other sources, citizens have reported that despite improvements,
tensions remained high in the area. For example, in 2012, rigid military checkpoints were in
place, and food was reportedly scarce. On a societal level, people remained suspicious of those
they believed to have cooperated with Islamist rebels. The town’s infrastructure—particularly
power lines and roads—was badly damaged, hampering activities in the town and making access
to Douentza from other parts of Mali difficult. Finally, as will be discussed in the next section,
the conflict deteriorated existing health and sanitation issues, which has negatively impacted
residents’ lives across the region.
C. Health Care in Douentza and the Mopti Region
As a result of the conflict, Douentza’s local health services were suspended, and the town has
faced challenges in rebuilding its critical services (Ulstrup 2015). Today, the town has a
community health center, a primary referral medical clinic that takes more complex cases that
the community health center is not equipped to handle, and a technical training center for nurses
(Ibid.). The referral center and community health center, or CSCOM, remained open during the
conflict; at that time, Doctors without Borders ran the referral center (Traoré 2015).
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The International Diabetes Foundation provides a good example of the health challenges faced
by towns like Douentza during the conflict. The conflict posed significant health dangers for the
hundreds of thousands of people living with diabetes and the more than 100 children with Type 1
Diabetes in Mali. As the conflict escalated, physicians left the northern regions of Timbuktu,
Kidal, Gao and Mopti. As of 2014, only one private pharmacy in Timbuktu had diabetes
medications; even where medications were available, their prohibitively high cost put them
beyond the reach of most diabetes patients.
In Douentza, there were no diabetes medications available, and local patients were “trapped in a
barren medical desert” (Besancon 2012). Two children with type 1 diabetes, one in Timbuktu
and the other in Douentza, were found to have run out of insulin entirely and risked imminent
death if a supply was not quickly organized by IDF. IDF also wrote that during the conflict, the
number of patients at the Mopti regional hospital skyrocketed. Large numbers of displaced
people arrived daily. They came from further north, usually with no resources whatsoever.
Now that the conflict has ended, access to medicines and health care remains challenging for
most local residents. The referral center in Douentza has four doctors and seven nurses on staff.
According to Dr. Gounde, the center’s médecin-chef, or chief doctor, a staff of eleven is
insufficient to serve the needs o of Douentza cercle (Gounde 2015). The CSCOM officially has a
staff of nine people, although there are usually six additional volunteers at the center. While
inadequate resources are a defining feature of Douentza’s healthcare environment, the resources
that are consistently available are not always utilized to their full capacity. For example, it is
common for women in Douentza to follow tradition by giving birth at home, attended by a
midwife (Gounde 2015). Only 27 percent of births are likely to take place in either health
facility; 70 percent of births take place at home. Additional health education is needed to ensure
that residents are aware of the treatment options available in the area and the benefits of taking
advantage of existing resources.
D. Education in Douentza
Section I(B)(3) addresses Mali’s challenges with respect to children’s education: throughout the
country, rates of attendance continue to fall below the country’s overall educational goals for
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school-age children. Here, we expand on that point in noting that there are substantial disparities
between rural and urban schools. In Mali, qualified teachers are typically assigned to urban
schools, while under-qualified teachers are generally more commonly employed in poor, rural
areas. For example, national statistics indicate for the 2008 academic year in Bamako, the capital
city, sixth grade attainment was at 103.5 percent. Yet in Kidal, in the northeast of the country,
only 24.7 per cent students reached grade six (UNICEF (b)).
UNICEF’s support of the Malian government’s efforts to improve education in the more rural
regions of Kayes, Koulikoro, Segou and Mopti further demonstrates the existence of an urbanrural education quality divide in Mali. The Malian government’s efforts in these regions have
been in effect since 2008 and are known as the “Basic Education and Equity program”. These
four regions were selected on the basis of low education criteria indicators including: enrollment
and completion rates, high gender gap, as well as the size of the district and the student
population. While Mali’s efforts to address the deficiencies in rural education are admirable, they
have not succeeded in closing the urban-rural gap.
Yet access to education has improved in Douentza in recent years, and it stands as an example
compared to the poor education indicators in the greater Mopti region. For those who do attend
school, Douentza represents “an important hub for educational trajectories in the region”
(Pelckmans 2011, 74). Douentza has a public school for children ages 5–15 and a nursing school
for students 16 and older (Ulstrup 2015). Despite Douentza’s relatively strong school
environment, enrollment figures remain low, particularly for Puelh children (Pelckmans 2011,
73), and girls. The area’s extreme poverty deprives many children of the opportunity to read or
attend school, and other socio-economic factors may put girls at a disadvantage with boys when
families decide which of their children to send to school. The community recognizes that
education for girls is an important issue; in fact, this concern has its own song on the Troupe de
Haire album (see Appendix B. The Album and its Lyrics (translated from French)for lyrics).
In the next section, we explain how girls’ education and other important health issues in the
region became the core concerns addressed on NAHP’s album intervention in Douentza.
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III. The Album Intervention: Organizational Partnerships Critical to the
Album’s Success
A. Northwestern Access to Health Project (NAHP)
NAHP was founded in 2012 with the goal of leveraging and integrating the legal, medical, and
business skills of Northwestern students to address health issues in underserved communities
worldwide. A further goal of the project was to implement student-developed research by
applying personalized, practical solutions to health problems in NAHP’s partner communities.
This section will demonstrate how this album project fits within the strategic framework of
NAHP, which implements projects using the “PONI” model. The PONI model emphasizes
Partnerships, capitalizes on existing Opportunities and addresses a Need with Idealism but
without Illusions. In producing this album, NAHP partnered with the Near East Foundation
(“NEF”), an American NGO, and its affiliate radio station, Radio Daande Duwansa (“Radio
Daande”). NEF has worked in Douentza for over 30 years, and its longstanding relationships in
Douentza provided invaluable insight and assistance to NAHP when it first came to the region,
including NAHP’s strategy in developing the album intervention. The survey design proposed in
the next section seeks to build upon the strength of these existing partnerships and solidify
NAHP’s evaluation within the PONI structure.
B. Near East Foundation (NEF)
NEF is an American NGO that has been active in Mali since 1984 (NEF Mali Overview). NEF’s
efforts in Douentza were originally focused on helping the local Bella people with sheep farming
following a severe Sahelian drought (Benjamin 2015). What began as an isolated relief activity
quickly grew, and NEF’s involvement expanded to include soil and water conservation,
promotion of agricultural growth, as well as mitigation and prevention of food shortages through
the construction of local cereal banks (Benjamin 2015).
Soon, NEF’s team recognized that its efforts would have greater impact if the organization
moved beyond discrete interventions and focused on shaping the broader institutional framework
of agricultural policies in rural Mali (such as land rights and tenure). As a result of this change in
16
the organization’s vision, NEF began to engage in forestry and conflict management initiatives
aimed at fostering community decision-making. Later, it became more involved in promoting
democracy and supporting decentralized government, particularly at the local level.
Today, NEF has continued to utilize its development expertise to promote capacity building for
local government in Douentza and improve the socio-economic status of local residents. While
NEF is currently headquartered in Sévaré, Mopti, Mali, it has deep roots in Douentza, having
been headquartered in the town for over 27 years before its 2012 move. It was the only NGO to
remain in the town during the conflict, and has had a positive impact on the area’s economic
recovery. It benefits from significant support from the people of Douentza. It also receives
monetary support from the US government via the Office of Foreign Disaster Assistance
(Benjamin 2015). In addition to its own efforts, NEF prides itself on having created durable
partnerships with local leaders (Benjamin 2015).
C. Radio Daande Duwansa
In Douentza, local music, community messages, educational programming, announcements and
news are available via the town’s independent radio station, Radio Daande. Founded in July
1993, Radio Daande reaches approximately 120,000 area listeners (Myers 2009, 55). Radio
Daande was and is a small but critical part of NEF’s operations in the area (Benjamin 2015). It
was envisioned as a “development tool[], designed and run to foster a spirit of local identity and
empowerment; to ‘bring knowledge to the rural communities and to give them a say’” (Myers
1998, 207).
NEF has funded Radio Daande for approximately 25 years, but the station is operated
autonomously (Benjamin 2015). The Association for the Promotion of Rural Communication
(APROCOR) controls Radio Daande’s organization and editorial content. All of the association’s
members come from Douentza Cercle (Tambouré 2015; Myers 1998, 207). APROCOR members
represent a wide swath of the population, with “peasants, traders, teachers, housewives,
traditional leaders and youth groups” (Myers 1998, 207). Radio Daande considers the
community’s sense of ownership and participation in and contributions to the radio to be its
greatest success (Tambouré 2015).
17
Radio Daande was originally founded to provide local residents with information about politics,
democracy, and their rights following former President Moussa Trouré’s ousting (Ibid.). At the
time of its founding, Radio Daande received “enthusiastic backing from local people in the
provision of land, labour and materials to build [its studio]” (Myers 1998, 207). In fact, “[w]hen
[the station] went on-air, radio ownership in the area is estimated to have jumped by 140%.”
(Myers 2009, 55; Myers 1998, 207). The radio offered programming on “health, agricultural
work, the environment, social issues, local and international news, local announcements; all
mixed with plenty of local and national music” (Myers 1998, 208).
Today, the radio station has similar programming, and it serves as a nexus of community
engagement and information sharing (Tambouré 2015). Typically, the programming depends
upon what is organized and recorded in the Douentza studios (see Myers 1998, 208). The
station’s local focus makes it an effective medium for dispersing messages particularly relevant
to the cercle, including those pertaining to health care and education (Tower 2008, 28). The
station has a loyal following. Approximately 75 percent of Douentza Cercle residents tune into
Radio Daande regularly (Tambouré 2015). It has more listeners than other single radio station
broadcast in the region.
Mr. Bouchary Tambouré has led Radio Daande since its inception (Benjamin 2015). Mr.
Tambouré’s imaginative and steadfast management of the radio has elevated its importance
within the community. His leadership during the conflict was critical to the radio’s continued
operations. Unlike other stations in northern Mali, Radio Daande never stopped functioning
during the occupation. In order to keep the station open, Mr. Tambouré agreed to play recordings
of readings from the Koran for four hours each day (Tambouré 2015). Mr. Tambouré believes
the radio’s ability to stay open during the conflict was a reflection of community support and
interest (Ibid.).
Post-conflict, the radio station has resumed its regular programming and remains an integral part
of the community. Radio Daande’s weekly programming is varied. The subjects of the
programming include: music, religion, political discourse and debate, community notices, youth
18
and development, agriculture, and other topics (Grille des Programmes Daande Duwansa 2015). 3
After the conflict, the station developed special programming regarding peace and reconciliation.
The programs featured local community and religious leaders. Nevertheless, its news,
agricultural, and youth programming remain among the most popular offerings (Tambouré
2015). Men, women and children all listen to Radio Daande’s programming, although each
demographic favors particular programs (Ibid). 4
D. The Album: Lyrics and Logistics
NAHP’s educational album from Troupe de Haire, a group of popular local musicians in
Douentza Cercle, has been broadcast regularly on Radio Daande, 106.7 FM since 2014. The goal
of the album was to provide health education to Puelh-speaking households in the region. The
production of the album demonstrates the partnership and opportunity pillars of the PONI model.
Mr. Tambouré found local musicians interested in producing such an album and the artists
identified the six topics as needs they wanted to sing about for the community’s benefit. The
Director of the CSCOM, Dr. Gounde served as the technical editor for the songs, ensuring the
medical information was correct and clear. NAHP approved the lyrics written by the musicians
(Gounde 2015). The production process leveraged existing partnerships and opportunities – a
key feature of the PONI model.
Each song provided key teaching messages about its respective topic and recommended actions
for listeners to take to avoid or mitigate problems related to the six topics. For example, the song
on AIDS explains the disease has no known cure, outlines methods of transmission, provides
recommendations for prevention, promotes testing and explains that anti-retroviral medication
will be provided free of charge to patients by local pharmacies. The full album lyrics for each of
3
In the past, Radio Daande appears to have offered largely similar programming. Myers reports that in the early
1990s, Radio Daande specifically aired the following programs:
Women’s programmes: excision, abortion, young unmarried mothers, being single, divorce, rape,
polygamy—the problems of children, old age, contraception, infidelity, sexual equality, AIDS, etc. Men’s
programmes: a programme around the them ‘there is no such thing as a useless job’, the generation gap,
crime, rape, traditional justice, credit, the cost of marriage, forced marriage, cheating, ignorance, etc. On
technology and society: breastfeeding, latrines, the fight against prostitution, public works, the problem of
loose livestock, taxation, unemployed graduates, etc.
(Myers 1998, 208 (citation omitted)).
4
Mr. Tambouré reports that women are most interested in programs about “feminine activities, maternal health,
children’s health and entertainment.” By contrast, mean are most interested in programming on “agriculture and
livestock”, and children simply prefer “entertainment”(Tambouré 2015).
19
the six songs appear below in Appendix B. The Album and its Lyrics (translated from
French).
The album was intended to reach a wide audience, although it was particularly aimed at female
listeners (Tambouré 2015). Mr. Tambouré believes the album has been a success because it used
“real facts and had themes that impacted each member of the community” (Ibid.). He further
noted that if the album were to be translated in to Tomascheck, Bombara, and Sunare, it would
have an even greater impact on reinforcing local residents’ knowledge of these topics (Ibid.). The
long history of radio use to spread knowledge and spur development in Africa is a distinct
advantage for this type of album intervention, and supports NAHP’s use of Radio Daande to
spread the album’s educational messages in the Douentza area.
IV. Prior Studies: Substantiating the Survey Method
This section summarizes several studies conducted in countries similar to Mali that either 1)
support the view that radio is a robust medium for health interventions or 2) measure the impact
of radio interventions through a survey method. These studies substantiate our view that a survey
is the most efficient manner of assessing the impact of the album. In particular, NEF’s
democracy teaching program known as the Programme d’Appui à la Democratie et à la
Décentralisation (the “Program in Support for Democracy and Decentralization” (Myers 1998,
209) [hereinafter “PPD”]), conducted in the Douentza region in the early 1990s, is highly
relevant: it was intended to teach residents in the same local communities and used Radio
Daande to spread its educational messages.
1. Radio as a Viable Method for Health Education Interventions
Entertainment-Education methods, specifically, folk media interventions, such as the album,
have often been used to reach out to those in rural communities. According to Panford, et al.,
“[f]olk media such as storytelling, drama, poetry recitals, proverbs, and music promoted on the
radio will appeal to rural audiences and potentially influence them to adopt responsible, healthy
behaviors” (Panford 2001, 1561). In Africa, various non-governmental entities have relied on
radio for years as an effective means of transmitting and promoting development agendas,
spreading information, and disseminating specific messages (Tower 2008, 39). Theorists have
20
proposed that Western aid organizations can harness the power of radio to transmit ideas about
social theory and development, enable the acceptance of new messages as well as to aid
development of new cultural standards and norms in a community (Ibid., 40).
In fact, the “donor community in Mali has long been aware of the indispensable vehicle radio
presents them and, across sectors—economic growth, improved health, education, culture, and
democracy and governance— a robust and well-distributed radio network offers a vital conduit
to the donor/development community” (Tower 2008, 48). The album builds on these ideas of
using radio as a teaching tool for residents in rural Africa, using Malians’ love for local music to
promote learning on current health and education issues identified by local residents and
confirmed by health experts at NAHP.
The idea that radio can transmit important ideas about social theory and development has been
proven in multiple contexts. The “Save the Children Fund, wh[ich] studied knowledge about
AIDS prevention in the whole Mopti region, found that those exposed to the radio were much
better informed about AIDS than other areas outside the radio's range: 70% of those claimed
radio as their main source of information. Literacy classes were attended by more villagers after
radio announcement, with an increase in attendance of nearly 120%.” (Myers 2009, 55).
Panford’s 2001 study employed folk media transmitted via radio to promote HIV/AIDS
prevention practices in rural Ghana. In another community-based study, folk theater, which is
referred to as Kalajatha and includes songs, dramas, and music, was used to promote malaria
education in rural India (Ghosh 2006, 2).
Other researchers have found that expanded access to radio communications and programming
positively impacts parental interest in and resources allocated for children’s education in Benin
(Keefer 2014, 57). With respect to health issues, organizations like USAID have reportedly
“hypothesized that access to donor-sponsored public radio messages improves knowledge and
discussion of politics, knowledge of public health practices and availability of nearby medical
services, economic outcomes, and gender equity issues such as female genital mutilation and
domestic violence” (Bleck 2011, 2). These various media campaigns discussed above provide
21
supporting evidence for the efficacy of the album based on their relative ease in promoting
specific health behaviors in a culturally appropriate, appealing and far-reaching manner.
2. Using Surveys to Measure the Impact of Radio-Based Interventions
Surveys provide a valuable means of assessing if and how residents hear the messages
transmitted through radio based interventions, and whether or not those messages are successful
in achieving their educational goals. As mentioned previously, in the early 1990s, NEF and
Radio Daande jointly developed a two-year series known as the “PPD” to broadcast educational
programming for Douentza’s residents regarding their emerging rights and the new political
structure following in introduction of democracy in Mali (Benjamin 2015; Myers 1998, 208).
The public understanding of the changes democracy would bring to the country was limited, and
because of the limited literacy and technology in rural areas, NEF (and other similarly situated
NGOs in Mali) and the Malian government turned to radio as a means of communicating
information about the new system to citizens.
As democracy moved forward, the Malian government took official steps to promote the
development of a robust radio environment throughout the country, becoming a leader in media
liberalization on the African continent. NEF became one of many organizations that capitalized
on this opportunity for increased community engagement through FM radio (Myers 1998, 202).
As Myers notes and as Dr. Benjamin confirms, rural radios like Radio Daande were focused not
only on promoting democracy but also on “assert[ing] rural people’s priorities, languages and
culture in order to counteract years of centralism” (Myers 1998, 202; Benjamin 2015).
The PPD program is notable because it was subject to a “relatively thorough impact assessment”
(Myers 1998, 209). According to an internal NEF report, the PPD was intended to “contribute to
the consolidation of democratic gains, promote the emergence of a civil society and of citizens’
consciousness of their rights and duties and make them capable of resisting infringements and
injustices” (Ibid.).
22
In this campaign, Radio Daande translated and transmitted key information about changes in
Mali’s laws, constitution, and electoral code to its estimated 120,000 listeners in Puelh. 5 In
addition to radio programming the station used other creative communication methods, such as
dramatic skits, 6 spots,7 interviews, 8 and game shows, 9 as well as basic translation and reading, to
explain new concepts of democracy to its listeners (Ibid.). The radio programming was supported
by the dissemination of information about democracy in local languages through other media,
including local theatre, pamphlets, and newspaper articles (Ibid.).
After two years of the PPD effort, NEF engaged in an impact study, which surveyed local
residents to qualitatively gauge the radio programming’s impact on their knowledge of
democratic processes and ideas (Ibid. 210). NEF compared the impact of its programming by
evaluating knowledge levels in villages that had been subject to the program of democratization
with those that had not (Ibid.). Ostensibly villages that were outside of the range of the radio
station—because of the area’s topography—were used as control groups (Ibid.). At the end of
the impact study, NEF concluded that the PPD program had “directly influenced” nearly 52,000
people living in Douentza (Ibid. 209), In response to survey questions several local residents
responded that the radio was their preferred medium for receiving information regarding
democracy and decentralization (Ibid. 210).
NEF reported that in the villages where the PPD program had successfully taught residents about
democracy, both women and men had expressed gratitude about the teachings (Ibid.) NEF also
noted that the radio station had served an important role in facilitating the democratization of
Mali by fielding questions from listeners via mail and in person (Ibid). The number, depth and
5
The programming was also translated into Dogon and Bambara (Myers 1998, 209).
“Mini dramas brought fictional characters together in scenes such as feuds between neighbours, which emphasised
respect for modern justice instead of resorting to ‘tit-for-tat’ violence. Another drama portrayed farmers and forestry
guards in conflict over pruning of trees; this drama reinforced the message that farmers should claim their legitimate
rights rather than submit to the illegal, but all too common, fines by corrupt officials” (Ibid.).
7
“Short ‘spots’ of about two minutes each were used in order to repeat simple pieces of information about voting
procedures and facts such as the length of the presidential mandate” (Ibid.).
8
“Interviews were organized with local members or parliament, judges, council officials and women’s groups to
discuss the implications of decentralisation at the commune level” (Ibid., 209–10).
9
“Recordings were broadcast of public ‘game-shows’ (jeux publics) in which whole villages would participate in
solving a riddle designed to make some deeper point about, for instance, the problem of domestic violence or the
importance of women’s literacy. These shows, with their musical interval and displays of traditional eloquence are
meant not only to make a serious point but to offer a high degree of entertainment” (Ibid., 210).
6
23
success of the studies summarized here lead us to believe the survey method is a reasonable
means of assessing the impact of the album.
More recently, Bleck and Michelitch developed a detailed questionnaire on household and
individual radio usage for use in rural northern Mali (Bleck 2011, 24–39). The study aimed to
assess women’s access to radio and its effect on their participation (or lack thereof) in local
democratic processes (Ibid.). Using groups of five villages, the researchers planned to compare
the differences between the attitudinal and behavioral changes in those who did not have access
to radio signals with those who had some access (only to national public radio), and those who
had access to the program directed at improving women’s radio access (Bleck 2011, 15).
As a result of the conflict in Mali, Professors Bleck and Michelitch had to adjust their research
plan, surveying over 600 individuals on how the “radio had impacted people’s political views in
a time of incredible upheaval” (Hendricksen 2013). While their data is not yet complete,
Professors Bleck and Michelitich have reported “with confidence that people given access to
radios do acquire and share new information” (Ibid.). Because we believe a survey constitutes
the best method of assessing the album’s impact in Douentza, we have developed several key
considerations for our specific intervention discussed below in Section V.
V. Considerations in Survey Design
A. The Album as Entertainment-Education
This section seeks to classify the album as an “Entertainment-Education” intervention; here, we
will utilize this classification to justify our survey method. Communication interventions in the
developing world are commonly used for distribution of education and messages. In an attempt
to evaluate the effectiveness of health communication campaigns in developing nations’ health
education disbursement, researchers have shown that “communication interventions are
necessary to bring about and maintain large-scale behavior and social change” (Sood 2014, 67).
Entertainment-Education is a specific strategy used in development communication and is based
on the principle that there need not be a dichotomy between entertainment and education.
24
According to HIV/AIDS communication researchers Singhal and Rogers, “EntertainmentEducation is the process of purposely designing and implementing a media message to both
entertain and educate, in order to increase audience members’ knowledge about an issue, create
favorable attitudes, shift social norms, and change the overt behavior of individuals and
communities” (Singhal and Rogers 2003, 289). The Troupe de Haire combines these two effects
in its educational album, which not only entertains local residents but also “contribute[s] to the
process of directed social change” in Douentza, at both the individual and community level
(Ibid.).
The two levels of engagement—individual and community—in the Entertainment-Education
strategy are meaningful in relation to the Troupe de Haire album. The first level involves
influencing audience awareness, attitudes, and behaviors toward a socially desirable end. This is
important on an individual level, as listeners hear the songs, which may potentially increase their
awareness of the issue, begin to shift or change their perspective on the issue, and ultimately may
alter their behavior or practice. This engagement is structured in the context of the second point,
which states that the strategy “help create the necessary conditions for social change at the group
or system level” (Singhal and Rogers 2003, 290). For example, community members who hear
the album’s song on sanitation may be moved to work together to improve local sanitation
practices, such as water and sewer services, to promote and maintain the greater health of the
community at large.
Understanding Entertainment-Education strategy from this bilateral perspective highlights two
critical aspects of directed social change: educating people on an individual level is important,
but the environment around these individuals is vital to creating more meaningful and consistent
change within the larger community. We fully recognize these individuals are not living in a
vacuum, but rather, interact with those around them and their environments. Individuals are not
only exposed to the knowledge of those around them but they are also affected by simultaneous
interventions in their area. In the case of this album that could be programs such as the National
Program of the Fight Against Incision (PNLE) and the National Program Against Child Marriage
(APDF) that utilize education in schools, written and poster campaigns (Ongoiba 2015). By
25
supporting existing awareness, attitudes, and changes, the album as a communication
intervention has the potential to be even more effective.
B. Radio Daande and the Flow of Information
Despite the many benefits of media campaigns, however, a disadvantage involves the “oftcriticized one-way flow of information” (Naugle 2014, 191). While this is a valid concern, Radio
Daande provides a station that includes interview segments as well as providing listeners the
opportunity to call-in to ask questions or comment. The radio station is also a gathering place for
the Douentza community, allowing for a great deal of dialogue and interaction to take place at
the radio station itself (Benjamin 2015; Tambouré 2015).
This interaction is reflected in the following summary of Bamako’s radio popularization in
March of 1991:
The switchboards are deluged with phone calls. For lack of a phone, listeners show up at
the studios, in the corridor or the courtyard, to continue—in the flesh—debates begun on
air. Others . . . stay glued to their transistors to follow their favorite programmes. Press
summaries are translated from French (which no one understood) into local languages. At
last! (Myers 1998, 204).
The increased dissemination of information, and specifically the two-way flow of this
information, provides support for the importance of radio programming in the rural community
of Douentza.
C. The Potential Drawbacks of Using a Survey Method
In spite of the positivity of radio based education programs like those described above, there are
still other factors that make assessment of the impact of the album’s radio play in Douentza
difficult (Myers 2009, 31–32). For example, while radio is a popular media option in Mali, it is
not necessarily accessible to everyone. In poverty-stricken areas like Douentza, radios can be
prohibitively expensive for some, thereby limiting access to the very programming we seek to
assess.
In addition, it is not clear whether Puelh-speaking women in the Douentza region have readily
available access to local radio. While there may not be significant barriers for women in
26
Douentza to listen to local radio programs (Benjamin 2015), there is some suspicion that because
of social barriers—perhaps viewing women’s work and radio listening as incompatible
activities—less than half of women in Mali are able to listen to a radio at will (Tower 2008, 32).
Men may also prioritize scant radio and energy resources for their own listening over women
(Bleck 2011, 2).
In fact, Bocoum Koumbourou Koita, the animatrice responsible for Radio Daande’s women’s
programming in Douentza, has said that “Unfortunately, women are busy and it’s a problem for
them to find the time to listen. Some men think it a waste of time for women to listen to the
radio. We broadcast women’s programs in the morning so that they can listen undisturbed while
the men are in the fields.” (Myers 2009, 32).
While we may find the album’s impact is affected by both of these factors they do not dissuade
us from proposing a survey method for evaluating the album. The way the survey is designed
these limitations in access to the album could be qualitatively captured and analyzed.
D. The Importance of Theory
However, the problem still remains that assessment of the effectiveness and success of these
campaigns is challenging—there are limited opportunities for objective assessment of changes in
practice or for listeners to demonstrate their knowledge of the relevant material. Sood et al. write
that “communication programmes are more likely to be successful if and when they are based on
sound theoretical principles” (Sood 2014, 81).
These theoretical principles are further explored by Naugle et al, who assessed and coded the 111
communication campaigns based on a variety of factors, one of which was use of theory. In their
review of reproductive health mass media campaigns, 78 percent mentioned a theoretical
framework. For diarrheal disease campaigns, this inclusion of theoretical frameworks rose to 80
percent. 75 percent of campaigns relating to immunizations mentioned behavior change theories
(Naugle 2014, 196). Across the interventions, the recurring theories included: Theory of
Reasoned Action, Health Belief Model, Entertainment-Education, Social Cognitive Theory, and
Applied Behavioral Analysis (Ibid).
27
E. The Health Belief Model
Based on the Sood study, health communication programs rooted in specific theories are more
effective. We therefore propose our survey will track with the health belief model. While the
album was not created with the intention of following a health communication theory, the Health
Belief Model (HBM) can be readily applied to NAHP’s commissioned album. HBM is a
framework that focuses on prevention and detection.
HBM involves four constructs that center on an individual’s perceptions of specific health
behaviors (Cameron 2014). The model begins with an individual’s perceived susceptibility to a
specific disease or condition, or his or her risk of contracting or experiencing the same. The
model also assesses an individual’s belief as to the “perceived seriousness” of the severity of a
given condition. Based on the perceived susceptibility and seriousness of a specific condition, an
individual may consider the perceived benefits and barriers of a specific course of action.
The benefits involve what an individual believes about the efficacy of a recommended response
and the barriers include the negative aspects or “costs” of this response, which may be tangible
or psychological. Based on an individual’s belief regarding his or her susceptibility to or
seriousness of a disease and the benefits of and barriers to a given cause of action, he or she will
require a “cue to action” in order to take a step toward changing a given health behavior. The
album’s lyrics discuss the perceptions of susceptibility as well as seriousness and call (or “cue”)
individuals to act with regard to their risk for a given health issue; this “cue” is key and is
supported with explicit instructions on what to do or where to go for each specific issue. As we
stated above, this is not the first time listeners have heard the information, it may be the first time
they have been “cued to action” in song. For these reasons, the HBM is an ideal framework for
creating evaluation tools for the effectiveness of the album in Douentza.
Individuals’ beliefs regarding their unique barriers related to a specific cause of action to address
or avoid a health problem comprise one of the HBM’s most important components. In fact, in
their meta-analysis of 29 HBM-related investigations, Janz and Becker determined that perceived
barriers were the most powerful construct of the model’s dimensions across various study
designs and behaviors, having the strongest relationship with behavior change (Janz 1984, 1).
28
This is important to consider in assessing the album and its impact, as the number and degree of
perceived barriers may negatively influence attitudes and potential behavioral outcomes.
Each of the Troupe de Haire songs includes specific instructions for listeners; this specificity
may help to manage perceived barriers and also serve as a call to action, however, gathering
information from listeners to assess the role of barriers is necessary. The barriers may be
psychological (e.g. women believe they must have FGM performed on their daughters because
of traditions and religion), structural (e.g. health clinic has limited hours), or financial (e.g. the
individual truly cannot afford treatment or, in the case of girls’ education, the family cannot
afford to have the child not work at home) (Witte 1998, 348). The perceived barriers may
impact the degree to which the songs influence the motivations and behavior of the radio
listeners.
The HBM has been applied to related studies of media health information campaigns in other
under developed countries. One study looking at the effect of media campaigns on family
planning in Bamako, Mali used baseline and post-intervention surveys—that included constructs
of the HBM—to determine the exposure to and agreement with the media campaigns used in that
community (Baron 1998, 309). Their pre and post-intervention survey data showed a positive
and significant increase in the use of contraception among targeted listeners following the media
campaign (Ibid). Their success using radio, along with a variety of other media tools, bodes well
for our similar health communication intervention.
F. Effect of Multiple Communication Interventions
It is notable that many studies have found that health communication campaigns in low income
countries are more effective when multiple interventions are used to transmit messages to a
target audience, essentially showing a dose-response effect (Bessinger 2004).
One of these studies looked specifically at the impact of various channels of communication on
health insurance enrollment in Burkina Faso. Analysis from this study found that the only
significant predictor of enrollment was the intensity of exposure to the campaign, and those
analyzed who had access to two or more channels of information were 6.7–7.8 times more likely
to enroll (Cofie 2013, 7).
29
Yet the study also noted that when community leaders were involved alongside the
communication campaign, there was an increased impact from messages among local residents
(Cofie 2013, 9). The combination of this study’s documented dose-response effect along with the
positive effect of community leaders’ involvement, greatly influenced our suggestions for the
album project in Douentza. Our ideas for additional communication interventions will be
discussed in our post-survey suggestions section in Section VI C. Suggestions for PostQualitative Analysis.
VI. The Survey
A. Survey Design
The survey we have designed for NAHP assesses how the album impacted the citizens of the
cercle of Douentza’s residents’ knowledge of the six topics discussed on NAHP’s health and
education album. Using the HBM as a guiding framework, we believe this qualitative survey will
accurately record individuals’ responses to the album and categorize their self-reports regarding
their perceptions of susceptibility, benefits, and perceived barriers related to issues addressed in
the songs.
As discussed above, effectively measuring change in behavior is difficult—barring the use of a
randomized control trial, which is not appropriate given the circumstances here and our current
resource constraints. 10 In collecting data regarding individuals’ change in perceptions, we will
gain insight into whether the album may have had behavioral effects among listeners. Even if we
do not find evidence of behavior changes among listeners we may nevertheless understand how
to change the album or its delivery mechanisms to more effectively influence future audiences,
either in Mali or other locations.
The survey (provided in Appendix A. The Survey) consists of a series of demographic questions
for individual survey respondents, including their gender, age and education level as well as the
10
This was confirmed by NEF’s new Director of Evaluation and Assessment, “A survey like you propose is the only
way I see to measure this” (Kata 2015).
30
number and gender of their children. The survey also asks for the primary language(s) spoken in
the home. Following these introductory questions, the survey asks questions regarding the six
topics that appear on the album. The questions are designed to evaluate perceived perceptions,
perceived seriousness, perceived susceptibility, perceived barriers, and whether or not the cue to
action was understood for each of the topics.
Many of the survey questions are structured, open-response questions; this will allow individuals
to offer lengthy and insightful answers where they have the energy and desire to do so. We hope
to use the insights provided by individuals in these open-ended questions to guide further
research and identify effects of the album that may not have been explicitly considered in
preparing this survey. We also may use these answers to guide further research of a more
quantitative nature (DiCola 2015). At the end of the survey, participants would then be asked a
series of question regarding radio use and about the album itself.
B. Expert Advice Considered in Our Survey Design
It is important to note that our current survey consists of more than 30 questions. It was
suggested that we only use 30 in order to generate the most detailed responses possible (Kata
2015). We had originally planned to solicit answers to two versions of the same survey. We
thought that each version of the survey would only address four topics, keeping the surveys
relatively short and thereby avoiding participant fatigue and maximizing the quality of responses
provided by individuals in the survey.
However, at the suggestion of both Mr. Tambouré and Mr. Kata, we have decided that it would
be best to survey our participants on each of the six topics in order to fully capture each
participant’s understanding and perceptions of each song. Currently, we are working on
translating our survey (below in Appendix A. The Survey) into French to send to both Mr.
Tambouré and Mr. Kata. We would not only like to have them evaluate the cultural
appropriateness of each question, but we would also like them to advise us on what questions
may not be relevant or useful, enabling us to reduce the number of survey questions to the
recommended thirty questions.
31
Our move away from our original conception of the survey is reflective of our belief in the PONI
model. It is important to leverage our partners’ expertise and local knowledge. Our already deep
confidence in our partners is bolstered by the fact that NEF has already undertaken the type of
assessment we propose in the aforementioned PPD survey.
Furthermore, based on suggestions from Mr. Tambouré and Mr. Kata, we propose surveying ten
villages for this survey. Five of which will be comprised of the villages from which the former
cutters in the microfinance program are located, therefore providing us a comparison group in
particular for the questions regarding FGM. The other five villages will be chosen with the help
of NEF, in particular Mr. Kata and Mr. Tambouré.
Within each village, we will be surveying four different types of subjects: 5 females between the
ages of 18–40, 5 males between the ages of 18–40, 5 females between 40–60, and 5 males
between 40–60. Like many of our survey recommendations, we came to this decision based on
the suggestions of our partner organizations. NEF program coordinator Aly Bocoum stated that
“[those 40–60 are] very important because they make decisions for the family” (Bocoum 2015).
Mr. Kata also pointed out that those in this older age group are “more sedentary and listen to
more radio” (Kata 2015).
Though the sample sizes within the villages may seem small, saturation in interview responses is
typically found after 12 people are surveyed (Cameron 2015). In the unlikely situation that
saturation was not found among the responses of the 20 people per village, re-evaluation of the
question structure, sample size, and group composition would be necessary.
In terms of recruitment, it was suggested by Mr. Kata to use village chiefs as a means of finding
appropriate people to survey. While neither he nor Mr. Tambouré believe we should use the
chiefs themselves as survey participants, using a village chief will not only help us identify the
appropriate age and language groups 11 for our survey but will also bolster our surveyors’
credibility among the villagers (Tambouré 2015).
11
We will only be utilizing Peuhl-speakers in NAHP’s forthcoming survey.
32
Another important suggestion is the use of neutral yet credible surveyors. Credible community
leaders will be necessary for ensuring participation in the survey, but if surveyors with a vested
interest or opinion 12 are used this will bias results with participants likely skewing their
responses to what they think the surveyor wants to hear. Mr. Tambouré went so far as to suggest
that the surveyors should not be people directly associated with NEF for fear that they would
skew responses as well (Tambouré 2015). We share Mr. Tambouré’s contention that
participating individuals must be questioned alone and in relatively quick succession to avoid
issues with word-of-mouth biasing subsequent participants’ responses. We plan to establish a
specific training regimen for those conducting the surveys once the survey is jointly approved by
NAHP and Mr. Tambouré and Mr. Kata.
We also suggest discussing the survey with Dr. Kenzie Cameron, a public health researcher at
Northwestern University, who specializes in the evaluation of health communication camps in
emerging economies. It might also be useful to seek her advice in training the surveyors to
ensure the efficacy and accuracy of the survey assessment (Galvin 2015).
C. Suggestions for Post-Qualitative Analysis
While it is difficult to assess behavioral changes using self-reported measures, if the qualitative
data collected using this survey suggests that the album created a change in perceptions, then the
next step will be to form a quantitative project. Due to the fact that a quantitative project would
require more time and resources as well as being difficult to design to allow for open-ended
questions, we believe a qualitative project makes the most sense at this early stage of the album’s
evaluation process (DiCola 2015).
It is likely that the qualitative data will direct us towards new ideas and developments on how to
improve the existing album, with respect to its lyrics, the manner in which the album is broadcast
on the radio, or the amount of airtime it receives during a station’s broadcast hours. A
12
For example, Ms. Laya Ongoiba is the community leader responsible for the alternative-FGM livelihood
initiative made possible by NAHP’s microfinance program in the Douentza. As such, community members are
likely aware she is opposed to FGM. As a result, if she were to serve as a surveyor, individual respondents might be
more likely to provide answers they believed she was looking for rather than honest responses. We hope to enroll
neutral surveyors to elicit the most honest responses possible for individuals participating in the survey.
33
quantitative study will allow us to more accurately assess tangible behavioral changes as a result
of the album and the need for additional communication interventions.
Once the qualitative analysis has been done and improvements have been implemented,
designing a quantitative study modeled after one performed by Reinsma et al. would be ideal.
Reinsma, et al. developed an Entertainment-Education audio program and post-listening
discussion series for the promotion of exclusive breastfeeding, one of the topics included in the
album by Troupe de Haire (Reinsma 2015, 3). They performed a qualitative study by having a
control group listen to a separate audio program while the experimental group listened to the
“Bobbi Be Best” (in English, “Breast is Best”) series and participate in post-listening
discussions. Both groups completed a questionnaire at the beginning of the 4-week program and
at the end to compare their changes in knowledge, misconceptions, perceived barriers, selfefficacy, and intentions regarding exclusive breastfeeding.
While our design would be slightly different because this album has been broadcast on the radio
for nearly one year, the experimental group would be the same in the sense that they would have
guided discussions based on the topics (and lyrics) of the album. Including this additional
intervention (in-person information and discussion) would provide us with a method to better
estimate changes in intentions and behaviors and also allow us the opportunity to expose
listeners to the educational information again, thereby increasing the “dose-response effect”
(discussed above with relation to the study by Cofie et al.). The overarching analysis by Sood et
al. stated “[t]he more communication, the better the impact” (Sood 2014, 81).
With the support of positive results from this experimental design, future suggestions would
include incorporating the songs from the album as well as discussions regarding the songs and
topics into the primary school and secondary (nursing) school curriculum. Other ideas for
additional communication platforms include concerts or public performances, skits, women’s
groups discussion groups, as well as forming formal guided discussions beyond the classroom
for local leaders such as health care workers and religious heads.
34
An alternative method of qualitative analysis would be to add a control arm to the existing study.
The control arm could be non-Peulh speakers or those in the region out of the broadcast area.
Some areas near Douentza do not get reception for Radio Daande for topographic reasons
(Myers 1998, 210). In comparing their responses to those of the original people surveyed, coded
data could be extracted from the responses and used in a statistical analysis to determine if there
was a significant difference between those who had access to and understood the album’s
perceptions and behavioral changes and those who did not.
Conclusion
Following months of research and several days of interviews with experts and NEF staff in
Douentza, Mali, our team has composed this intervention evaluation with a two-part goal:
first, to assess the album’s impact on community members’ knowledge and perception of the six
topics, and secondly, to evaluate the effectiveness of this type of public health album as a
teaching tool, both in Douentza and in other NAHP locations. We have proposed that a
qualitative survey is the best method for NAHP to evaluate the album’s impact at this time. With
careful planning, we posit that a successful qualitative survey effort will inform potential
quantitative analysis of the album’s impact on residents’ knowledge of health and education.
These impact assessments will allow NAHP to understand the implications of the album
intervention and assess the potential for horizontal or vertical expansion of these efforts in Mali
and beyond.
35
Appendices
A. The Survey
1. Demographic Questions:
1. Gender:
2. Age:
3. Education level:
4. # and gender of children:
5. What is your primary language at home?
a. If not Peuhl: Do you speak or understand any Peuhl?
2. Malaria:
1. Tell me what you know about malaria?
2. Where do you get your information about malaria?
3. Do you think you are at risk for malaria?
a. Why or why not?
4. What can you do to prevent malaria in yourself/your children?
a. Listen specifically for: bednets, cleanliness, free treatment for pregnant women
and children under 5, medicating bednets, and other practices
5. What makes it difficult to prevent malaria for yourself/your children?
3. HIV/AIDS:
1. Tell me what you know about HIV/AIDS?
2. Where do you get your information about HIV/AIDS?
3. Do you think you are at risk for HIV/AIDS?
a. Why or why not?
4. What can you do to prevent HIV/AIDS in yourself/your children?
a. Listen specifically for: syringes, razor blades, sexual relations/condoms
5. What makes it difficult to prevent HIV/AIDS for yourself/your children?
4. FGM:
1. Tell me what you know about FGM?
2. What are the risks of FGM?
a. Listen specifically for: death, fistula, complications in childbirth, sterility,
Caesarean section/surgery during childbirth
3. What do others say about FGM?
a. Listen specifically for: religion, family, government, etc.
4. Do you feel you have control over you/your daughter getting FGM?
36
5. Education:
1. How do you feel about education for boys?
2. How do you feel about education for girls?
3. If applicable:
a. Do you feel your daughter(s) has/have access to education?
b. What makes access to education for your daughter(s) difficult?
6. Breastfeeding:
1. Tell me what you know about breastfeeding?
2. Where do you get your information about breastfeeding?
3. If applicable:
a. Do you feel you are in control of whether you can breastfeed your child?
b. What makes it difficult to breastfeed your children?
4. What do you do if your baby is sick?
a. Listen specifically for: go to health center
7. Hygiene and Sanitation:
1. Tell me what you know about hygiene and sanitation?
2. Where do you get your information about hygiene and sanitation?
3. How can good hygiene and sanitation preserve your health?
4. What can good hygiene and sanitation prevent?
a. Listen specifically for: Diarrhea, malaria, bilharzia, stomachache
5. What makes it difficult to practice good hygiene and sanitation?
a. Listen specifically for: Lack of access to clean water, gutters, unclean
environment
8. Radio Questions
1. Do you own a radio?
2. Who in your home listens to the radio?
3. Do you listen to the radio every day?
a. If yes: Less than an hour a day?
i. 1–3 hours a day?
ii. 3–5 hours a day?
iii. 5+ a day?
b. If no: Every other day?
i. Once per week?
9. Album Questions:
1. Have you heard songs on the radio discussing the health topics we asked you about?
2. Did you remember any specific instructions or information from the songs on the album?
3. Did you make any changes after hearing the songs on the album?
37
B. The Album and its Lyrics (translated from French)
1. Malaria
(refrain)
Dear Parents, listen to this message
Cleanliness is the mother of human health
Listen to better understand this message
We cleanse our environment to stop mosquitoes from having places to live and multiply
The government of Mali has taken steps to confront malaria
Pregnant women and children under 5 are treated for free
Cleanliness is the mother of human health
We cleanse our environment to stop mosquitoes from having places to live and multiply
(Messenger)
You have told the truth
Cleanliness is the mother of human health, we cleanse our environment to stop
mosquitoes from having places to live and multiply
We must avoid pollution of our streets by latrine water, which is the ideal place for the
growth of malarial mosquitoes
We sleep under medicated bednets
We regularly put medication on the bednets
In case of malaria we quickly send the patient to our closest health centers
Parents here is the message that these girls have wanted you to deliver in their songs with
this advice
We can avoid malaria
(refrain)
2. AIDS
(refrain)
AIDS is a danger more dangerous than fire
Men, women: AIDS is what we must avoid at all cost
Black people can do nothing about this dangerous illness
Westerners can do nothing about this dangerous illness
(Messenger)
We hear what these girls have just said
AIDS is among us, it is more dangerous than fire; one catches it by:
-sexual relations between a person with AIDS and one who doesn’t have it
-a syringe used by someone with AIDS and another who doesn’t have it
38
-razor blades of someone with AIDS and another who doesn’t have it
To avoid it
We use condoms in the event of sexual relations
Fidelity
One syringe for one individual
One razor blade for one individual
Better safe than sorry
What’s more, get tested to know your health
If you’re infected with AIDS you can go to the pharmacy for free treatment and you’ll
live as long as God wishes
(refrain)
3. No to Female Genital Cutting
Parents listen well to this message, it will serve you well
“No” to FGM is a decision from the highest authorities of Mali
Health works proposed the order to the government and the government agreed
A non-circumcised girl as a complete girl, who carries herself in a perfect state of health
Cutting a girl can cause her death
Cutting a girl can cause her to have a fistula
Cutting a girl can cause complications when she has a baby
Cutting a girl can make her sterile
Cutting a girl makes surgery necessary when she is having a baby
For all of these reasons health works asked the state to take a decision against the practice
of FGM that was accepted by the government of Mali
Parents listen to this message, it will serve you well
“No” to FGM is a decision from the highest authorities of Mali
Health works proposed the order to the government and the government agreed
A non-circumcised girl as a complete girl, who carries herself in a perfect state of health
A circumcised girl runs many risks that we have just listed.
4. Girls’ Education
Parents, we enroll our girls in school for the development of the country
Mothers, we enroll our girls in school to prepare them for the future
An uneducated girl is a loss for the country
(Messenger)
You have spoken the sad truth
39
The education of girls has been neglected by us; we must confront it
An educated girl will serve her family in the village and the entire country
To teach a girl is like teaching the entire family, the entire village, the entire country, and
the entire world
Fathers, mothers, we invite you to send all our little sisters to school for their future
Parents, we enroll our girls in school for the development of the country
Mothers, we enroll our girls in school to prepare them for the future
An uneducated girl is a loss for the country
Fathers, mothers, we invite you to send all our little sisters to school for their future
5. Breastfeeding
Parents, listen to this message because we are the messengers of the midwives
This message is especially for women, they must listen to better understand
A newborn: don’t give him water or broth until six months
Don’t give him animal milk either
Don’t make him drink from a bottle
Listen and understand what you must do for a newborn
He must nurse his mother for six months
Breast milk is the best milk for a newborn
If he becomes sick you must bring him to the closest health center
Only health workers know the best treatment for a newborn
(refrain)
6. Hygiene and Sanitation
Parents, dirt is very bad for our health
We must wash our streets, our houses, and clean out our gutters
We men, we women must pitch in to clean all of our surroundings for our health and that
of our children
Moreover we must drink clean water
We avoid drinking stagnant water from ponds and streams for our health
(Messenger)
We hear what the children say in their chant
Hygiene and sanitation are the only means of preserving our health
Mayors, chiefs of villages, advisors, committees of youth and women let us rise and pitch
in to clean our environment
We clean our houses, our streets, we unclog our gutters
40
What’s more, we avoid drinking water from ponds and streams, the source of many
illnesses like diarrhea, bilharzia, and stomachache
We avoid growing millet, gombo, and peanut in our houses because these places cause
the arrival of mosquitoes, the source of malaria
(refrain)
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