Examining Media Habits: implications for health promotion programs among the Toposa in Southern Sudan

Article Outline

• Summary
• 1. Introduction
• 2. Materials & Methods
  • 2.1. Setting
  • 2.2. Purpose of Study
  • 2.3. Sampling Frame
  • 2.4. Questionnaire and Data Collection
  • 2.5. Statistical Analysis
• 3. Results
  • 3.1. Study Population
  • 3.2. Access and Use of Contemporary Forms of Media
  • 3.3. Traditional Forms of Entertainment and Communication
• 4. Discussion
• Authors’ contributions
• Funding
• Conflicts of Interest
• Ethical Clearance
• Acknowledgements
• References
• Copyright

Summary 

Dissemination of appropriate health education messages is essential to any health promotion campaign. This cross-sectional study examined media ownership, access and media preferences by target groups in Kapoeta South County, Southern Sudan. The target groups were segmented into household heads (n=368); women with children under five years (n=580); and youth 11-16 years old (n=349). Interviewees were selected at random from 49 villages. Overall, a small portion owned radios (6.8%) and television sets (0.2%); more had access to radio (27.1%), listened to cassettes (50.8%), and had access to television and movies (21.4%). The majority were interested in programs developed in the vernacular (89.0%). A very low literacy rate (1.3%) and difficulty in understanding signage (29.7%) posed potential obstacles for use of print media as a primary source of health communication. Heads of household were more likely to own radios (P<0.001), watch TV outside of the home (P=0.034), and see posters (P=0.038) than other groups. Traditional entertainment was attended by 94.4% of respondents. Information from chiefs (61.5%) and elders (51.5%) was considered trustworthy by the majority of respondents. This research highlights the utility in understanding media access, habits and preferences of community members when designing a health promotion campaign.

Keywords: Communication, Health Education, Media, Media-habits, Southern Sudan

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1. Introduction 

Health communication messages are essential for promoting behavior change among individuals and groups. If successfully produced, they can increase knowledge and awareness of a health problem, influence perceptions which may lead to behavior change, increase demand for health services, and inform decision-making.¹, ², ³, ⁴

Audience segmentation is the process of dividing the audience into homogeneous groups that have one or several similar characteristics that can be addressed in a communication campaign.⁵ Audience segmentation allows for the creation of health messages that are designed to reach specific groups of individuals, ultimately making the messages more relevant and providing the basis for selection of media, community, organizational or interpersonal channels most appropriate for reaching the targeted populations.⁶, ⁷, ⁸, ⁹ However, target population preferences for, and access to, media must also be considered in order to effectively segment audiences. Therefore, in addition to identifying the purpose and content of the health message, formative research should be conducted to identify the most appropriate channels of communication, based on availability and preferences of the intended audience.¹⁰

A number of programs in Africa have successfully used radio, video, drama and other forms of mass media to increase knowledge and promote behavior change.¹⁰, ¹¹, ¹², ¹³, ¹⁴ In Nigeria, access to television was correlated with increased uptake of family planning;¹¹ in rural Kenya, access to various types of mass media had an impact on female reproductive behaviours;¹⁴ and in West Africa, radio, film, billboards, and discussion groups were found to increase knowledge of HIV among truckers and other mobile people.¹³

A better understanding of mass media access and preferences in post-conflict Southern Sudan would aid the development of communications strategies designed to increase knowledge and promote behavior change. Areas that lack access to basic necessities such as clean water and sanitation facilities are often burdened with numerous communicable diseases; Southern Sudan, emerging from a 22-year civil war, is no exception. Recent reports from the Government of South Sudan Ministry of Health show that cholera is endemic, vector-borne diseases such as malaria and visceral leishmaniasis cause significant morbidity and mortality, and the prevalence of trachoma is as high as 80% in some counties.¹⁵

State and county health departments are emerging, but suffer from a lack of qualified personnel and necessary support (i.e. monetary resources and trained staff) to provide health services. Given the environment, with poor access to curative services, disease control programs may be able to achieve substantial reductions in preventable infections through mass media campaigns. Accordingly, this study aimed to identify:

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2. Materials & Methods 

2.1. Setting 

The study was conducted in Kapoeta South County, Eastern Equatoria State, Southern Sudan (see Figure 1) during May and June 2007. The county has an estimated population of 39,846 and is predominantly rural, although all 330 villages are located within a 30km radius of a semi-urban area, Kapoeta Town. The resettlement of refugees to Kapoeta Town has diversified the population, whilst beyond the town the population is predominately Toposa. The Toposa practice a form of agro-pastoralism tied to seasonal rainfall. Typical of Southern Sudan, Kapoeta South has minimal infrastructure and lacks access to electricity, safe water, and sanitation facilities.

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• Figure 1. 

  Map of southern Sudan showing study site – Kapoeta South County.

• The lines on this map represent approximate border lines for which there may not yet be full agreement.

2.2. Purpose of Study 

The study aimed to identify the types of media people access, how they receive information, their preferred channels of receiving information, and to determine how each channel is accepted. Contemporary forms of mass media communication assessed included radio, tape cassettes, television, movies, print media, and signage; traditional forms of communication were also examined, including traditional entertainment (singing, dancing, drama, and storytelling), and systems for receiving information through social and political structures (elders, chiefs, civil service workers, and families). The study protocol was approved by the Emory University Institutional Review Board.

2.3. Sampling Frame 

The population was segmented into three distinct groups 1) heads of household 2) women with children under five years old and 3) youth aged 11-16 years (both young men and women). These segments were selected based on the individual's role in decision-making and for targeting disease control and prevention activities at the household level. Individuals belonging to more than one group (e.g. women heads of household with children under five years old) were allowed to self-identify with the group they felt best represented them.

Village population information was not available making it impossible to select sampling units by probability proportional to size. Additionally, differential mortality during the war and polygamy suggested that the sex ratio would not be 1:1. Therefore a simple random sample of villages was used; it was assumed that adult heads of household (typically men) would form the smallest segment of the sample population. In the absence of any reliable background data on media habits, it was estimated that a sample of at least 350 from each segment would be needed. Random numbers were used to list the 330 villages in random order; each village was visited sequentially until the 350 household heads had been interviewed. No villages were excluded from the sampling frame and a maximum of 30 eligible participants were interviewed per village. All eligible persons were interviewed. In villages with 30 or fewer eligible participants (estimated at five or fewer households), all those eligible were interviewed. In villages which had more than 30 eligible community members, a map was drawn and the households numbered. Five households were selected for participation using computer-generated random numbers. If there were no eligible participants in a selected household, the next nearest household was selected. Field work was scheduled to stop at the end of the day on which the 350th household head was interviewed, which occurred after 49 villages had been visited.

2.4. Questionnaire and Data Collection 

Interviews were conducted in local language by trained and supervised interviewers using a structured questionnaire. The questionnaire was developed in English, translated to Toposa and pre-tested in a non-study community. After modification it was back-translated to English to ensure the original meaning was intact. Demographic and background information, access to contemporary forms of media (radio, cassettes, TV and movies, print media, posters and sign boards) and to traditional forms of communication (singing and word-of-mouth news sharing), as well as attitudes toward each type of media were collected. Identical questionnaires were used for all three segments. Interviewers asked open-ended questions and recorded the most appropriate response using the validated code lists; un-coded responses were recorded verbatim.

2.5. Statistical Analysis 

Survey data were double entered and validated using Epi Data 3.1 (EpiData Association, Odense, Denmark). Initial frequency and descriptive statistics were computed for all measures of interest in SPSS 16.0 (SPSS Inc., Chicago. IL, USA). Chi-square tests were used to examine initial differences among the three groups (heads of household, women with children <5 years of age and youth 11–16 years of age). A confidence level of 95% was accepted as significant. Tukey style multiple comparisons tests were used to identify differences between groups at α=0.05 using SAS version 9.1 (SAS Institute Inc., Cary, NC, USA).¹⁶

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3. Results 

3.1. Study Population 

Background and demographic findings are shown in Table 1. A total of 1297 participants were interviewed: 368 heads of household (28.4%); 580 women with children under five years (44.7%); and 349 youth ages 11-16 (26.9%). Among the youth, 134/349 (38.5%) were young men. Most participants, 1243/1297 (95.8%), had either no education or some non-formal education; none of the youth and only 4/948 (0.4%) of the adults had any secondary school education. The majority of the adults 909/948 (95.9%) were subsistence farmers, cattle herders or home-makers, whilst 28 (3.0%) held paid positions. Virtually all participants (99.2%) were native Toposas from Kapoeta South County (98.2%).

Table 1. Background characteristics of Heads of Households, Women with children<5 years and Youth aged 11-16 who participated in the study^*.

Background Characteristic	All Participants		Head of Household		Women with children<5 years		Youth aged 11–16
	n=1297	%	n=368	%	n=580	%	n=349	%
Gender
Male	453/1297	34.9	318/368	86.4	N/A	N/A	134/349	38.5
Female	844/1297	65.1	50/368	13.6	580/580	100	214/349	61.5
Education
No Education	774/1296	59.7	205/368	55.7	334/579	57.7	235/349	67.3
Some Primary	49/1296	3.8	13/368	3.5	13/579	2.2	23/349	6.6
Secondary +	4/1296	0.4	3/368	0.8	1/579	0.2	0/349	0.0
Non-Formal	469/1296	36.2	147/368	39.9	231/579	39.9	91/349	30.7
Religion
Christian	1112/1293	86.0	332/367	90.5	512/578	88.6	268/348	77.0
Muslim	1/1293	0.1	1/367	0.3	0/578	0.0	0/348	0.0
Atheist/Traditional	180/1293	13.9	34/367	9.3	66/578	11.4	80/348	23.0
Occupation
Youth	173/1294	13.4	N/A	N/A	N/A	N/A	173/348	49.7
Student	5/1294	1.4	0/367	0.0	0/579	0.0	5/348	1.4
Household Work	233/1294	18.0	9/367	3.9	223/579	38.5	63/348	38.5
Cattle Herder	333/1294	25.7	236/367	64.3	1/579	0.2	96/348	27.6
Subsistence Farmer	503/1294	38.9	91/367	24.8	349/579	60.3	63/348	18.1
Trade or employed	33/1294	1.6	23/367	6.3	5/579	0.9	5/348	1.5
Ethnicity
Toposa	1284/1295	99.2	366/368	99.5	570/578	98.6	348/349	99.7
Other	11/1295	0.8	2/368	0.5	8/578	1.4	1/349	0.3
Nativity
Kapoeta South County	1273/1296	98.2	363/368	98.6	562/579	97.1	348/349	99.7
Other	23/1296	0.8	5/368	1.4	17/579	2.9	1/349	0.3

3.2. Access and Use of Contemporary Forms of Media 

As presented in Table 2 6.8% of the participants owned a radio; statistically significant differences across segments were found regarding radio ownership: heads of household 12.5%, women 4.8% and youth 14.0%. Despite low ownership, over a quarter of the respondents (27.1%) reported listening to the radio and just over half listened to cassettes (50.8%). There were no differences between segments in the proportions reporting radio and cassette listenership. Not shown in the table, the majority, 307/345 (89.0%), of participants who reported listening to the radio preferred programming in their local language, were likely to listen in both the morning 142/349 (40.7%) and evening 265/349 (75.9%), and preferred to listen at home 148/346 (42.8%) or at a friend's home 142/346 (41.0%). Additionally, 80.8% (278/344) of participants who listened to the radio reported listening at least weekly. When asked what radio stations they listened to participants responded they enjoyed listening to music from any station 118/348 (33.9%) and Radio Sudan 106/348 (30.5%) although, 32.2% (112/348) of respondents did not know the name of the radio stations they listened to.

Table 2. Access to contemporary forms of media by group^*.

Type of Media	All Participants		Head of Household		Women with children <5 years		Youth aged 11–16		P-value**
	n=1297	%	n=368	%	n=580	%	n=349	%
Radio
Own a radio	88/1297	6.8	46/368	12.5	28/579	4.8	14/349	4.0	<0.001
Listen to the radio	351/1297	27.1	112/368	30.4	139/580	24.0	100/349	28.7	0.068
Cassettes
Listen to cassettes	659/1297	50.8	187/368	50.8	284/580	49.0	188/349	53.9	0.351
TV
Own a TV	2/1297	0.2	1/368	0.3	1/580	0.2	0/349	0.0	0.643
Watch TV outside home	278/1297	21.4	96/368	26.1	116/580	20.0	66/349	18.9	0.034
Print/Written
Read in any language	17/1297	1.3	8/368	2.2	4/580	0.7	5/349	1.4	0.143
Look at newspapers	47/1297	3.6	22/368	6.0	16/580	2.8	9/349	2.6	0.017
Ever see posters	593/1297	45.7	181/368	49.2	272/580	46.9	140/349	40.1	0.038
Ever see billboards	428/1297	33.0	118/368	32.1	195/580	33.6	115/349	33.0	0.884

Only two participants reported television ownership, yet 21.4% reported watching television outside of the home. Access to television outside the home was statistically significantly different among the segments: heads of household 26.1%, women 20.0% and youth 18.9%. Yet despite having to leave home to watch, 96.1% (248/258) of the participants who had watched television reported enjoying watching it (not shown in table).

In total 1.3% of participants were able to read in any language and 3.6% had ever looked at newspapers; 58.7% (27/46) of these individuals reported they understood what they were reading (not shown in table). Almost half the respondents, 45.7%, had ever seen posters and one-third, 33.0%, had ever seen billboards. However, only 29.7% (175/589) of the participants reported that they understood the posters (not shown in table). When comparing the differences between groups who had ever seen posters, a greater proportion of heads of household had seen posters than youth q=3.46 (not shown in table).

Access to contemporary forms of media among the youth by gender is shown in Table 3. Young men were more likely to own radios than young women, 9.7% compared to 0.5% (P<0.001), and more likely to listen to them, 35.1% compared to 24.8% (P=0.043). However, a greater number of youth reported listening to cassette tapes (53.9%); no difference in listenership between young men (56.0%) and women (52.3%), P=0.47 was found. Although neither young men nor women owned television sets, both groups reported watching television outside the home (14.9% and 21.5% respectively). Few young men and women were able to read in any language (0.7% and 1.9% respectively) and they had limited access to newspapers (9/349, 2.6%). Signage was seen more frequently by young women than men: posters 48.1% compared to 27.6%, P<0.001; and billboards 39.7% compared to 22.4%, P=0.001.

Table 3. Youth age 11-16 access to contemporary media based on gender^*.

Access to Media	Youth aged 11–16		Male		Female		P-value**
	n=349	%	n=135	%	n=214	%
Radio
Own a radio	14/349	4.0	13/134	9.7	1/214	0.5	<0.001
Listen to the radio	100/349	28.7	47/134	35.1	53/214	24.8	0.043
Cassette
Listen to cassettes	188/349	53.9	75/134	56.0	112/214	52.3	0.47
TV
Own a TV	0/349	0.0		N/A		N/A
Watch TV outside home	66/349	18.9	20/134	14.9	46/214	21.5	0.121
Print/Written
Read in any language	5/349	1.4	1/134	0.7	4/214	1.9	0.653
Look at newspapers	9/349	2.6	3/134	2.2	6/214	2.8	1.0
Ever see posters	140/349	40.1	37/134	27.6	103/214	48.1	<0.001
Ever see billboards	115/349	33.0	30/134	22.4	85/214	39.7	0.001

3.3. Traditional Forms of Entertainment and Communication 

In contrast to contemporary modes of communication, access to, enjoyment of, and acceptability/trust in messages conveyed through traditional means was high across all segments studied, see Table 4. Nearly all participants (94.4%) reported attending traditional entertainment activities and 88.2% of the participants believed the messages portrayed in traditional forms of entertainment were accurate, although heads of household (93.5%) were more likely than the youth (83.4%) and women with children (87.7%) to believe these messages (q=5.82 and 4.07 respectively). Additionally, most participants (1158/1203, 96.3%) said they enjoyed traditional entertainment (not shown in table).

Table 4. Attendance and belief in traditional forms of communication by group^*.

Traditional forms of communication	All Participants		Head of Household		Women with children <5 years		Youth aged 11–16		P-value**
	n=1279	%	n=368	%	n=580	%	n=349	%
Attend traditional Entertainment	1223/1295	94.4	342/368	92.9	556/579	96.0	325/348	93.4	0.078
Believe the message in traditional entertainment	1061/1203	88.2	317/339	93.5	477/544	87.7	267/320	83.4	0.002
Believe someone in the community gives trustworthy information	1155/1290	89.5	336/364	92.3	515/578	89.1	304/348	87.4	0.174

News or messages delivered by word-of-mouth from individuals in the community are considered trustworthy by 89.5% of participants. Trustworthy information was most often considered to be provided by village elders (708/1152, 61.5%) and chiefs (580/1152, 50.3%) (not shown in table). Traditional entertainment was attended by the majority of the youth (93.4%), although attendance was higher among young women than men, 98.1% compared to 85.7% (P<0.001) (see Table 5). Both young men and women reported that they believed the messages delivered in traditional entertainment (85.5% and 82.3% respectively).

Table 5. Youth age 11–16 attendance and belief in traditional forms of communication based on gender^*.

Traditional forms of communication	Youth aged 11-16		Male		Female		P-value**
	n=349	%	n=135	%	n=214	%
Attend traditional entertainment	325/348	93.4	114/133	85.7	210/214	98.1	<0.001
Believe the message in traditional entertainment	267/320	83.4	94/110	85.5	172/209	82.3	0.478
Believe someone in the community gives trustworthy information	304/348	87.4	118/134	88.1	185/213	86.9	0.844

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4. Discussion 

These findings are particularly useful for introduction of a health communications strategy in Southern Sudan, where there is a dearth of information on the populations’ access and preferred types of media. Quantifying media access and preferences will allow public health and other socio-economic initiatives to identify the most appropriate means for reaching the target audience. While health communications campaigns have been demonstrated to work with a high degree of success, they hinge on an understanding of the audience in order to best target groups with similar characteristics, resulting in greater reach and more effective delivery of health education messages.⁹, ¹⁷ Segmenting the audience into meaningful groups in this population may allow for more efficient use of program resources and funds. Segmentation also facilitates the creation of messages targeting specific age and gender-related risk behaviors, thereby increasing the likelihood of designing messages that effectively promote behavior change.⁸

One component of targeting population segments is to understand the appropriateness and effectiveness of various channels for communication. Results indicate that given the popularity of radio, cassettes, and traditional entertainment, messages targeting heads of households, the traditional decision makers, and women may be most effective and have a broader appeal and reach if delivered through these channels of communication. Messages targeted toward boys may most effectively reach their audience if delivered through the use of radio or cassettes; and girls may best be reached through traditional entertainment or cassettes.

Study results indicate that despite the lack of infrastructure and low levels of development in the area, a higher-than-expected number of people have access to radio, cassettes, and television. Heads of household were more likely than women and youth to own a radio, look at newspapers and magazines, and believe in traditional entertainment messages. Additionally, among youth, boys were significantly more likely to listen to the radio than girls, although girls were more likely to notice posters and signboards and attend traditional entertainment.

Despite this encouraging access to contemporary forms of mass media, there are still many socio-economic barriers to comprehensive access, suggesting that strengthening existing traditional channels could be more efficient for dissemination of health messages on a more routine basis, while supplementing campaigns with contemporary techniques, where practical. For example, less than a quarter of the participants surveyed watched television at bars and shops in town (presumably programmes not in their local language or culture are shown) yet nearly all of these individuals reported enjoying watching television. Currently, there is limited or no access to electricity in rural communities, however, the incorporation of mobile video units and health promotion videos could provide access to television, a preferred source of entertainment, through messages that are culturally-tailored to target the Southern Sudanese. When creating audio-visual tools it is important to note that almost 90% of the survey participants preferred materials produced in their local language. This may have implications in the creation of health messages since there are over 39 tribes in Southern Sudan, all with unique cultures and languages.

In addition to issues associated with media access, understanding the audience is also crucial to developing appropriate and effective health promotion materials.¹⁸ The low literacy levels seen in this survey population effectively prohibits the use of written health promotion materials. Findings indicate that more than two-thirds of the individuals who have seen posters have difficulty understanding written messages. Before creating health promotion materials that incorporate text or illustrations, formative research should be conducted to ensure the essential health educational messages are acceptable to the target audience.

Findings indicate that nearly 90% of the participants believe that there are individuals within their community who provide trustworthy information by word-of-mouth. This is important to note as the first impression a health worker makes when entering a community will likely impact their work in the community. Therefore, it is vital that the health worker gain the trust of community members by identifying and partnering with perceived leaders in the community.¹⁹

Villages were randomly selected from the list of all those available giving an equal probability of selection; however, it was not possible to use probability proportional to size which resulted in an increased likelihood of selection for individuals living in smaller villages than larger ones. This is unlikely to have introduced bias to this survey given the homogeneity of the population. Villages in Kapoeta South are near a main road and have access to a daily market, something not accessible to the majority of other settlements in the area, making it difficult to generalize this information to more remote, rural populations. The overwhelming majority of individuals interviewed belonged to the Toposa tribe. Tribal differences may limit our ability to generalize this information beyond the Toposas; accordingly, future research should collect data from other ethnic groups in Southern Sudan. Because some items are considered community property it may be difficult to determine independence for radio ownership; however, interviews were literally translated to ‘who is in charge of radios’, a question that more accurately identifies who is in charge of listening times and stations. Finally, participants were asked about their belief in, and enjoyment of, traditional forms of communication, but not about contemporary forms of media due to the paucity of television and radio messages in their local language. However, questions that assessed their access and enjoyment of contemporary forms of media were asked.

In-depth analysis of traditional forms of health communication both within and between communities, and their remote cattle camps is necessary to better understand the existing structures for community mobilization and identification of agents for delivery and dissemination of messages to their community. As much as contemporary forms of mass media can assist, they will only be as relevant as they are able to establish points of contact with these traditional modes and mechanisms of communication in remote, rural settlements.

In conclusion, a higher-than-expected number of individuals have access to radio, cassettes, and television channels outside of their homes. Access to various types of media was partly dependent on age and gender. Health promotion campaigns need to not only estimate access to various forms of media but address strategies to increase access among all individuals. Since video and radio have not been used extensively to promote health education messages in this area, formative research is necessary to ensure messages are both appropriate and understood by community members. An existing, visible channel for traditional communication through local leaders was also found within communities surveyed, and, if used appropriately, could be influential in increasing the scope and depth of outreach, developing trusting relationships with communities, and ultimately creating sustainable health programs that incorporate community context in the development of the program. This constructive synergy between contemporary and traditional forms of communication, especially as access to media improves among populations like the Toposa, will be important for reaching the desired population and working with them to design health communications strategies that are appropriate and trustworthy.

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Authors’ contributions 

PME, AEH, AFR, JDK, LWK and GG designed the study protocol; AEH collected the data; AEH, MAV, JDK and SB carried out the analysis and interpretation of the data; AEH wrote the manuscript with input from MAV, PME, SB, JDK, GG and LWK. All authors read and approved of the final manuscript. PME is a guarantor of the paper.

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Funding 

The Carter Center, Atlanta, Georgia, USA.

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Conflicts of Interest 

None declared.

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Ethical Clearance 

The work has been approved by Emory University Institutional Review Board and subjects gave informed consent to the work.

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Acknowledgements 

We would like to thank Anthony Sebasio Abdallah, Scott McPherson, Mike Lochi and the Carter Center staff in Kapoeta; Elizabeth Cromwell; and the community interviewers and local leaders who assisted with the study.

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