1
Cand. Public
Department of Aesthetics and Communication
Aarhus University, April 2012
Supervisor: Poul Erik Nielsen
You know, to give birth is just
a lucky gamble
An analysis of communicative aspects and perceived impact of the
mHealth project Wired Mothers in Zanzibar.
Johanne Højbjerg Møller: 20052699 & Iben Sander Christensen: 20053736
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TABLE OF CONTENT
1. PREFACE 1
1.1 Thesis statement 3
1.2 Thesis structure 3
2. THE MOBILE REVOLUTION 4
2.1 ICT4D 4
2.2 mHealth 4
3. CASE PRESENTATION 8
3.1 Maternal mortality in the developing world 8
3.2 Zanzibar 9
3.3 Pregnancy, childbirth and maternal mortality in Zanzibar 10
3.4 Facing Maternal Mortality 11
3.5 Political Attention 12
3.6 Wired Mothers 13
3.7 Being a Wired Mother 14
3.8 SMS and Emergency Phone 15
3.9 Wired Mothers results 16
4. THEORETICAL CHAPTER 19
4.1 Development Theory 19
4.1.1 The History of Development thinking 19
4.1.2 Modernization 21
4.1.3 Media and Modernization 24
4.2 Development Communication 26
4.2.1 Diffusion 27
3
4.2.1.1 Modifications of Diffusion 28
4.2.1.2 Diffusion in Practice 29
4.2.2 Participation 30
4.2.2.1 Levels of participation 31
4.2.2.2 Freire 32
4.2.3 Entertainment-Education 33
4.2.4 Combining approaches in practice 35
4.3 Health Communication 37
4.3.1 Effective Health Communication 38
4.3.2 Health Belief Model 39
4.3.3 Different aspects of Health Communication 40
4.3.3.1 Communication perception 41
4.3.3.2 Shift in paradigms 41
4.3.3.3 Contextual focus 43
5. METHODOLOGY 45
5.1 Selecting respondents 45
5.1.1 Urban/rural 45
5.1.2 Other criteria 46
5.1.3 Contextual factors 47
5.1.4 Deselections 48
5.1.5 Staff interviews 49
5.1.6 Our respondents 49
5.2 Intention and reality 50
5.2.1 Dr. Mkoko 50
5.3 Planning the interviews 52
5.3.1 Making it fit 54
5.4 Using a translator 55
5.4.1 Determining our roles 56
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5.4.2 Lost in translation 56
5.5 Interviewing the voiceless 57
5.6 Translation 59
5.7 Trancription 60
5.8 Condensation and Categorization 60
6. INTRODUCING OUR RESPONDENTS 62
6.1 A Homogeneus group? 66
7. ANALYSIS 67
7.1 Contextualizing the project 67
7.1.1 Defining health 67
7.1.2 Designing an intervention 69
7.1.3 Wired Mothers’ self perception 70
7.1.4 Providing information 71
7.2 Local context: Articulation pregnancy and birth 73
7.2.1 Family planning in Zanzibar 73
7.2.2 Privacy 74
7.2.3 Seeking advice about pregnancy 75
7.2.4 Knowledge about reproduction 77
7.2.5 General relationship to the health system 78
7.2.6 Individual or collective? 79
7.2.7 Partial Conclusion 80
7.3 Perception of danger in childbirth 80
7.3.1 Practical circumstances 82
7.3.2 Perception of doctors and hospitals 84
7.3.3 A costly affair 86
7.3.4 God’s will vs. modern medicine 88
7.3.5 Health Behaviour and Health Belief 90
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7.3.6 Partial conclusion 92
7.4 SMS and Emergency phone 93
7.4.1 Modes of communication 93
7.4.2 SMS 95
7.4.2.1 Access to information 95
7.4.2.2 The medium or the message 96
7.4.2.3 A connection 98
7.4.3 Emergency phone 101
7.4.3.1 Minimizing distance 101
7.4.3.2 Feeling prioritised 104
7.4.4 Addressing the recipient 106
7.4.5 Diffusion and participation in the intervention 107
7.5 Wired Mothers Identity 109
7.5.1 Access to free services 109
7.5.2 Somebody cares 111
7.5.3 Empowerment 112
7.5.3.1 Practical realities 113
7.5.4 Partial conclusion 115
DISCUSSION AND ASSESSMENTS:
FITTING THE SOULTION TO THE PROBLEM 116
8.1 The future of Wired Mothers 116
8.2 Intention vs. reality 117
8.3 Project premises 118
8.4 Determining obstacles 120
8.4.1 Physical obstacles 121
8.4.2 Contextual obstacles 122
8.4.2.1 Traditional birth helpers 122
8.4.2.2 Domestic power structures 124
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8.4.2.3 Articulation of pregnancy and birth 125
8.4.3 Relational obstacles 126
8.4.4 Financial obstacles 127
8.5 Why mHealth? 128
8.5.1 Participation through SMS 129
8.6 mHealth by coincidence 130
8.7 Up-scaling mHealth: A reocurring struggle 131
9. VERIFICATION 134
9.1 Reliablity 134
9.2 Validity 135
9.3 Generalisability 136
10. SUGGESTIONS TO FURTHER RESEARCH 138
11. CONCLUSION 139
BIBILIOGRAPHY 141
LIST OF APPENDIXES 146
RESUME 147
This thesis was written in close collaboration between the two of us and should be seen as a
cohesive product. However, because of formality requirements we are each responsible for
the following sections:
Iben: 4-8, 19-26, 38-40, 52-62, 73-101, 109-116, 126-139
Johanne: 8-19, 26-37, 41-52, 62-73, 101-109, 116-126
The thesis consists of a total amount of 293.469 characters (with spaces) equal to 122,28
standard pages.
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1. PREFACE
We are somewhat pioneers in this field. As far as I know, we are
among the very first scientific research projects, where mobile phones
are used on a trial basis to improve health among pregnant women and
their newborn babies.
Stine Lund, MD, Wired Mothers
Using mobile phones as tools for development is a widely expanding tendency
worldwide, and today development projects revolving around mobile technology to
trigger social change covers a wide variety of fields and sectors. Health is a field
where mobile phones are especially popular tools to boost development, a concept
commonly referred to as mHealth. The Danish initiated mHealth project Wired
Mothers in Zanzibar have been using mobile phones to strengthen the link between
pregnant women and the formal health system in an attempt to increase maternal and
newborn health. As suggested in the introducing quotation from the originator of the
project, Stine Lund, Wired Mothers has received a great amount of attention because
of its innovative ways to combine maternal health initiatives with mobile technology.1
The Wired Mothers project will be the case object for this study.
Being media students with a special interest in the potentials of mobile phones in
development settings, the project quickly caught our attention, and we were curious to
learn how a combination of mobile technology, development communication and
health science works in practice and, especially, how it is perceived by the people it is
designed to help. The Wired Mothers project is announced successful and innovative
by the international development community but how does this description translate
to the intended recipients’ perception, we wondered. What do women in Zanzibar
believe to have gained from Wired Mothers and what is their take on health
communication through mobile phones?
Further research of our initial wondering came to show that there is very little
knowledge on the recipients’ perceptions of development communication initiatives
1 The quote is from the article Mobiltelefoner redder liv [translated: Mobile phones save lives] published in Danish Association for Midwives’ periodical no. 6 in 2010.
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such as Wired Mothers. At the Örecomm Festival in September 2011, where
researchers, scholars and professionals were gathered to discuss present and future
challenges for development communication, a general notion throughout the
discussions was, that despite the movement’s large coverage within development
initiatives, very little research has been made to examine the receivers’ point of view.
In August 2011 we contacted Stine Lund and her research assistant Ida Boas at
University of Copenhagen’s department of Global Health, where they are currently
processing data from the pilot project in Stine Lund’s Ph.D. thesis on the subject.
They too called attention to the missing insight into the women’s perception of the
project and they granted us access to their project documents and agreed that we
travelled to Zanzibar to conduct interviews with women who were enrolled in the
Wired Mothers pilot project from 2009 to 2010. While in Zanzibar, we were in close
contact with Ida Boas, who was working in the Danida office in Ministry of Health in
Zanzibar at the time, and she helped us obtain contact with respondents and relevant
stakeholders around the island. In total, we conducted 17 qualitative interviews with
women from the project and two with health staff members at a local health clinic.
These interviews compose the empirical foundation of our study. Furthermore,
several meetings, talks, emails and SMS’ with Stine Lund and especially Ida Boas
have contributed to getting the information we needed to obtain a thorough insight to
the project design, vision and challenges.
This study is an attempt to include the recipients’ perception in the assessment of
Wired Mothers’ success, impact and further challenges. It will hopefully contribute to
bringing projects and their recipients closer together in their efforts to foster
development through mobile phones.
By placing the project within a theoretical framework of development theory,
development communication theories and health communication theory we aim to
achieve a broader understanding of the project’s ontological point of departure and
compare it to the women’s cultural context and perception of the project to get a
clearer view of where the project’s and the women’s points of view correlate and
where the project would benefit from meeting the women’s realities to a greater
extend.
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1.1 Thesis statement
Our study will be based on the following thesis statement:
We wish to analyse the communicative aspects of the mHealth project Wired
Mothers, focusing partly on the project’s impact on recipients’ health behaviour,
partly on an assessment of whether the project’s intentions are consistent with its
recipient’s reality. Finally, and based on the results of our analysis, we wish to
present recommendations to what can be learned in a potential expansion of the
project.
1.2 Thesis structure
Our thesis is structured in the following way: Chapter 2 is an introduction to the field
to which Wired Mothers belongs, elaborating on movements within Information- and
Communication Technologies for Development (ICT4D), Mobile phones for
development (M4D) and mHealth, while chapter 3 is an introduction to the case
object, Wired Mothers, and the context in which it operates. In chapter 4 we present
the theoretical realm of understanding for the analysis, elaborating on three main
schools of thought: Development theories, communication for development theory
and health communication theory. Chapter 5 elaborates our methodological
framework and reflections, setting the ground for our empirical data, while chapter 6
contains a brief presentation of our respondents. In chapter 7 we analyse the
communicational factors, impact and intentions in Wired Mothers, based on our
empirical data and theoretical framework. The analysis is divided in to 5 sub-chapters,
each elaborating different aspects of the intervention. In chapter 8 we discuss and
assess the impact of Wired Mothers, and based on these assessments we present
recommendations on how to strengthen the communications strategy and intended
impact in a potential up-scale or redefinition of Wired Mothers. In chapter 9 we
perform verifications of the design, execution and results of the thesis and in chapter
10 we briefly comment on suggestions to further research on the topic. Ultimately we
sum up the conclusive remarks of the thesis in chapter 11.
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2. THE MOBILE REVOLUTION
Today, a world without mobile phones is unimaginable. The mobile has become the
most widely spread form of communicational device. With over 5,3 billion
subscribers worldwide this little handheld piece of technology is rapidly changing life
as we know it. 90% of the world’s population is covered by wireless signal and in the
past decade the number of countries with a mobile penetration over 100% has gone
from 2 in 2002 to 97 in 20102. The aggressive growth is not just a phenomenon
happening in developed countries with the developing world falling behind western
technology. While more than 2,4 billion people still lack access to toilets, there are
now more than 3,8 billion cellular subscribers3 in the developing world. At the end of
2010 mobile penetration in the developing world reached 70%, only six years after
reaching the same level in the developed world. And in 2010 the mobile penetration
in Africa was higher than it was in America in 2004. 4
2.1 ICT4D
Within the field of development initiatives the rapid spread of mobile phones have
given way to the announcement of the rise of a mobile revolution in developing
regions. The mobile phone has changed the way people connect, and within that
change many spectators see a golden path towards effective development strategies
for the developing world.
Since the early 1990's information and communication technologies, commonly
referred to as ICTs, have received enormous attention from the international
development community, declaring ICTs powerful tools in strengthening the impact
of development initiatives. After formulating the Millennium Development Goals
(MDG) in 2000, the United Nations formed an ICT task force to support the MDG
plan of action. The primary mission of this task force was to “lend a truly global
2 Mobile phone penetration rate is a term generally used to describe the number of active mobile phone numbers within a specific population. 3 Active SIM-cards. 4 http://www.itu.int/net/pressoffice/stats/2011/03/index.aspx
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dimension to the multitude of efforts to bridge the global digital divide, foster digital
opportunity and thus firmly put ICT at the service of development for all”.5 Other
development agents, i.e. the World Bank and national and international non-
governmental organizations have turned their attention to the blooming field of
Information and Communication Technologies For Development (ICT4D) – a field
often associated with the practice and theory from communication for social change.
Despite differences in design and implementation ICT4D-initiatives often share the
assumption, that access to information is vital for economic and social development.
Within the landscape of ICT4D we find the slightly more specified branch, M4D
(mobile phones for development) covering mobile technology based development
initiatives. Especially in an African context, the mobile phone is seen as an important
key to close the digital divide, making people who were previously identified as
unreachable, reachable. Mobile phones repeal the boundaries set by geography and
softens financial limitations, making friendly, familiar or business related interaction
possible and affordable.
Reasons for the explosive growth of mobile penetration in the developing parts of the
world are many. The mobile contains a number of easy access factors, which is by
large contributing to the medium’s popularity – even in low-income areas. First of all
it is cheap. At this point in time, mobile technology has advanced to a point where a
simple phone is accessible even on a very low income. Competition among the
telecommunication companies drives airtime costs to a minimum and prepaid
subscription, which counts for more than 90% of mobile subscriptions in Sub Saharan
Africa, are especially appealing to people with lower or irregular incomes. Several
African countries, i.e. Kenya, Tanzania and Rwanda, have more or less skipped the
era of the fixed landlines and jumped straight to mobile satellites. In addition to this, a
simple mobile phone does not require a certain level of education or advanced
technical skills to operate; you do not even have to know how to read – you simply
dial and press call to connect to the world.
Another important factor is the widely used and socially accepted sharing culture that
exists in many African cultures. James & Versteeg stress that:
5 http://www.unicttf.org/about/planofaction.html
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In the African context, the Western idea that only those who own a phone
can use one is not at all accurate, since the phenomenon of ‘‘sharing’’ is of
particular importance.6
Not having a mobile phone of your own, does not exclude you from accessing mobile
phones.
Sounding to good to be true the growing popularity of including mobile phones in
development initiatives faces the risk of falling into the lurking misconception:
Adding a mobile phone to an intervention does not automatically generate
development and social change. The impact of mobile technology based interventions
depends heavily on the underlying communication strategy.
2.2 mHealth
If done right literate and illiterate, rich and poor, urban and rural, owners and users
are able to become a part of the ongoing mobile revolution in the developing world.
The easy access factors are to a large extend the reasons why the international
development community holds such high hopes for the mobile phone in the future
history of ICT-based development initiatives. Especially within the area of public
health and health care, the mobile phones have proven extremely applicable giving
name to yet another movement: mHealth.
mHealth is the popular term for mobile health information technology and refers to
health initiatives using portable devices, such as mobile phone technology, to improve
patient safety and the quality of health care. 7 The explosive number of mHealth
related development projects popping up around the world has captured the attention
of the UN. In 2009, the UN Foundation and Vodafone Foundation published the
report mHealth for Development, which includes a description of 51 ongoing mobile
technology based health care projects in developing countries around the world. 8 The
report exemplifies how incorporation of mobile applications in health-related
programmes are used to address specific health-threatening issues by methods of
monitoring, health education, resource expansion and reaching groups of patients that
6 James & Versteeg 2007: 4 7 http://ehealth-connection.org/content/mhealth-and-mobile-telemedicine-overview 8 UN foundation: ”mHealth for Development” (2009)
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have previously been considered unreachable outside the health system. The
following examples illustrate the diversity in designs and objectives. Included in the
report, and often referred to as a good example on how to utilize the mobile phones’
communicational potential, is Text to Change (TTC), an mHealth project set in
Uganda. TTC was an interactive SMS-based intervention aiming to create awareness
about HIV/AIDS through a quiz format. The main objectives were to improve the
general knowledge about HIV/AIDS and at the end of the quiz persuade the receiver
to volunteer for testing. Results from the project state that the quiz produced a 40%
increase of patients coming in for a test. HealthLine, set in Pakistan, addresses the
problem with health workers struggling to read the right treatment plan and
procedures because of the high rate of literacy. Microsoft and other partners
developed a speech recognition based information system accessible through
landlines and mobile phones.
As the UN report illustrates numerous mHealth interventions see the light of day in
these years and the development of the M4D wave is followed closely by stakeholders
at all levels. In November 2011 the Foundation for the National Institutes of Health
hosted the annual mHealth summit in Washington inviting developers, practitioners,
NGO's, representatives from corporate industries and government officials to discuss
the current state and future of mHealth. The central discussion of the summit was how
to successfully upscale short-term pilot projects to sustainable regional and national
mHealth projects. 9 An operation proven to be quite a common challenge for mobile
technology based interventions. We will return to this matter in chapter 8.
The project Wired Mothers, which is the case of interest in this thesis, was mentioned
at both occasions.
9 http://www.mhealthsummit.org/about_attending.php
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3. CASE PRESENTATION
Maternal, newborn, and child mortality are one of the biggest threats to the
developing world. The Millennium Development Goals 4 and 5 set out by United
Nations in 2000 specifically aim to strengthen maternal and child health in developing
countries. 10 For the same reason, numerous projects and initiatives have been
implemented in the developing world in an attempt to turn the curve around and reach
the Millennium Development Goals by 2015. Before introducing the Wired Mothers
project, a presentation of the status of maternal and neonatal health in the developing
world in general and in Zanzibar in particular will be conducted to set the frame for
the project.
3.1 Maternal mortality in the developing world
Globally, it is estimated that around 530,000 women die during pregnancy and
childbirth every year, 99% of them in developing countries. For every woman who
dies, 30 others suffer from acute complications, a total of 15 million women per year.
11 Additionally, an estimated 4 million newborns die annually in their first four weeks
of life. The risk of maternal death is estimated to be 50 times higher in sub-Saharan
Africa compared to developed countries, which is why this inequity is considered the
largest discrepancy of all public health statistics.12 Strengthening maternal health in
developing countries has a high priority on the global agenda which its presence in
the Millennium Development Goals (MDG’s) bears witness to. MDG 5 aims to
improve maternal health by reducing the maternal mortality ration by three quarters,
mainly through an increase in skilled attendance during labour and increased access to
effective 24-hour emergency obstetric care.13 MDG 4 aims to reduce the under-five
child mortality by two-thirds, a goal that is unavoidably interlinked with goal number
5.
The biggest effort to reduce maternal and child mortality by 2015 is focused in sub-
10 http://www.un.org/millenniumgoals/ 11 Danida Strategy for Reproductive Health 2006: 28 12 Appendix 2: WM presentation 2011, slide 3 13 Ronsmans C, Graham W. J., Maternal Mortality: Who, When, Where, and Why. The Lancet Maternal Survival Series, Lancet 2006; 368:1189-200
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Saharan Africa where the problem is largest by far. Ten sub-Saharan African
countries contribute to 66% of global neonatal deaths and 61% of maternal deaths.
Tanzania, including Zanzibar, is one of these countries, where the high maternal and
child mortality rates dominate public health challenges, and where the problem does
not seem to be getting any smaller over time.14
3.2 Zanzibar
The islands of Zanzibar, located off the coast of southeast Africa, consist of two main
islands, Unguja and Pemba. Since 1964 Zanzibar has formed the republic of Tanzania
with Tanganikya mainland. Being the centre of slavery trade from East Africa to the
Arab world in previous centuries, the diversity of people, culture and architecture on
the island gives evidence of a community with great history under the influence of
many different nations and populations. Today, though still a part of the Republic of
Tanzania, Zanzibar is a semi-autonomous society with its own government, president
as well as legal and public institutions. 95% of Zanzibar’s approximately one million
inhabitants are Muslims, and the Zanzibarian society is dominated by great religious
and traditional norms. The level of education, especially among women, is very low.
Mainly in rural areas, where two thirds of the population lives, most women have
minimal or no education. For the same reason, there is a high level of illiteracy and
poverty among the population, making the general living and health standards
considerably low. The population has an annual growth rate of 3.1%, which is among
the highest in Africa.15
Life expectancy at birth in Zanzibar was in 2010 estimated to be 60 years16, a
significant increase since 2003 where it was estimated to be 53 years. The increased
life expectancy, which happened in only 7 years, is most likely a reflection of changes
in the political scene in Zanzibar in those years. In 1995 all international donors
retracted the aid funding from Zanzibar because of political disagreements. The
international donors accused the Zanzibarian government of fraud in the national
14 Roadmap to accelerate the reduction of maternal, newborn and child mortality in Zanzibar 2008-2015: 2 15 Ibid, p.1 16 Zanzibar Strategy for Growth and Reduction of Poverty 2010-2015 (Mkuza II): 46
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elections that year, which secured the ruling party, CCM17, another five years in the
ruling seat. As a result, all development assistance to Zanzibar was withdrawn in a ten
year period up until 2004, where Danida as the first international donor re-established
its work in and funding to Zanzibar. The public sectors, including the health sector,
were significantly affected by the donor retraction, and the increased life expectancy
from 2003 to 2010 could very well be a result of the re-establishment of international
development assistance to Zanzibar in 2004.
3.3 Pregnancy, childbirth and maternal mortality in Zanzibar
Women in Zanzibar give birth to an average of 4.9 children, starting motherhood from
as young as 14 years of age.18 Approximately 50% of women in Zanzibar go through
pregnancy and childbirth with minimal or no contact to the formal health system.19
Instead, these women give birth at home with help from traditional birth attendants
(TBA), neighbours or family members. The TBA’s are lay midwifes providing basic
health care and support during pregnancy and childbirth. Their skills are generally
based on knowledge gained from tradition and experience.20 99% of pregnant women
attend their first antenatal visit at the local clinic or hospital but the rate of visits drops
proportionally with the gestational age of the woman’s pregnancy, which means that
only around 10% attend the five antenatal visits recommended to secure the health of
both mother and child.21 All in all, for many women in Zanzibar, their contact to the
formal health system during pregnancy and birth is very limited.
A study conducted by Danida Health Sector Programme Support and Ministry of
Health and Social Welfare in Zanzibar found an increase in maternal mortality from
377 out of 100,000 births in 199822 to 545 per 100,000 in 2007.23 The maternal
mortality ratio in Zanzibar is now by some assessed to be similar to that of Tanzania 17 Chama cha Mapinduzi 18 Tanzania HIV/AIDS and Malaria Indicator Survey 2007/08 19 Appendix 1: Wired Mothers - use of mobile phones to improve maternal and neonatal health in Zanzibar: 1 20
Within the field of health science they are often referred to as unskilled attendants. 21 Appendix 1: Wired Mothers - use of mobile phones to improve maternal and neonatal health in Zanzibar:1 22 Unicef, Study on Maternal Mortality in Zanzibar, December 1998, as quoted in appendix 1: Wired Mothers: Use of mobile phones to improve maternal and neonatal health in Zanzibar 23 Appendix 1: Wired Mothers: Use of mobile phones to improve maternal and neonatal health in Zanzibar
17
mainland (529/100,000), which has historically always been higher than in
Zanzibar.24 However, many official institutions, including Ministry of Health and
Social Welfare in Zanzibar, still consider the official maternal death ratio to be
377/100,000.25
3.4 Facing maternal mortality
According to Ministry of Health and Social Welfare in Zanzibar, the challenges of
reducing maternal, newborn and child morbidity and mortality consist of two main
categories: health system factors and non health system factors. The first category
includes weak infrastructure, limited access to health services, lack of equipment,
shortage of skilled personal and poor attitude of health workers towards their patients.
The non-health system factors are issues such as inadequate involvement and
participation of the community, socio-cultural beliefs and practices, gender
inequalities and poor health care seeking behaviour.26
In other words practical, traditional, religious, social, socio-economic, and structural
circumstances cause many women in Zanzibar to go through pregnancy and labour
with minimal contact to the formal health system, risking the health of themselves and
their baby. This group of women normally only visit the local health clinic one time,
often to confirm that they are in fact pregnant. After this first antenatal health check
they stay away from the clinics, terminating pregnancy and birth without help from
others than neighbours or traditional birth helpers, who often lack the required
knowledge and expertise to conduct safe births if any complications should occur.27 If
these women experience complications during pregnancy or birth, they often find out
too late to seek help, and in many cases that can cost the life of mother, baby or both.
24 Appendix 1: Wired Mothers: Use of mobile phones to improve maternal and neonatal health in Zanzibar 25 Roadmap to accelerate the reduction of maternal, newborn and child mortality in Zanzibar 2008-2015: 1 26 Ibid 27 Appendix 2: WM presentation 2011: 3
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3.5 Political attention
The problem with high maternal and newborn mortality has received a great deal of
political attention in Zanzibar, both among the government and international donors,
and several special attempts have been made to address the challenges. The
government of Zanzibar has adopted the Safe Motherhood initiative developed by
WHO28, which aims to reduce maternal, neonatal and child deaths. Zanzibar has also
developed the Zanzibar Health Sector Policy, Child Policy, Women Protection and
Development Policy, the Health Sector Reform Strategic Plan and the Zanzibar
Reproductive and Child Health Strategy (2006-2010), responding to reproductive and
child health issues. Furthermore, the Roadmap to Accelerate the Reduction of
Maternal, Newborn and Child Mortality in Zanzibar 2008-2015 has been developed.
The Zanzibar strategy for Growth and Reduction of Poverty 2010-2015 (Mkuza II)
targets to improve maternal health by increasing the number of births through skilled
attendance to 80% and by decreasing maternal mortality to 130 per 100,000 births by
2015.29
Tanzania (including Zanzibar) is one of the top recipients of Danish development
assistance and Denmark is among the largest bilateral donor to the country.30
Danida´s31 Health Sector Programme Support to Tanzania and Zanzibar alone covers
total of 910 million DKK in the period from 2009 to 2014, and part of this amount is
earmarked to strengthen reproductive, maternal and child health.32
Within Danish development work maternal and child health is generally a high
priority, which is specified in Danida’s strategy for the promotion of sexual and
reproductive health and rights.33 In the strategy it is pointed out how:
Preventing pregnancy-related deaths requires a skilled attendant at delivery
backed up by access to 24-hour 7-day-a-week emergency obstetric care
services, and a functional referral system with access to transportation.34
28 http://www.internationalmidwives.org/Partners/WHO/tabid/554/Default.aspx 29 Roadmap to Accelerate the Reduction of Maternal, Newborn and Child Mortality in Zanzibar 2008-2015: 11 30 http://tanzania.um.dk/en/danida-en/ 31 Danish Development Coorporation 32 http://tanzania.um.dk/en/danida-en/health/ 33 Danida, Strategy for the promotion of sexual and reproductive health and rights, May 2006 34
Ibid: 25
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The Wired Mothers project is among Danida’s projects working to reduce maternal
mortality in Zanzibar and increase the number of births with skilled attendants present
and it will function as the case study for this thesis. The following introduction to
Wired Mothers is mainly based on the project's own documents and results, while our
own results and comments will appear in the analysis in chapter 7.
3.6 Wired Mothers
Wired Mothers is an ICT-based project with the aim to strengthen the connection
between pregnant women and the health system of Zanzibar through the use of mobile
technology based communication. By communicating with pregnant women via
mobile phones, the project aims to strengthen the link between pregnant women and
the formal health system to increase the number of deliveries attended by skilled
health staff and thereby reduce the number of maternal deaths in Zanzibar.
Wired Mothers is a Danish initiated Ph.D.-project conducted by MD Stine Lund from
Institute of International Health at Copenhagen University. The project, which was a
pilot project, took place from January 2009 to December 2010.35
The project had three main objectives stated in the project document, which all
revolve around communication through mobile phones:36
• To improve attendance to antenatal and postnatal care
• To improve attendance to skilled delivery attendance
• To improve access to emergency obstetric care
It was also an aim of the project to study the health system's response in relation to
obstetric emergencies when using mobile phones to strengthen communication
between different levels.
The Wired Mothers project is a collaboration between Danida, University of
Copenhagen and Ministry of Health and Social Welfare in Zanzibar. It is supported
35 At the time of writing, Stine Lund is on maternity leave. 36 Appendix 1: WM - use of mobile phones to improve maternal and neonatal health in Zanzibar
20
by Danida with a total budget of DKK 3,305,19237, funded partly through Danida´s
Health Sector Programme Support to Tanzania and Zanzibar and through funding of
Stine Lund’s Ph.D. with 2.6 million DKK. 38
3.7 Being a Wired Mother
A Wired Mother is a pregnant woman connected to a primary health care unit
(PHCU) (clinic or hospital) through a mobile phone. She is enrolled in the project
from her first antenatal visit at the clinic and up until 42 days after giving birth.
Through a mobile phone she receives standard SMS reminders for routine health care
appointments and she has the possibility to contact her local primary health care unit
by phone in case of acute or none-acute problems. Furthermore, the local PHCU has a
direct number to a referral hospital in case of emergencies that need consultation from
a doctor.
The women enrolled in the Wired Mothers project participated from all over the
island of Unguja. This was secured through a random selection of 24 clinics, four
from each of the islands six districts. Half of the clinics were selected to be
intervention sites, half to be control sites. In addition, four hospitals were included as
referral contacts to the clinics. In total, 2550 women were enrolled in the project;
1311 from intervention and 1239 from control sites.39
Besides an informed consent from the women, the project carried out questionnaires
to illustrate background characteristics, pregnant and cultural aspects and barriers of
the women and their families. At each contact with the PHCU, antenatal and postnatal
care attendance was registered and the provided care and outcome of the
examinations entered in to forms, which together with the questionnaires were kept in
individual files. After delivery, another questionnaire was performed to capture
delivery history, outcome of the delivery, emergency care seeking behaviour and
37 http://www.enrecahealth.dk/archive/wiredmothers/ 38 http://www.jordemoderforeningen.dk/tidsskrift-for-jordemoedre/singlevisning/artikel/mobiltelefoner-redder-liv/ 39 Appendix 2: WM presentation 2011: slide 21
21
perceived morbidity of mother and child.40 In addition, an evaluation questionnaire of
the project was conducted with each woman enrolled.
3.8 SMS and Emergency phone
Mobile phones were chosen as the primary intervention tool because of its high
penetration in Zanzibar. Mobile network coverage on Zanzibar is 95% and it is
estimated that 75-80% of the population has access to a mobile phone41, either
because they own one or have access through family, friends or community. A pilot
conducted by the Wired Mothers research team in 2008 showed that 49% of women
in the study area have their own phone and an additional 20% have immediate access
to a phone. The Wired Mothers study aims to examine potential beneficial impacts of
use of mobile phones for health care regarding maternal and neonatal morbidity and
mortality, and to seek innovative ways to ensure access to skilled attendance at
delivery.42
Software developed especially for the project automatically generated and sent text
reminders for appointments depending on the women’s gestational week. Health
educational messages were sent on a monthly basis and included general advise on
how to act and eat during pregnancy and after delivery. Frequency and content of the
SMS varied depending on how far along in her pregnancy the woman was. In total,
9587 messages were sent during the pilot project. The content of the SMS would for
instance be (translated from Swahili):
Please do not forget to attend your ANC43 as this is important for the health
of you and your baby. Please keep in mind that it is important for you to
deliver at a health facility under skilled attendance. If you experience health
problems at any time, it is important that you either call your local health
facility or seek health care immediately.44
40 Appendix 1: WM - use of mobile phones to improve maternal and neonatal health in Zanzibar 41 Ibid 42 Ibid 43 Antenatal care 44 Appendix 4: Text messages in Swahili and English
22
The Wired Mothers in the intervention group would receive an ID-card from the
project with a 24-hour emergency number for them to carry around and to use as
documentation of their participation in the project when going to the clinic.
Furthermore, when enrolling in the project, women from the intervention group
received a voucher with credit for their phone to ensure that they would be able to
afford to call the clinic in case of an emergency. As part of the project, expenses that
would normally have to be paid by the woman or her family when visiting the clinic
or hospital, such as medical equipment, blood tests or fuel for the ambulance, were
paid by the project for women in both the intervention and control group. The main
differences between the intervention and control group was thus the communication
between the women and the health system through mobile phones. The financial
benefits were equal for both groups, except for the phone voucher.
The SMS represent a continuous one-way communication from the project to the
women, whereas the emergency phone would enable direct contact between a) the
women and the midwife and b) the midwife and the referral institutions (hospitals).
The communication between women and the midwives could potentially go both
ways. Their main function was to enable women to call the midwives for health
advise and treatment but it also enabled the midwives to call the women and their
families to follow up on default, treatment, test results etc.45
The ways of communication are in the project documents illustrated in the following
model:46
3.9 Wired Mothers results
In the project documents it is stated that the research team will evaluate the
intervention on a cohort of pregnant women focusing on interventions effect of care
seeking behaviour, facility based delivery, access to emergency obstetric care,
45 Appendix 2: WM presentation 2011: slide 39 46 Appendix 1: WM- use of mobile phones to improve maternal and neonatal health in Zanzibar
23
morbidity and quality of care. 47 The data from the project was analysed by Stine
Lund and her research team during 2010 and though Stine Lund’s Ph.D. thesis is still
not finished, the basic results from the project are ready.
First and foremost, Wired Mothers had a significant effect on how many women
attended skilled attendance during labour: 60% of women from the intervention group
gave birth in a health facility with attendance from skilled health staff, whilst 47% of
women from the control group did the same.48 Furthermore, 39% of women from the
intervention group in Wired Mothers called their midwife on the emergency phone at
least one time.49
The results from the project data show that the intervention had an impact widely
across subgroups of socioeconomic variables such as age, literacy, education,
religion, marital status, mobile phone status, and parity.50 The project turned out to
have a great impact amongst women who typically chose to deliver with unskilled
attendance, such as housewives and women with only primary education. The women
hardest to reach were completely illiterate women from rural areas and therefore the
group of women to whom Wired Mothers had the smallest impact. Furthermore, the
project had a positive impact that resulted in improved skilled delivery attendance,
reduced fresh still births and increased regular ANC attendance.
Overall, the results from the project are referred to as a positive example of a
communication systems intervention and the research team experienced that the
intervention was widely accepted amongst the implicated actors - both health workers
and women. The conclusion of the project from the Wired Mothers research team is
that:
Mobile phone solutions may contribute to saving women’s and newborn
lives and towards achievement of MDG 5 and mHealth solutions should be
considered by maternal health policy makers in developing countries.51
The results from the Wired Mothers research team are made from a health science
point of view and the focus is therefore mostly of quantitative and health scientific
nature. In our processing of Wired Mothers we will focus on communication, media
47 Appendix 1: WM- use of mobile phones to improve maternal and neonatal health in Zanzibar 48 Appendix 2: WM presentation 2011: slide 28 49 During the rest of this study, our focus will be entirely on women from the intervention group. 50 Parity is used as a term for how many children the woman has given birth to. 51 Appendix 2: WM presentation 2011: slide 46
24
and humanities and our study will mostly be of qualitative nature. We will use the
results from the Wired Mothers research team as a back bone of our research but we
will use the freedom to reach our own results, more or less independent from the
results of the research team.
25
4. THEORETICAL CHAPTER
The following chapter will present the theoretical foundation of the study, setting the
frame for our analysis, discussion and assessment. The theoretical chapter elaborates
three different theoretical scopes; development theory, theories on communication for
development, and health communication theories. Each of them will provide us with a
necessary understanding of the theoretical foundation, in which the project takes its
point of departure.
4.1 Development theory
The interest for the development of foreign societies can by traced back to the early
days of the European colonization of Latin America, Asia and Africa. Still, the
discipline first became scientifically grounded throughout the 18th century and the
beginning of the 19th century by a wide range of theorists.52 Today, the field of
development theories consists of many different traditions each true to their own
theoretical heritage. Different trails within development thinking have inevitably had
a visible impact on the theory and practice of communication for social change. In
order to fully understand the dynamics within communication for social change one
has to understand the fundamental currents, which have influenced development
thinking.
4.1.1 The history of development thinking
The very word development implies a movement or change from one stage to another.
This understanding is central to one of the most influential theories within the field of
development, the modernization theory. When talking about development as
economic growth or growth in the welfare sector, both Coetzee53 and Martinussen54
use the words development and modernization synonymously. The essence of
52 Martinussen 1997: 33-34 53 Coetzee 2002: 32 54 Martinussen 1997: 57
26
modernization is a linear movement or transition from a traditional form to a modern
form. The main goal is to improve the quality of life.55
This transition is also the key element in the liberal economical modernization
theories dominating the development tradition from the 1940's up to the 1960's. After
the political decolonization in the 1940's and early 1950's, the postcolonial states of
many African, Asian and Latin American countries were, by the Western World,
considered underdeveloped compared to the industrialized northern America and
western Europe.56 Economical development theorists' main interest was to expose the
reasons for the underdevelopment and present strategies to launch development.57 The
dominant development strategy at this point was: Economic growth and
industrialization will lead to a particular direction of change away from traditional
values towards a modern society.58
Perceiving the capitalistic society as the symbol of a fully developed society, W. W.
Rostow presented the Rostivian take off theory in The Stages of Economic Growth59
claiming that societies sooner or later will go through five stages of development and
in the end reach the age of high mass consumption. Rostow's theory is a central
example of the general perception viewing the transition from traditional to modern as
a positive process, which dominated the field of development at this time. Most
development theories resting on an economical development basis consider a modern
society synonymous with a western society and take for granted that the
underdevelopment parts of the world would be best off looking like the west.60
By the 1960's, dependency theories belonging to the socio political development
tradition challenged the view on imperialism as a positive thing claiming that it has in
fact caused underdevelopment in the third world. From a dependency theoretical
point of view, traditional values and societal structures are not the responsible factors
for lack of development in the third world. The chain is in fact the contact and trading
arrangements with the West. Studies conducted by the UN Latin American
commission (ECLA)61 pointed out that Latin America had in fact not benefited from
55 Coetzee, 2002: 27 56 Martinussen 1997: 53 57 Ibid: 34 58 Coetzee, 2002: 27 59 Rostow 1960 60 Martinussen, 1994: 53 61 Conducted by Latin American economist Raul Prebisch in particular
27
trading goods with the USA. Also, studies based on African and Asian contexts
started questioning whether following the recommendations of the modernization
theorists was the best way to launch development.62
In terms of development thinking, the period after the 1970's is characterized by acts
of rethinking and expanding the grounding theories. Up until this point, developing
countries were thought of as one identical mass under the common name The Third
World. The fact that the economies of these countries had very different reactions to
the global oil crisis in 1973 and 1979 stressed the need for a more differentiated view
on developing countries than practised under the modernization and dependency era.63
Experiences from developing countries, using recommendations from the
modernization or dependency theories, showed that economic growth was happening
only very slowly and in some cases only in certain geographically areas of the
country.64 With no intention of presenting a complete description, two main directions
came to dominate the developing discourse after the 1970's: the Keynesian
Development Economy and the Neoclassical Economy. The first one emphasizes the
role of the state in the battle to prevent unemployment and economical stagnation.
The second one, on the other hand, believes in the power of the free market, claiming
that the way to launch development is to privatize parts of the public sector, liberalize
the trade market and get rid of market regulations.65 After the 1980s, development
theorists found the Keynesian development economy and the neoclassical economy to
be too extensive in their original form. Since then the question dominating the field of
development theory is how to reach a balanced compromise between the two.66
4.1.2 Modernization
Before moving on to the field of communication for social change we will shortly
return to the transition from tradition to modern, which is central to modernization
theories. The consequences of this transition have become a subject of investigation
for many development theorists and as we will see in the following analysis in chapter
62 Martinussen 1995: 34 63
Ibid: 41 64 Ibid: 43 65 Ibid: 108 66 Ibid: 109
28
7, the transition needs to be taken into consideration, when designing and
implementing interventions within the field of communication for social change. The
following offers a closer look at the concept of modernization. As Jan K. Coetzee
points out in a review of modernization theories in Development theory, policy and
practice, the very idea of modernization is portrayed as a kind of final stage in the
social and economical development of a society.67 This perception rests on a western
way of thinking progress as a change from a primitive state towards a state of greater
control. Modernization is a process where individual/society moves from traditional
arena with a restricted capacity to solve problems and control the physical
environment and towards a modern arena, which is capable of handling a wide variety
of internal and external pressures.68 Modernization is often explained as a “movement
on a continuum” emphasising that “most modernization typologies imply a
unidirectional, irreversible, and measurable view over time”.69
Most modernization theories concentrate on the structural changes examining which
parameters within the societal structure are affected by the transition from traditional
to modern and how. Although originally intended for sociology and not economical
modernization theory, Talcott Parson's five variables are often used to distinguish
traditional and modern societies.70 These variables are:
• Generality vs. specificity
• Ascription vs. achievement
• Individualism vs. universalism
• Collective orientation vs. self orientation
• Affectivity vs. affective neutrality
According to Parson, modernization implies a change in the choices people tend to
make. The five dichotomies represent different ways of action, preferences,
predispositions and normative expectations. In addition to this, Parson also presents
three main components by which the modernization process can be analysed:
differentiation, integration and adaption. According to Parson71, modernization is
67 Coetzee 2002: 27 68 Ibid: 28-29 69 Ibid: 31 70 Ibid: 34 71 As quoted in Coetzee 2002
29
inseparably linked with the differentiation of social subsystems such as the family
institution. In a traditional society the role and function of the family and the state
cannot easily be separated. The modernization process shows a differentiation for
these subsystems. A high level of differentiation is the most important structural
indication of modernization. Integration follows differentiation making sure that the
now differentiated parts of the old subsystems are integrated in new specialized and
bureaucratic structures – for example political, cultural or economic groupings.
Differentiation and integration are the results of a changing society – adaption is a
collective accept of the change happening in the systems.72 As Coetzee stresses,
adaption itself is not a guarantee for a smooth transition from traditional to modern.
Problems with adaption occur when integration cannot keep up with differentiation.73
With reference to David McClelland (1960) Coetzee stresses that people have to
emancipate themselves from the mindset of traditional values in order to move into
the modern era. This process is:
…illustrated by evidence in change in views on traditional authority and
social networks. People display an openness to new experiences, as well as a
readiness and willingness to change.
Alongside emancipation also comes a “growing awareness of the possibility to
intervene in physical and social matters”.74
Although most theories of modernization tend to focus primarily on the societal
tendencies on display, some have turned scientific attention to the individual
consequences of the transition from traditional to modern. In Becoming Modern
Inkeles and Smith present a scale to measure the overall modernity of an individual
based on a list of the characteristics found in a modern person.75 In a condensed
version of the list individuals rising towards the modern stage would be describes as
the following: Open and ready for new experiences and social change. Seeking
information to form and hold opinions. Oriented towards the present and future
instead of the past. Changing attitude towards the role of the family, family size,
importance of religion and the function of politics. Changing attitude towards the
72 Coetzee 2002: 36 73 Ibid: 36 74 Ibid: 37 75 Inkeles & Smith, 1974: 35
30
communication media, consumer behaviour and social stratification plus stronger
trust in own ability.76 The list of characteristics is based on the results of
questionnaires conducted among workers in a factory77 aiming to “classify as modern
those personal qualities which are likely to be inculcated by participation in large-
scale modern productive enterprises (…)”.78
The purpose of this paragraph is to tune in on the theoretical perception of the basic
societal and individual indicators accompanied by the transition from traditional to
modern. Keeping these indicators in mind when turning to our empirical data will
help us to comprehend the behaviour of the respondents.
4.1.3 Media and modernization
In a western context the industrial production had a huge impact on the development
of modern mass media. First of all, new technological opportunities saw the light of
day. Secondly, the perception of time changed and the hours of a day were divided
into working hours and spare time, where especially the spare time included mass
media exposure.79 When considering the role of the media in the process of
modernization, the changing dimensions of time and space are often highlighted.
In The Media and Modernity80
, John B. Thompson explains how the technical
constructions of modern media change interpersonal relations. Especially
telecommunication media such as the phone have revolutionised the way we engage
with each other by enabling people to communicate despite physical distance and
varying time zones. Before the invention of the phone and telegraph the only way to
contact people, was through the postal service or physically connecting with them.81
This perspective is extremely relevant to our study considering the articulation of the
mobile revolution, which is currently taking place on the African continent. As a
textbook example of Thompson's argument the prevalence of mobile phones has
indeed affected the influence of great distances and impassable roads on personal
76 Inkeles & Smith, 1974: 34 77 According to Inkeles & Smith a factory is one of the distinctive institutions of the industrialized modern society and therefore a perfect environment to submit to study 78 Inkeles & Smith, 1974: 19 79 Drotner et. al. 2005: 31 80 Thompson 2001 81
Ibid: 41-42
31
relations and business opportunities.82
Thompson's reflections on time and place are similar to the perception presented years
earlier by sociologist Anthony Giddens in Modernity and Self-Identity.83 Although
Giddens' comments on media and the modernization process are relatively few, he
emphasizes that in the modern society the function of the media is to mediate social
experience and reorganising time and place on new terms. Different from the pre-
modern society, the modern audience is no longer a specific, physical group of
people, but a generalized mass-audience.84 The ability to communicate with the
masses was earlier considered the primary function of the media within the field of
development. Considering the role of the media in modernization theories, Everett
Rogers characterizes the period around the 1950s and 1960 as “optimistic about the
potential contribution of communication to development”.85 In terms of moving a
society from traditional to modern, mass media was perceived as a powerful tool and
the influence from sender to receiver direct. Development researchers noted how
mass media enabled governments to transfer information or persuasive messages to
the public. Inkeles & Smith argues that mass media are strong indicators of modernity
within an individual.86 The at the time dominant perception of mass medias’ power to
influence, was as Rogers states, “mainly assumed rather than proven”.87 As
researchers began to question the modernization theorists' recommendations on
development issues, communication researchers began to criticize the field's lack of
attention to the content of the mass media, the degree of impact on the receiver and
the role of the context and culture.88 The shift in the perception of the receivers
presents a central division between two paradigms within the field of development
communication. We will leave the theories of development for now and turn to the
field of development communication and communication for social change.
82 Thompson 200: 166 83 Nielsen 1994 84 Ibid 1994: 48 85 Rogers 1976: 226 86 Inkeles & Smith 1974: 146 87 Rogers 1976: 226 88 Ibid 1976: 226-27
32
4.2 Development Communication
Communication plays a significant role in the field of development. In order to change
living standards in developing countries, communication is crucial; whether the
development initiative is to create awareness about HIV/AIDS, build a new school, or
fight corruption, communication is a necessity to make it happen.
Development communication is a field under constant progress and for the same reason
it still lacks a clear definition. Many attempts have been made to set a clear frame for
the field and to give it a widely recognized name. Development communication,
communication for social change, and communication for development are just some of
the titles for the movement in which communication is used in a development
perspective.89
In Redeveloping Communication For Social Change (2000), Karin Wilkins defines the
field as ”the strategic application of communication technologies and processes to
promote social change”.90 Meanwhile, the Rockefeller Foundation’s report on
communication for social change (2002) defines it as “a process of public and private
dialogue through which people define who they are, what they want and how they can
get it”91. Both definitions focus on change through communication but the means of
achieving it differs; from a technological and strategic point of view to a dialogue and
community based focus. Several other definitions have been applied to the concept of
development communication, and though the definitions vary in focus, they all seem to
agree on the assumption that communication, whether through ICT’s or face-to-face-
interaction, is a key tool to achieve social change in the developing world.
Within the field of development communication, two different approaches are
dominant. Paolo Mefalopulos (2008) makes the distinction of, on one hand, a
monological mode, based on a one-way communication model, and on the other hand a
dialogical mode based on an interactive two-way communication model.92 Within the
field of development communication these two modes are commonly referred to as the
diffusion model and the participation model, respectively.93 Both the diffusion model
and the participation model are widely accepted and used within development 89 In the following, we will be using the terms development communication and communication for social change according to where it is appropriate. 90 Wilkins 2000: 197 91 Figuerora et al. 2002: ii (in preface) 92 Mefalopulos 2008: 21 93 Morris 2005: 123
33
communication and are often defined as each other’s opposites. In the following, we
will present the two models separately and thus expose their theoretical differences.
After outlining their differences we will examine how the two models are in fact
interconnected and often combined in practical development work. 94
4.2.1. Diffusion
The diffusion model comes from the modernization and economic growth theory of
development and was first introduced by Everett Rogers in his theory on Diffusion of
Innovations from 1963. From a diffusion perspective, lack of knowledge in traditional
cultures is viewed as the main reason for underdevelopment. Lack of knowledge is
equated with lack of information and therefore, the solution is to bring information to
underdeveloped communities to foster development. 95 From this point of view,
development is primarily viewed as economic growth.
The main idea behind the diffusion model is a one-way communication in which
knowledge is transferred from a sender; professionals, researchers, specialists,
institutions etc., to recipients through communication channels with the purpose of
educating them into preforming behavioural changes. The original model thus mainly
sees communication from a hierarchic view that can be summarized in a vertical
Sender-Message-Channel-Receiver-model (SMCR), which is often being
implemented in communications and campaigns with the aim to induce behaviour
change.96 Rogers explains the diffusion of innovation “at its most elementary form”
to involve:
(1) an innovation, (2) an individual or other unit of adoption that has
knowledge of, or has experienced using, the innovation, (3) another
individual or other unit that does not yet have knowledge of, or experience
with, the innovation, and (4) a communication channel connecting the two
units.97
94 Throughout our elaboration of the field, we will use the terms diffusion and participation when touching upon the two modes. 95 Morris 2005: 124 96 Mefalopulos 2008: 6 97 Rogers 2003: 18
34
While the diffusion of innovations model was initially composed in an American
context, the model has been adopted into the field of development communication and
therefore the model’s scope on communication has been adjusted into a development
context. As Roger points out:
What has happened in Western nations regarding their pathways to
development is not necessarily an accurate predictor of the process in non-
Western states.98
Rogers thus emphasises how cultural conditions and contexts are of crucial matter in
order to implement successful development communication.
4.2.1.1 Modifications of diffusion
Since it was initially framed, the diffusion model has changed to involve a deeper
understanding of human behaviour, the function of the media, and theories of
communication. While the classic diffusion model focused on mass media as the main
communication channel to link sender and recipients because of its wide audience and
perceived high credibility, the model now recognizes interpersonal communication,
networks, and personal sources as crucial to the adoption of innovations. 99 The
diffusion model thus represents a less simplistic view on communication than the
classic vertical communication model, and Rogers emphasizes that diffusion of
innovations happens far beyond the scope of mass media:
Mass media exposure is able to create a generally favourable mental set
toward change but it is seldom able to form or change specific attitudes
toward innovations – a task better accomplished by interpersonal
communication channels or by a combination of mass and interpersonal
channels.100
98 Rogers 1976: 214 99 Rogers 1974: 54 100 Ibid: 48
35
The idea behind the diffusion model is that individuals draw on experiences and
inspiration from other individuals and, thus, this is the main catalyst for the spreading
of new knowledge, ideas and behaviours.
4.2.1.2 Diffusion in practice
Within development communication, diffusion is effective when it is necessary to
provide facts, deliver messages, develop a brand, seek donor funding and for what
Mefalopulos calls communication about development, informing audiences about
development initiatives, activities, and results101. Therefore, it is commonly used in
communication initiatives such as campaigns, slogans, social advertising, corporate
communication etc.
According to Mefalopulos, the monologic mode, which he associates with diffusion,
can be divided into two main intentions, both with the aim to foster behaviour change
among receivers: Communication to inform and communication to persuade.102
Communication to inform is appropriate when it is believed that merely information
about a project or initiative is enough to foster a behaviour change, while
communication to persuade uses media channels and strategic methods more or less
directly to persuade the recipients into a behaviour change. Communication to
persuade is often used in health initiatives, for instance in health interventions
encouraging mothers of newborns to join a local immunization program or to
advocate for being tested for HIV.103
The main objectives of the diffusion model are thus measurable, often quantitative,
results deriving from behaviour change within individuals or communities in
developing societies such as how many individuals have tested for HIV as a result of
sexual health campaigns. Even with the model’s emphasis on interpersonal channels
in mind, the belief that individuals and communities can be led to behaviour change
by providing them with the right information remains. And despite increased attention
on dialogue and involvement of the community, the main assumption of the diffusion
model is the notion of development as something triggered from an external source.
101 Mefalopulos 2008 102 Ibid 2008: 22 103 We will elaborate more on health communication in regards to diffusion and participation later in this chapter.
36
4.2.2 Participation
Newer perspectives on communication for social change claim the diffusion model to be
outdated and insufficient. According to the critics, development must accelerate mainly
through active involvement of the (so-called) recipients in the process of
communication, not merely by transformation of knowledge.104 The main opposing
approach to the diffusion model is the participatory model, introduced in the 1970’s and
widely used and modified since. The participatory model stresses participation, dialogue
and community involvement as the ground pillars for development. The main argument
of the participatory approach is that the point of departure in development must be the
community and people in question.105 According to Servaes, the participatory approach
means a shift in focus from a ’communicator’ to a more ’receiver-centric’ orientation,
emphasizing perceived meaning over transmission of information:
With this shift in focus, one is no longer attempting to create a need for the
information one is disseminating, but one is rather disseminating information
for which there is a need. Experts and development workers rather respond
than dictate, choose what is relevant to the context in which they are
working. The emphasis is on information exchange rather than on persuasion
in the diffusion model.106
While acknowledging that the classic Sender-Message-Channel-Receiver model can
still be useful in some cases, the participatory model favours people’s active and direct
interaction, stressing how focus should be on dialogue rather than information
dissemination, participation rather than persuasion.107 A desired outcome of
participation is empowerment of people affected by the initiative rather than specific
behaviour change. Empowerment is a widely used term with various definitions. Our
use of the term empowerment in the following reflects the definition of empowerment
set by the World Bank:
Empowerment is the process of enhancing the capacity of individuals or
groups to make choices and to transform those choices into desired actions 104 Servaes & Malikho 2005: 94 105 Ibid: 95 106 Servaes 1996: 77 107 Mefalopulos 2008: 7
37
and outcomes. Central to this process are actions, which both build
individual and collective assets, and improve the efficiency and fairness of
the organizational and institutional context which govern the use of these
assets.108
Within the participatory approach The Rockefeller Foundation report on communication
for social change identifies six key concepts to secure successful communication for
social change: dialogue, horizontal communication, participation, local ownership,
empowerment, and social change (opposite individual change).109 Participation is highly
recognized within the development field today. The World Bank, one of the main
development institutions, acknowledges that:
Internationally, emphasis is being placed on the challenge of
sustainable development, and participation is increasingly recognized
as a necessary part of sustainable development strategies.110
According to Mefalopulos, many experts point to the lack of dialogue and involvement
as the main reason for the failures of previous development projects.111
4.2.2.1 Levels of participation
Mefalopulos associates the participatory model with the dialogical mode; an interactive
two-way communications model, which aims “not to inform, but to truly communicate”
and where stakeholders can participate in the definition of problems and solutions.112 He
introduces the participation ladder, pointing out four different levels of participation in
development113:
1. Passive participation; stakeholders participate only by being informed about what
has or will happen. Minimal or no level of feedback or dialogue.
2. Participation by consultation; stakeholders have the opportunity to participate by
108
www.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTPOVERTY/EXTEMPOWERMENT/0,,contentMDK:20272299~pagePK:210058~piPK:210062~theSitePK:486411~isCURL:Y,00.html 109 Figueroa et. al. 2002: 3 110 Mefalopulos 2008: 7 111 Ibid: 8 112 Mefalopulos 2008: 23 113 Ibid: 11
38
providing feedback to an existing or ongoing initiative. All decisions are made
by external experts or researchers, who are under no obligation to take the
feedback into consideration.
3. Functional participation; stakeholders take part in discussions and analysis about
pre-determined objectives set by the project. While they have no influence on
the ”what” part of the project, they have influence on the ”how” part.
4. Empowered and meaningful participation; Creates opportunity of joint decision
making by stakeholders and external researchers and experts about what should
be achieved and how. It is based on equality and dialogue among external
contributors and the community.
Empowered and meaningful participation is what many participatory development
projects aim for, achieving an increase in the involvement of socially and
economically marginalized people in the decision-making process. However, passive,
consultative and functional participation is the reality of many development projects,
and sometimes a complete level of participation is not possible or desirable for the
project.
4.2.2.2 Freire
One of the major approaches to participatory communication is the dialogical
pedagogy of Paulo Freire. The Freirian argument is based on his dialogue model and
stresses how collective solutions rather than individual opportunities will influence
and challenge power imbalances and thus create development. According to Tufte,
one of Freire’s main assumptions is the critical capacity of the illiterate:
He argued that every human being, no matter how uneducated, is capable of
looking at his/her world in a critical manner leading to a dialogical encounter
with others.114
Freire’s dialogue model enhances development as a self-determined and self-initiated
process best sustained “when it is not artificially imposed from outside the
114 Tufte 2005: 234
39
community” and when everyone participates as equals in the development
communication process.115 In a Freiran view, development will happen when people
know and understand their rights and opportunities as human beings and act
according to them. Only then will people take matters into their own hands and
generate change. Freire uses the term conscientization, the process of advancing
critical consciousness and take action.
In this process, participants increase their willingness to take risks. They
become a party to or stakeholders of social change, based on a conscious
decision to engage in such change, uncomfortable as conditions brought
about by change may be, and based on a deeper understanding of their
realities.116
In a Freirian perspective, development communicators serve as facilitators of the
process of social change rather than as mere transmitters or translators of information.117
Critics of Freire’s approach claim that development will never just emerge on its own.
Development needs some sort of catalyst, which will often be external to the
community. Furthermore, participatory communication is highly resource demanding;
resources that development initiatives often lack. Therefore, less cost-intensive
approaches such as mass communication can be favourable in order to reach as many
people as possible, even with limited resources. An alternative is Entertainment-
education, combining elements from diffusion, participation and mass media.
4.2.3 Entertainment-education
While representing different scopes on development communication, the diffusion
model and the participation model agree on the notion that mediated content should
always be accompanied, supplemented or strengthened by interpersonal
communication. One highly recognised and commonly practised way of combining
media based communication with personal communication is Entertainment-
education, also identified as edutainment. Edutainment uses entertaining elements
115 Cadiz 2005: 148 116 Ibid: 149 117 Ibid: 147-148
40
such as storytelling, music and dancing to communicate about issues of educational
matter. It is a way of transforming otherwise information-heavy topics into an easier
adaptable form in order to break down boundaries and taboos and stimulate
communication. Edutainment is often used in health communication to create
awareness and action on areas such as family planning, HIV/AIDS and immunization
programs.
Thomas Tufte suggests a broad definition of edutainment to be:
…the use of entertainment as a communicative practice crafted to
strategically communicate about development issues in a manner and with a
purpose that can range from the more narrowly defined social marketing of
individual behaviors to the liberating and citizen-driven articulation of social
change agendas.118
According to Tufte, edutainment has managed to transcend traditional dichotomies
within development communication by breaking down otherwise prevailing
boundaries between diffusion and participation, modernization and dependency, top-
down and bottom-up approaches.119 Tufte identifies three generations of edutainment:
The first generation focuses on individual behaviour change and is highly inspired by
the diffusion model. The second generation leans more on participatory
considerations, and while development is still considered to be something triggered
from outside the community, focus is now on development beyond the individual.
The third generation, which is highly inspired by Freire’s work, deconstructs the
divide between diffusion and participation by focusing on how to change social
inequality and existing power structures by triggering development and change from
within the community.120
Rogers (1999), who also recognizes edutainment as an efficient tool in development
communication, states that the purpose of edutainment is always to contribute to social
change, which can happen in two ways: First, it can influence audience awareness,
attitudes and behaviours toward a socially desirable end within the individual. Second, it
can influence the audience’s external environment to help create the necessary
118 Tufte 2005: 162 119 Ibid: 161 120 Ibid: 163-166
41
conditions for social change at a group or system level.121 This distinction between
individual and social effects, attitude and scopes is something we will touch upon
further in the next section concerning health communication.
4.2.4 Combining approaches in practice
Although participatory communication and the diffusion model are often defined as
each other’s opposites they are not mutually exclusive. In fact, many development
projects use a combination of the two models in their approach to development
communication.122 Especially the diffusion model is acknowledging the participatory
approach, including more and more participatory and dialogical elements in diffusion
interventions. Particularly the acknowledgement of interpersonal communication and
social media has broadened the scope of diffusion in a more participatory direction.
But the influence works the other way around as well. Servaes stresses that
participation does not mean that there is no longer a role for development specialists
and institutions to play. Rather, participation means that the viewpoint of the local
community is taken into account before any projects or initiatives are being
implemented.123 A combination of the two approaches into a, what by some is called a
semi-participatory approach124, can have its advantages in for instance health related
development initiatives: There is a need for vertical communication from skilled
professionals to educate local stakeholders about the health aspect in question in order
for any development to take place.
Even so, it is not in everyone’s interest to employ participatory methods as they
threaten existing hierarchies and are not necessarily easily implemented, highly
predictable nor readily controlled.125 Additionally, the results of participatory
communication are not as easily measured or evaluative as is the case with diffusion.
Participatory initiatives often aim towards empowerment as an outcome of
development work rather than a specific behavioural change. Social change and
empowerment of marginalized groups of people is a time consuming task and have no
121 Rogers & Singhai 1999: 9 122 Morris 2005: 125 123 Ibid: 140 124 Ibid: 140 125 Servaes & Malikho 2005: 99
42
quantifiable measurements available. As Mefalopulos states (participatory)
“communication is a process rather than a product”126, and a process can be hard to
prove a measurable outcome of. Justifying development projects with empowerment
as stated objectives to tax payers and private donors thus sometimes takes an effort,
because the outcomes are rarely of quantifiable or tangible character. Even so, as
Morris (2005) stresses, participatory communication interventions necessarily have
specific goals that go beyond achievements such as empowerment, equity and
community building. These goals often include some sort of behavioural change and
are somewhat related to that of diffusion interventions. Concurrently, diffusion
campaigns may well give outcomes connected to the participatory framework, such as
reduced inequality through improved health care to all levels of society.127
In reality, the two approaches are more interconnected and used in combination with
each other than the theories reflect. As Morris emphasizes:
The gap between diffusion and participatory approaches is being bridged by
proponents of both models, who, knowingly or unknowingly, have borrowed
elements from one another. What will work in the local environment is not a
question of which is the superior approach. It is a question of shaping project
goals to community needs and finding the most appropriate means to pursue
those goals.128
Communication for development is a broad definition of using communicative tools to
promote some sort of social change, covering various aspects of change. Seeking to
affect people’s health behaviour is one of these aspects and very much connected to our
field of study. The following chapter is thus a delimited exposition of the field of health
communication.
126 Mefalopulos 2008: xi 127 Morris 2005: 135 128 Ibid: 142
43
4.3 Health Communication
According to Glanz, Rimer & Viswanath (2008) health behaviour, in the broadest
sense, refers to the:
…actions of individuals, groups and organizations, as well as their
determinants, correlates, and consequences, including social change, policy
development and implementation, improved coping skills, and enhanced
quality of life.129
The field of health communication is strongly connected to health behaviour as it, in
one way or another, works to influence, change and develop the health behaviour of
people towards the better. It is a field drawing on different scopes of communication
for social change and the role of communication as a tool to facilitate health
promotion. Aspects of diffusion, participation and edutainment are present in many
health communication approaches seeking to change attitudes, behaviours and
realities in terms of health and living standards of people and communities.
The field of Health communication is broad and complex and beyond the scope of
this paper to fully account for. However, in the following we will go through the
aspects of health communication relevant for the objective of this thesis, focusing on
a theoretical take on how to ensure an effective intervention through health
communication and information.
Based on the World Health Organisation's official perception, Obregon and Mosquera
(2005) define health communication as:
…the study and use of communication strategies to inform and influence
individual and community decisions to improve people’s health.130
According to WHO, health communication is perceived as the door way to inform the
public about health concerns and maintaining important health issues on the public
agenda.131 Furthermore, it is acknowledged that health communication is useful and
necessary in all aspects and at all levels of disease prevention, including physician-
129 Glanz et al. 2008: 12 130 Obregon & Mosquera, 2005: 238 131 WHO, 1998: 8
44
patient communication, adherence to treatment, and the design, implementation and
evaluation of public health communication campaigns.132
4.3.1 Effective health communication
In a review of the practice of health education and communication, Gerjo Kok
presents a rule of thumb concerning the initial process of health communication
interventions: “the effectiveness of health education is dependent on the quality of the
planning process”.133
When researching the field further, it becomes clear that the
question of what determines our actions is central to the practice of health
communication. Behavioural theories dominating the field are often based on the
assumption, that in order to change behaviour, one must first understand the factors,
which determine it. 134 Presenting the model of Planning and Evaluation of Health
Education, Gerjo Kok emphasizes the importance of a proper analysis of the situation
prior to launching an actual intervention:135
! Planning !
Problem – behaviour – determinants – intervention - implementation
" Evaluation "
As the model illustrates, analysing a situation involves asking and answering the
following questions before intervention and implementation:
How serious is the problem?
What and whose behaviours are responsible for the problem?
What are the determinants of these behaviours?
In the context of Kok's notions and the empirical data of this thesis136, one model
132 Obregon & Mosquera, 2005: 238 133 Kok, 1991: 1 134 Berry, 2007: 30 135 Kok, 1991: 1 136 Qualitative interviews with the women enrolled in Wired Mothers
45
central to the field of health communication is relevant to elaborate. The Health Belief
model attempts to explain and predict health behaviour as based on rational reasoning,
stressing that choice is determined by two reflections: subjective probabilities that a
given action will lead to expected outcomes, and an evaluation of the outcome.137
With regards to the processes described in the Planning and Evaluation of Health
Education model, the Health Belief Model offers important insight to the initial
analysis of a situation.
4.3.2 Health Belief Model
The Health Belief Model138 offers a descriptive model to analyse people's subjective
perceptions of a potential health threat and relevant behaviour.139 The model was
developed in the 1950's by social psychologist in the USA to help explain why people
failed to participate in programs to prevent and detect disease. Since then the model
has been refined and is still one of the most widely used conceptual frameworks in
health behaviour research. The model is founded on the assumption that human
behaviour is controlled by a) the personal value of a particular goal and b) the belief
that certain actions will lead to achieving that goal.140 A person's willingness to
change his/her health behaviour is based on five psychological factors:
• Perceived susceptibility: how likely a person thinks he/she is to develop a
certain health condition.
• Perceived severity: How serious a person thinks the condition and the
consequences are.
• Perceived benefits: A person's belief regarding the effectiveness of the risk
reducing actions represented.
• Perceived barriers: How high the cost of a health changing behaviour will be
(money, personal sacrifice)
137 Berry 2007: 30-31 138 Originally presented by Rosenstock in 1966, adjusted by Rosenstock & Becker in 1984. Here referred to through Berry 2007, Bartholomew et al. 2001 and Glanz et al. 2008. 139 Berry 2007: 31 140 Bartholomew et al. 2001: 94
46
• Perceived efficacy: A person's belief in her own ability to make the health
related change.
Before deciding whether or not to act, a person weighs his/her beliefs concerning
susceptibility and severity and conducts what Bartholomew et al. describe as an
“informal cost-benefit-analysis of perceived benefits and barriers”.141 The five factors
or constructs are not of equal priority as massive empirical studies show that
perceived barriers are the most powerful single predictor and perceived severity the
least powerful.142 Furthermore, the decision making process (whether or not to change
a health behaviour) can be influenced by cues to action e.g. external influences like
posters, losing a relative to a certain condition, experiencing symptoms or cues that
might encourage a person to adopt a desired behaviour.
According to Rosenstock, who first presented the model, effective health
communication requires attention to all levels of perception.143 The Health Belief
Model suggests that modifying factors such as diverse demographic as well as socio-
psychological and structural variables may also indirectly influence a person’s health
belief. Although modifying factors and cues to action affect the perception, the major
constructs of the model, susceptibility, severity, benefits, barriers and self-efficacy,
forms the health belief.
4.3.3 Different aspects of health communication
In the case of health communication as well as in the field of development
communication in general, it is relevant to make a distinction between a vertical,
diffusion-based approach and a horizontal participatory approach, though, as we will
see, the two approaches have a tendency of overlapping in many health
communication initiatives. Furthermore, it is useful to make a distinction between
individual based and context based health communication, as they represent the two
main, and often opposing, approaches when communicating health related issues. In
an attempt to link health communication to the field of development communication,
we will take a closer look at how the field perceives communication and how 141 Bartholomew et al. 2001: 94 142 Glanz et al. 2008: 50 143 Berry 2007: 31
47
different approaches from development communication are used and modified within
health communication.
4.3.3.1 Communication perception
According to Rafael Obregon and Mario Mosquera in their analysis of participatory
and cultural challenges for research and practice in health communication, four key
elements of the communication process are typically used in health communication:
Source, message, channel and audience; a definition of communication typically
associated with the hierarchic constellation of the diffusion model. 144 However,
Obregon and Mosquera point to a tendency in health communication of increasingly
combining the four elements with social mobilization and participatory components;
elements commonly associated with participation. This coupling of both vertical and
horizontal communication, information transfer and dialogue within health
communication indicates a general tendency of combining different approaches to
communicate about health related issues and use what was earlier described as a semi-
participatory approach.145 However, literature on health communication gives an
impression of another distinction dominating the discourse of the field; the distinction
between individual and community based health communication.
4.3.3.2 Shift in paradigms
According to Obregon and Mosquera, there has been a significant shift in health
communication approaches over time. From focusing mainly on effects, individual
behavioural change and biomedical thinking, more recent health communication
focuses on active participation of people directly affected as well as culture and social
relations in design, implementation and evaluation of health communication
programs.146 The shift is visible in for instance communication of HIV/AIDS related
topics. In the framework for HIV/AIDS communication (1999), UNAIDS states that:
144 Obregon & Mosquera 2005: 238 145 cf. Chapter 4.2. Development Communication 146 Obregon and Mosquera 2005: 241
48
…seeking to influence behaviour alone is insufficient if the underlying
social factors that shape the behaviour remain unchallenged. Many
communications and health promotion programs proceed on the assumption
that behaviour, alone, needs to be changed, when, in reality, such change is
unlikely to be sustainable without incurring in some minimum social change.
This necessitates attention to social environmental contexts.147148
Obregon and Mosquera use the following model to describe the central
themes and changes within health communication.149
Approach Strategies Characteristics Centrality of…
Information and education
Counseling: Health education
Extensionist model: top-down communication
Messages, recommendations of behavior
Information, Education, Communication (IEC)
Increasing use of mass and interpersonal communication
Greater articulation of interventions and more strategic character; limitations with complex behaviors (i.e. HIV/AIDS)
Media messages and products, educational materials, planning methodologies, KAP research, focus on changing behaviors
Communication for behavior change (CBC)
Increasing use of multiple communication strategies, linkages with social mobilizations interventions and health services
Strong use of social and behavioral psychology and communication theories; more research-driven processes
Focus on behaviors (ideal and attainable), barriers and enablers, focus on behavior change at the individual level, efforts to reach measurable impacts
Context-based approaches (UNAIDS´ HIV/AIDS framework)
Integration of various communication strategies and media interventions; use of local media
Contextual domains as areas subject to change through communications (government & policy, socio-economic status, culture, gender, spirituality)
Focus on changing context to facilitate individual and collective behavior change
Communication for social change
Social mobilization, community participation, dialogue-based, alternative media
Greater emphasis on empowerment and local ownership
Focus on changing structural dimensions through communication processes, impact at the individual and collective levels, social norms, rights
147 UNAIDS, 1999: 15 148 HIV/AIDS communication is one of the biggest areas within health communication. In the following we will draw on experiences and frameworks from HIV/AIDS communication when it is suitable to general health communication. 149 Obregon & Mosquera 2005: 239
49
As the model shows, participatory and dialogical elements were more or less absent in
the initial approaches to health communication and drew much of its inspiration from
what we have earlier characterized as the monologic one-way communication model.
The latter two approaches are significantly more influenced by dialogue and
participation, as we associated earlier with the dialogical two-way communication
mode, or the participatory model.150 Furthermore, the changes shown in the model
suggest a shift in focus from an individually based approach focusing on behavioural
change as something that occurs within the individual, while the latter revolves more
around culture, context and participation as the means of health communication.
While behaviour change is the primary goal of the first three approaches and
undoubtedly present in the latter two, what mainly differentiates the approaches are
their views on how to reach this change of behaviour. 151 Emphasis on cultural context
and collective behaviour grows, the further down the model one gets, and health
behaviour is no longer seen as a merely individual matter but as something that
involves structural changes, local ownership and social mobilization.
4.3.3.3 Contextual focus
Today, it is generally recommended to take the local and cultural context into
consideration when designing and implementing health communication. When
dealing with health communication for development in the global south, the need for
a contextual focus is even bigger. As UNAIDS points out in their framework for
communication, the family, group and community play a great role in decision-
making in the majority of non-Western contexts.152 Even so, approaches and theories
based on individual behaviour often tend to dominate the field.
UNAIDS identifies five contextual domains, which need to be taken into
consideration when designing and implementing health communication: Government
policy, socioeconomic status, culture, gender relations and spirituality.153 While
recognizing the obvious important role of the individual, UNAIDS emphasizes that
health intervention projects should always target individuals within the context of one
150 cf. Mefalopulos 2008 151 Obregon & Mosquera 2005: 239 152 UNAIDS 1999: 20 153 Ibid: 29
50
or more of these domains154. As stated by Glanz, Rimer & Viswanath, “Individual
health does not exist in a social vacuum.”155
According to UNAIDS, positive health behaviours are more likely to be attained and
sustained when people within a cultural setting are involved in a contextual
transformation process.156 However, UNAIDS states:
…there is little attempt to convey understanding through viable channels of
local belief and practice. Instead, these channels are used to disguise
imported knowledge by presenting it in the local idiom. Beliefs or
knowledge of illness and traditional health practice should become the
substance of local (or culturally appropriate) messages and interventions.157
Based on these statements, it seems that despite a wide agreement on the importance
of including the context and local community in planning and implementation of
health communication interventions, there is still quite a way to go before it is the
main approach to health communication.
This concludes the theoretical chapter of the thesis leaving us with the theoretical
framework of development theory, development communication theories and health
communication and setting the ground for the analysis. Before continuing with the
analysis, we will clarify the methodological choices on which our empirical data is
founded.
154 In our analysis of Wired Mothers we will emphasize some of these domains more than others while elaborating the context of the project in a health communication perspective. 155 Glanz et. al. 2008: 29 156 UNAIDS 1999: 24 157 Ibid: 37
51
5. METHODOLOGY
Our analysis of the Wired Mothers project is an inductive study, resting mainly on
empirical data from our semi-structured qualitative interviews with ’wired mothers’
from the project conducted in Zanzibar in October 2011. Because of the empirical
data’s essential role to the study, we find a thorough introduction to the methodology
necessary. In the following chapter we will elaborate on the methodological
considerations and approaches prior to, during and after finishing the qualitative
interviews that set the empirical ground for this study.
5.1 Selecting respondents
Before arriving in Zanzibar we planned to conduct qualitative interviews with 10-15
women enrolled in the Wired Mothers project in 2009-2010. In reality, we ended up
conducting a total of 17 interviews with so-called wired mothers and two interviews
with members of staff from one of the health clinics involved in the project. Before
conducting interviews we set up a line of criteria and distinctions to frame the
selection of respondents in a suitable manner. The main issue for us was to ensure that
all groups of women enrolled in the project were represented through the respondents.
5.1.1 Urban / rural
The main distinction made prior to the interviews was between women living in urban
and rural areas as we had a clear assumption that this distinction would account for
the biggest differences in behaviour, living standards and access to health facilities.
Therefore, we aimed to conduct half of our interviews with women living in rural
areas and half with women from urban settings.
When speaking of urban settings in Zanzibar we refer to the main town, Zanzibar
Town, and its suburban surroundings. With regards to rural areas, we concentrated
52
our interviews to take place in the northern part of the main island, Unguja158, more
specifically in the district called North A.159 Generally, the northern part of Zanzibar
is poorer and has a lower level of education among the population than the rest of the
island, representing the rural district in biggest contrast to the urban setting.
The distinction between urban and rural will help clarify if there is a difference in
how women respond to the project, and how they use and if they own mobile phones
according to which setting they live in. Factors which we expect to play a significant
role for women's decisions on where and how to give birth. Furthermore, the
distinction between urban and rural can help determine if the distance to health
facilities is a significant factor when deciding where to give birth, and if use of the
emergency phone number was influenced by the women's distance to the nearest
health facility.
5.1.2 Other Criteria
Among other criteria, in which we targeted a certain amount of dispersion among the
selected respondents were:
• Age: To help determine if age plays a role in regards to the influence of local
authorities. We aimed towards dispersion of women within the child-bearing
age. Even though women have children as early as 14 years of age, we only
talked to women over 18. All in all, we ended up interviewing women from
the age of 18 up to 40.
• Parity: we wanted to talk to both first-time mothers and women who gave
birth before the project to examine which differences are visible among
women with different levels of experience when deciding where and how to
give birth.
• Place of birth: Another distinction is between women who gave birth at
health facilities with skilled attendance and women who gave birth at home
with the help of family or traditional birth helpers. Furthermore, we aimed to
interview women who have tried both delivering at home and at a health
158 Wired Mothers was only conducted in the main island, Unguja, and not in Pemba, which is generally considerably more rural and poor than Unguja. 159 Unguja is divided into 6 districts; urban, north a, north b, south, west and central.
53
facility to hear their takes on the different options and why they gave birth
where they did.
• Complications during pregnancy and birth is a factor in regards to the
project's influence as women, who experienced complications, had the
opportunity to call the emergency phone. What does this mean for the
women's reception of the project?
• Emergency phone: We aimed towards talking to women who had used the
emergency phone number and women who had not, women who called once
and those who called several times. What did they call about? Why did they
choose to call? Why did they choose not to call? How did they experience it
when they called?
5.1.3 Contextual factors
While planning the interviews we kept certain factors in mind that would play a
significant role in the lives of our respondents. With regards to UNAIDS’s five
contextual domains (government policy, socioeconomic status, culture, gender
relations, and spirituality)160 bound to affect the actions of individuals, we expected
certain variables to have high influence on the women’s answers and reception of the
project. The factors primarily relevant for our framing of the interviews were:
• Tradition: Traditional factors affect how willing people are to adapt modern
approaches and initiatives. Keeping traditional influences in mind will help us
obtain an image of how factors such as authorities within the local community,
husbands, elderly, parents and in-laws, traditional birth helpers etc. take part in
the women's decision pattern.
• Religion: 95% of the population in Zanzibar are Muslims, and especially in
rural areas religion plays a significant role in every day lives and decisions of
the population. Therefore, religion is a significant factor when deciding where
and how to give birth.
• Literacy: A significant factor in terms of how much the women actually gain
from the information distributed via SMS. Furthermore, the level of literacy in
the population or sub-groups often gives an indication of the level of choice, 160 UNAIDS 1999: 29
54
empowerment and self-dependence present for the people in question. In
general, the level of literacy is higher in urban areas than in rural, which
connects this factor with the urban/rural distinction.
• Mobile ownership: Mobile ownership is also a dominant factor for the
communication between the project and the women. A large number of
women are not mobile phone owners but rely on their husbands’ or
neighbour’s phone. Despite a large degree of sharing, we still expect it to
make a big difference in the project’s attempt to reach the women, if they
possess their own phone or not.
5.1.4 Deselections
Due to limited time, resources and scope for the thesis, we found it necessary to make
some limitations to our selection of respondents.
First of all, we only conducted interviews with women from the intervention group
and thus left out the women from the control group, who represent half of all the
women enrolled in the project. We prioritised the intervention group because we
wanted to examine how women perceived and used the communicational aspects of
the intervention. Interviews with women from the control group would have been
useful in order to do a comparative analysis of the project´s impact, but we assessed
that a comparative aspect will be adequately illustrated through women from the
intervention group who have given birth to other children before joining the project.
To illustrate the differences between the intervention and control group we will use
quantitative results from project documents available to us as support.
Furthermore, it would have been useful to interview women who had been offered to
join the project but declined it. Talking to women who actively chose not to take part
in the project would have helped us to understand which elements of the project seem
repellent to women in Zanzibar, why they chose not to participate and what could
have been done differently in order to make them want to join. However, very few
women declined to participate in the project and those who did (approximately 10 out
of 2500), we were not able to find contact information on.
55
5.1.5 Staff interviews
As a supplement to our interviews with women enrolled in the project, we carried out
interviews with members of staff on the health clinics attached to Wired Mothers. Our
initial plan was to carry out interviews with staff from clinics in both urban and rural
areas to compare their answers. However, we ended up only conducting two
interviews with staff members from the same rural clinic, Matemwe. Health clinics in
all areas of Zanzibar are incredibly busy and often understaffed. When we arrived at
the clinic in the morning a long line of women and children were already waiting to
see a doctor or health worker. Patients would keep coming to the clinic throughout the
morning and into the afternoon and the two members of staff from Matemwe were the
only ones, who had time to talk to us.
5.1.6 Our respondents
All in all, we conducted 19 interviews; 17 with so-called Wired Mothers, 9 from two
clinics in the rural districts and 8 from two urban clinic. Furthermore, we conducted
two interviews with health staff from a rural clinic. The grouping of interviews
conducted was:
Rural: District North A
Matemwe Clinic: 6 women + 2 health staff
Chaani Kubwa Clinic: 3 women
Urban
Jangombe Clinic: 2 women
Sebleni Clinic: 6 women
All respondents will be presented with further details in chapter 5: Introducing our
respondents.
56
5.2 Intention and reality
The difference between intentions and reality when conducting interviews can be
quite large. And in our case, it was.
The project has data on all the women enrolled in the project compiled in big paper
files in the Danida and Ministry of Health office in central Stonetown (Zanzibar
Town). We spent two days going through the project documents and from the files we
extracted information on women who matched the before mentioned criteria for our
respondents. We found contact information and phone numbers of 10 women from
each of the four clinics we had decided to visit and hoped to make appointments with
approximately 3-5 women in each clinic.
After hiring a translator161 we had her call each of the women from our selection to
ask them to participate in an interview with us. However, after calling all the phone
numbers from our list we had not been able to make a single appointment with the
women in question. Many of the phone numbers were out of use or belonged to
somebody else than the women. When we realised how difficult it was to reach the
women, we decided to start from the top of the files and call every single woman
enrolled until we had arranged enough interviews for us to go to the clinics. Our
careful selection of women who would fit the criteria was trashed and we basically
made appointments with all of the women who agreed to talk to us. Inevitably, we
ended up with a more random selection of respondents than planned. Luckily, the
women turned out to represent a rather big dispersion within the before mentioned
criteria; age, parity, place of birth, complications and use of emergency phone. All
aspects of the criteria were represented in the group of women interviewed and we
ended up with a large degree of diversity within our respondents.
5.2.1 Dr. Mkoko
One very big reason why we were even able to conduct interviews with 17 women
was a local doctor called Mkoko. Dr. Mkoko has worked as a doctor in Zanzibar for
decades, and while now retired from medical practice, he is still involved in several
aspects of the health system in Zanzibar. He was also a part of the initial research
team in charge of implementing the Wired Mothers project. As soon as we arrived in
161 We will elaborate more on the translator and her role later in this chapter.
57
Zanzibar we were advised to see him for information about the project and to get him
to introduce us to relevant people and stakeholders of the project. Dr. Mkoko is a very
respected man in Zanzibar and his name is very useful to be associated with when
conducting health related work on the island. People tend to listen to what he says and
he brings a great amount of ethos with him. After our first day of conducting
interviews in the rural clinics, Matemwe and Chaani Kubwa, we still needed to do at
least five more interviews in order to reach our stated objectives in rural settings. We
struggled to reach women available for interviews. Throughout the day we were in
contact with Mkoko, who was very interested in the progress of our project and would
sometimes talk to staff from the clinics we visited to explain them properly who we
were, what we were doing and why we had a tape recorder e.g. We told Mkoko about
the difficulties we endured trying to find women for the interviews and that we would
return to the rural clinics the next day to give it another try. When we returned to the
clinic in Matemwe the following morning, six women were lined up in the waiting
room, told by Mkoko to come to the clinic to be interviewed. While it was of great
help to us, it also gave rise to some reflections on what it meant for our selection
process to be associated with such a powerful man. We were not able to find out how
Mkoko had asked (or told) the women to come by the clinic for an interview or what
he had told them about us and our study. A main concern for us was whether the
women came voluntary or because they thought they didn’t have a choice.
Throughout our fieldwork we made an effort to ensure the women and staff that we
were not from the project or the ministry, that they should only participate if they
wanted to and that there were no right or wrong answers. With the work of Dr.
Mkoko, we were pretty certain that this was not at all how the six women in the
waiting room understood the situation. In our processing of the interviews we held
special attention to whether the women’s answers in these six interviews somehow
differed from the rest of the interviews but all in all their answers held high similarity
to the other interviews and did not reflect the circumstances of their recruitment.
58
5.3 Planning the interviews
In preparation for the interview guide for our research interviews we found inspiration
in the Norwegian professor Steinar Kvale’s Introduction to the qualitative research
interview.162 The following section will to a large extend be based on Kvale’s take on
preparing interview guides and conducting semi-structured, qualitative interviews.
Kvale stresses that his guidelines to conducting interviews revolve around settings
with people from northern Europe and USA and stresses that in other cultures, other
norms for interaction in terms of issues such as initiative, straight forwardness,
openness etc. can be dominant.163 Because our interviews took place in a developing
country in east Africa we are very much aware that we cannot directly translate
Kvale’s guidelines into an African context and that we will always need to take the
contextual factors of the Zanzibarian society into consideration when conducting
interviews. However, we still use Kvale’s guidelines as the main basis for the
following section.
Based on our thesis statement we outlined four different aspects on which we aimed
to elaborate during the interviews. Using Kvale’s recommendations for preparing
academic interview questions we set up four research questions, which would
constitute the basis of our interview guide. 164 The main objective was to adequately
elaborate each of the research questions, and it was thus of less importance to us if
they were conducted and elaborated in the exact same way in each interview. From
each of the research questions we would develop interview questions for a semi-
structured interview, meaning that we would not follow the questions strictly but ask
them in the order and speed we would find appropriate for each of the interviews.
The following is a short presentation followed by an elaboration of the four research
questions.
1. How did the women use the information and options presented to them
through the Wired Mothers project?
How can Wired Mothers contribute to enable women in Zanzibar to make informed
decisions about where and how they should give birth. To examine this aspect we
need to know how the women acted in previous pregnancies and what thoughts they
162 Kvale 2005 163 Ibid: 132 164 Ibid: 135
59
have on giving birth with and without skilled attendance. Did their participation in the
project lead to a behavioural change in regards to pregnancy and general health?
Furthermore, we aim explore how women relate to and reflect on their own
participation in the project. Did they share the project content within their
surroundings or did they keep it to themselves? Which (if any) reactions did they
receive from their surroundings to the project?
2. What do the women think about receiving health information on their mobile
phone?
In order to determine whether or not the information from SMS and the emergency
phone make a difference to the women, we need information about the women’s
access to mobile phones in general. For instance, some of the women are registered in
the project files through their husband’s phone and cannot be expected to receive all
of the information via SMS. What does that mean for the women’s perception of the
project? What can be done to make communicational aspects of the intervention more
accessible to the women? Is it even useful to them to receive health related
information on SMS or would they rather hear it from another source?
3. What thoughts do the women have on the danger of giving birth at home
without a skilled attendant?
With the objective to decrease maternal mortality on the island the Wired Mothers
project aims to convince women to give birth at clinics and hospitals with skilled
attendants present instead of at home. We want the women to reflect on the dangers of
giving birth at home and why they think so many women in Zanzibar give birth
without skilled attendance. Addressing the general tendency of Zanzibarian women to
give birth at home we hope to make the women more willing to reflect on and talk
about the potential dangers of giving birth. It is easier to talk about the choices of
other women and use general terms than to talk about personal experiences.
4. Understanding the local culture and communication concerning pregnancy
and birth.
Pregnancy and birth is a personal matter and it is dealt with very differently
depending on culture and context. It is therefore important to obtain insight into how
pregnancy and birth is usually dealt with and articulated in the Zanzibarian
community. Is it a subject naturally shared and discussed among women and others or
60
do they keep their pregnancy to themselves? Who do they seek advice and guidance
from? Who and what decides how and where deliveries take place? What do the local
traditions and norms prescribe? The more insight we gain of this aspect of pregnancy
and birth, the more we will know about which normative, traditional and cultural
structures the project is challenging and if they are dealt with in an adequate fashion.
5.3.1 Making it fit
As Kvale states, the first few minutes of an interview are crucial in terms of
connecting to the respondent, creating mutual respect and setting a decent frame for
the project.165 Through our interview guide we aimed to create an as respectful and
comfortable atmosphere as possible where the respondent would know why we asked
her about the rather personal things we did.166 It was therefore of great importance to
us to structure the interview in a way that would make sense for both the respondent,
the translator and in terms of our objectives. After conducting the first few interviews
we made a few adjustments to smoothen the interview a bit more. We assessed that it
was of interest to the objectives of our study to make the interviews run as smooth as
possible even if it caused some structural changes along the way. According to Kvale,
the structural and dynamic aspects of an interview are sometimes conflicting167 and
that was also the case in our interviews.
Having decided on a semi-structured approach to the interviews we always aimed to
weigh our academic interests with the interests of the interpersonal relationship
between the respondents, the translator and ourselves. This meant that we found it
necessary to cut some edges to make the interview fit each of our respondents,
prioritising a dynamic interaction with the women over keeping a certain structure: as
for example when we learned that a woman had lost her child or if she did not know
what the Wired Mothers project was about. These situations called for improvised
questions to maintain a comfortable atmosphere even though it compromised the
structure of the interview. Because of the language barrier, this improvisation could
165 Kvale 2005: 132 166 Appendix 5: Interviewguide WM women 167 Kvale 2005: 134
61
be quite a challenge and sometimes we were more successful than others, but it was
necessary to make the interviews work.
5.4 Using a translator
In Zanzibar the main language is Swahili and only very few people speak English
properly. Therefore, although never an ideal solution in qualitative interviews, using a
translator was the only way for us to get the empirical data we needed. When
including a translator in an interview situation the material will inevitably be
“contaminated” by this choice. We attempted to minimize the interpreters' influence
by laying down some ground rules prior to the selection of the translator as well as
during the interviews.
Our primary criterion was that the translator should be a local woman. The
Zanzibarian society is based on traditional and Islamic values, which means that the
position of men and women in society differs from a modern western cultural context.
Using a male translator to speak to women about pregnancy was not an option, and
even in a modern, Western context that would most likely have been the same case. A
local, female translator would fill two important purposes: 1) guidance on and
knowledge of the local culture and customs and 2) offering the respondent a person in
the interview situation, which she can relate to culturally, minimizing the cultural
distance and hoping to create a positive atmosphere.
Upon request, the director of State University of Zanzibar, SUZA, recommended
Fatma Muhammed, a 26 year old English and Swahili student at SUZA. Fatma
Muhammed was born and raised in Stone Town as was her mother, while her father’s
family is from Oman. Being a woman of Arabic heritage, with a university degree and
a reasonable level of English language skills automatically gives Fatma Muhammed a
higher societal status than the women we were interviewing. There were episodes
where the tone during an interview indicated that both respondent and translator were
aware of Fatma's cultural and educational superiority.168 Even so, she was less alien to
the women than us and most of the time, she seemed to connect with the women in a
way that made most of them relaxed.
168 It was in fact also mentioned by a local staff member at a clinic, that she 'did not look very Zanzibarian’.
62
5.4.1 Determining our roles
Days of interviewing were also characterized by the three of us having to define the
relationship between us as employers and our translator as employee. Outside the
interview situation, Fatma showed great interest in our private lives and as we had
quite a lot of spare time between interviews, we often talked about personal things.
She was very open and shared her views on her own life, future marriage and
thoughts on pregnancy, birth and life in Zanzibar in general. She often asked for our
opinion on a matter, wanting to know more about how certain topics were dealt with
in Denmark. On one hand this friendly relationship sometimes made it difficult for
her to maintain the professional facade required during interviews. On the other hand,
she granted us access to a female culture, helping us deciphering the ways of thinking,
acting and perceiving yourself as a woman in Zanzibar, and our working relationship
clearly benefitted from her interest and trust in us. Her comments both during the
interviews and in more informal settings added new indispensable dimensions to the
empirical data. In fact, the title quotation of this study, ‘You know, giving birth is just
a lucky gamble’, is a statement made by Fatma Mohammed during the very first
interview169, were she reflects on women’s odds to survive when they give birth at
home. We found the quotation to be quite incisive for our study, and the fact that it
was a statement from Fatma just made it fit the situation surrounding the interviews
even better: While we sometimes had difficulties making our respondents reflect on
their own situation, Fatma was always ready to put a label on it and offer her personal
interpretation as to why the women answered as they did.
5.4.2 Lost in translation
Despite a detailed review of the interview guide prior to the interviews to ensure that
the meaning was understood as intended, and a thorough briefing explaining the terms
and focus of the interview, the translator expressed difficulties understanding the
meaning of certain questions once we initiated the first interviews. This led to some
simplifications of the questions, which might have resulted in lost details in the
women's answers. If we deviated from the interview guide and asked question in a
different order than planned, it threw the translator a bit off balance in the beginning, 169 Appendix 6: i1
63
which would result in short breaks, where we took time to explain the premises of the
qualitative, semi-structured interview.
Despite our best efforts to inform Fatma Muhammad how the details of the women's
answers were of extreme importance to us, we sometimes got the feeling that our
“open questions” were mediated to the respondent in a slightly more closed form,
when for example long answers were translated with a “she said yes”. Another
example is when Fatma would sometimes offer the respondent examples of what was
written in an SMS from the project to speed along the interview, when in fact the
question (for a reason) simply would sound, “Do you remember what the SMS were
about”. Understanding a bit of Swahili, Johanne confronted Famta with this during an
interview, when she recognized words from Swahili that were not being translated
into English.170 Fatma explained that the woman had just told her “about the situation,
just like bla bla bla”, and once again we had to stress that this bla bla bla was very
important to us. After this we paid close attention to the correlation between the
length of the women's answers and the translation of the answers. Throughout the
days of interviewing, Fatma Muhammed felt more and more secure in the role of
interpreter and developed a deeper understanding of what we were aiming for. In
hindsight, one could argue that the quality of the interviews improved over time along
with our own and the interpreter's gained experience and that the fact that the first
nine interviews were conducted in rural areas, while the last eight were conducted in
urban areas could influence the validity of the data. Being aware of these obstacles
from the beginning and correcting the interpreter to the best of our ability, we feel that
the data did not suffer severely by this.
5.5 Interviewing the voiceless
Conducting interviews in a traditional founded culture, offering a voice to a usually
voiceless segment involves certain challenges. The above-mentioned difficulties of
understanding the premises of qualitative interviews were also displayed in the ways
the respondents answered the questions. Although urging them to elaborate on their
thoughts and emotions and frequently reassuring them that there were no right or
170 Appendix 6: i10
64
wrong answers, most of the respondents answered the questions in few, short
sentences. It became clear to us that the discipline of reflecting upon reasons for own
actions was unusual for them. When asked to explain certain behaviour or reflect on
an earlier answer, many of them ducted displaying an opinion by saying “I don't
know”. In some cases this seemed as a way to avoid expressing critic on a topic, at
other times it seemed as if they did in fact not know how to explain their actions.
Despite attempts to create a positive and informal atmosphere during the interviews,
the cultural differences and unfamiliar situation of being interviewed did to some
extent retain an unwanted hierarchical relationship between respondent and
interviewer. During a thorough briefing prior to the interview, we explicitly distanced
our own relation to the Wired Mothers project, letting the respondent know, that we
were not there to check up on them, we needed their help etc. In spite of this, it was
very difficult to make them express any form of criticism on any topic. At first we
blamed this on the construction of the interview situation, but throughout our visit in
Zanzibar and Tanzania, we came to realise that expressing criticism on any matter is
in fact just not a part of the Swahili way of life. This cultural phenomenon also had an
influence on the way the respondents answered our questions. Trying to work around
obstacles we constructed questions where the respondents were asked to talk about a
topic on behalf of “women in Zanzibar” removing the responsibility of the answer
from the woman onto some unknown “others”. 171 This generally had a positive effect,
helping the respondents to open up and share thoughts on why women act and think
as they do.
It is hard to determine to what extent the women answered according to their personal
belief or according to what they felt was expected of them due to their participation in
the project. When dealing with qualitative data, you are dealing with people. When
asking people to explain their actions and thoughts to you, they tend to explain them
the “suitable” way, sometimes slightly manipulating the reality. An interviewer’s job
is then to ask the right questions. Questions that are able to verify how big a
discrepancy the answer consists.172
Participating in qualitative interviews is not at all common for people in Zanzibar,
especially not women. In fact, being interviewed by two students from a European
171 Appendix 5: Interviewguide WM women 172 Kvale 2005: 272-282
65
University, answering questions about giving birth and being pregnant while being
recorded and having their picture taken can be very intimidating to a group of
marginalized group who are not in any way familiar with this setting. While knowing
that we would never be able to make it a natural setting for the women, we tried to do
our best to make the experience as pleasant as possible. We took turns interviewing so
that the women would only have to deal with one of us and our translator. While the
other would wait outside and not disturb the interview. We initially wanted to conduct
the interviews in the shade under a tree or just in less formal settings than at the clinic
to create a calm and relaxing atmosphere, but we somehow struggled to turn down the
clinic staff's kind offer to use the clinic premises for the interviews.
5.6 Translation
We decided to let the Fatma Muhammad translate after each question and answer. She
was instructed in the following procedure: We asked the question in English, she
would then translate it to the respondent in Swahili and then translate the answer back
to us in English. Another option was to let the interpreter conduct the interview on her
own based on our instructions and then having the interviews transcribed and
translated. This would perhaps have created a better flow (and feeling of safety/trust)
throughout the interviews diminishing the natural stops when translator and
interviewer spoke to each other in a language mostly unknown to the respondent. We
abandoned this option based on the experiences from a Danish researcher and because
we felt uncomfortable surrendering control with the pace, order and depth of the
questions to another interviewer. Considering this and the awareness of how different
both cultural and hierarchical we would probably appear to the respondent we decided
on simultaneous interpretation. Using this approach we made an effort to minimize
the distance naturally created by the language barrier by looking at the respondent and
not the interpreter when asking a question, smiling, nodding and in other ways
encouraging the women to go on.
66
5.7 Transcription
When conducting an analysis based on transcriptions of interviews, Steinar Kvale
stresses the importance of not perceiving the transcription itself as the empirical
material but as a somewhat fake construction of a verbal context in textual form.173
The act of transcription implies that the data undergoes a certain amount of
processing. Attempting to maintain most original details from the interview situation
we each transcribed our “own” interviews carefully noting (based on observations
from the interview situation) details like changes in the mood, body language,
interruptions, misunderstandings, emotional utterances and so on. Ensuring the
reliability of the transcription we agreed on a procedure prior to the transcription and
performed a reliability control afterwards by reading and commenting on
uncertainties in each other's transcriptions afterwards.174
5.8 Condensation and categorization
Preparing the data for further analysis involved extracting categories from the
statements and condensing the meaning. Condensation and categorization are both
tools offering the researcher a way into the real matter of the statements.175 In our
process we went through the transcripts of the interviews one by one condensing what
was said. Meanwhile we wanted to organize the condensed data in eight categories,
which were constructed based on a) redundancy in certain topics which were
addressed in similar ways by the respondents and b) topics brought forward by our
interview guide. Furthermore some of the categories were expanded with
subcategories.
The eight categories and their subcategories are:
• SMS
• Pregnancy and birth articulation (risk awareness)
• Articulation of hospitals and doctors (local doctors)
• WM articulation 173 Kvale 2005:163 174 Ibid: 164-165 175 Ibid: 186
67
• Exchanging health information (doctor, mother, neighbours)
• Privacy (relationship to husband)
• Emergency phone
• Intention and reality (practical circumstances, God vs. medicine, risk
awareness)
While performing this task we realised, that we had in fact in some parts of the
interviews already conducted a form of condensation, when making sure we
understood the translation. In these cases the condensation was confirmed or adjusted
by the translator and not the respondent herself, e.g. interview with Habiba Juma
Said:176
I: oh ok, so she called for a car (T: yeah) but when the car came it was too
late [T: yeah). ok.
T: Yeah, it was too late
I: But she wanted to give birth at hospital?
T: She wanted to give birth at hospital
Condensing and categorizing all 17 interviews together would have ensured a higher
degree of reliability177, but due to time limitation we chose to divide the interviews
between us. To optimize the reliability of this process we afterwards controlled the
work of the other. After preparing all interviews like this we created a condensed
summary of each.
Before we continue to the analysis our empirical findings, we will make a short
introduction of the 17 women whose statements the analysis is based on.
176 Appendix 6: i12 177 Kvale 1997: 202
68
6. INTRODUCING OUR RESPONDENTS
The empirical part of our analysis rests on qualitative interviews with 17 women
enrolled in the Wired Mothers project. They are the main source to our findings and
the backbone of this entire study. For that very reason, we want to prioritise a proper
introduction before we begin analysing their statements, so that readers will have
these women in mind throughout the study.
In our analysis, we use statements from these 17 women to illustrate opinions,
experiences and tendencies within the group of respondents. When we quote a
particular woman it is thus often because her statement reflects how several women
articulated a certain topic. While reading the women’s statements it is important to
keep the circumstances of the interviews in mind. First of all, the quotes are not the
women’s own statements but the words of our translator, Fatma. This is why the
women are always referred to in the third person. Secondly, being interviewed was a
very unfamiliar setting for these women, which is sometimes reflected in their short
and somewhat insecure answers. However, we value their statements very much and
we see them as an opportunity to give a voice to an otherwise voiceless group in the
Zanzibarian society.
The 17 women from four different clinics in urban and rural districts of Zanzibar
are:178
RURAL
Matemwe, district North A
Tum Mosi Haji – i1
21 years old, mother of one child and nine months pregnant with her second. She gave
birth to her first child at home and state that it is up to God, where she will give birth
to her second. Tum has attended primary school, she is married and she doesn’t have
a job.
178 Transcripts of each of the interviews are enclosed in appendix 6 and can be identified by the number next to the woman’s name – example Tum Mosi Haji – i1.
69
Maua Omar Ali – i5
25 years old, mother of two children. She gave birth to her first child at home and her
second child, the wired mothers child, at a health facility. When she was pregnant
with her second child she didn’t realise she was pregnant until her husband suggested
it. Maua attended secondary school, and she doesn’t have a job.
Jabu Silima Mawazo – i6
30 years old and mother of four children. She gave birth to one child at home and
three children, including the wired mothers child, at a health facility. When she gave
birth at home, they were building the clinic, so it was too far for her to go to another.
Jabu attended secondary school, she is married and she doesn’t have a job.
Tatu Juma Khamis – i7
34 years old and mother of four children. She gave birth to all of her children in a
health facility. She never considered giving birth at home. Tatu attended secondary
school and now she makes hand made plates for a living. She is married.
Fatuma Mohammed Shabani – i8
30 years old and mother of four children. Her youngest child, the wired mothers child,
died when she was three months old after being sick for a while. Fatuma gave birth to
all her children in a health facility. She attended primary school and has no job. She is
married.
Mboja Mwadhini Wadi – i9
Mboja is 21 years old and mother of one child, to whom she gave birth at home.
Mboja went to secondary school, she has no job, and she is married. She was scared
when she gave birth at home but she didn’t experience any complications.
Chaani Kubwa, district North A:
Hadia Seif Abdallah – i2
35 years old and mother of six children. She gave birth to four children, including the
wired mothers child, at home and two in a health facility. When she gave birth at
70
home, her mother helped her. Hadia never attended school, she is married and doesn’t
have a job.
Nyamato Vuaij Hija – i3
33 years old, mother of six children and pregnant with number seven. She gave birth
to four children, including the Wired Mothers child, at home, and two at a health
facility. One of her children died four months before the interview at the age of two.
Nyamato is three months pregnant, and if no problems occur during her pregnancy
she plans to give birth at home. She went to primary school, she is married, and she
doesn’t have a job.
Mtumwa Faki Jashu – i4
23 years old, mother of one child, which she gave birth to at a health facility. She
attended secondary school. She is married and she doesn’t have a job. If she gets
pregnant again she wants to give birth at the hospital.
URBAN
Sebleni, Urban district
Fatma Armlani – i10
40 years old and mother of five children. She gave birth to two of her children at
home and three, including the Wired Mothers child, at the hospital. Fatma attended
secondary school and now she works as a dressmaker and she sells vegetables. She is
married.
Fatma Ali Amour – i11
35 years old and mother of four children. She gave birth to all of her children in the
hospital. Fatma only told her husband about being pregnant. Her surroundings
discovered when she grew big. She is married and she attended secondary school. She
doesn’t have a job.
Habiba Juma Said – i12
71
37 years old, mother of four children. She gave birth to one child at home and three
children, including the wired mothers child, at a health facility. Habiba didn’t go to
school, and she doesn’t have a job. She is married. She laughed when we asked her if
she was married.
Aisha Juma Said – i13
37 years old and mother of six children. She gave birth to two children at home,
including the wired mothers child, and four children at a health facility. When she
gave birth at home, her neighbours helped her. Aisha went to secondary school, she is
married and she doesn’t have a job.
Hawa Suleman – i14
27 years old and mother of two children. She gave birth to both of her children in a
health facility. Hawa attended secondary school, she is married and she doesn’t have a
job. Her daughter, who is the Wired Mothers child, was with her when we
interviewed her. She is almost two years old now.
Hidaya Rashid Nasar – i15
20 years old and mother of two children. She gave birth to both of her children at the
hospital. She attended primary school, she is married and she doesn’t have a job. Her
Wired Mothers child, a boy named Salu, was sleeping in her lab while we interviewed
her.
Jangombe, Urban district
Zaituna Omar Salum – i16
36 years old, mother of five children, but one of her children died when it was four
months old. She gave birth to four of her children at a health facility. The child who
passed away was delivered at home. Zaituna attended secondary school, she is
married and she doesn’t have a job.
Asha Khamis – i17
40 years old and mother of seven children. Asha gave birth to all of her children at a
health facility. When she gave birth to her first child in the hospital she decided that
72
she wanted to do that with all her future children. She attended primary school, she is
married, and she doesn’t have a job.
6.1 A homogenous group?
As stated in our methodological reflections about selecting our respondents179 our
main distinction was between women living in urban and rural settings as we
expected it to constitute the biggest demographic and social differences among
women in Zanzibar. However, as the analysis will show, women from urban and rural
settings turned out to be much more alike than initially assumed, and our group of
respondents is in fact quite homogenous based on their answers and health behaviour.
In retrospective, we find two main possible explanations to this. First of all, Zanzibar
is a small island, where it is possible to drive by car from the northern to the southern
tip in just a few hours, and the distance between urban and rural is thus very limited,
both physically and in terms of living standards. Even though Zanzibar Town is an
urban setting, the island is in general still dominated by rural ways of life and the
difference between urban and rural is not nearly as distinct as for instance in Tanzania
mainland. Although women in urban areas possibly have shorter distance to health
facilities, it seems as if the determinant factors to where and how you give birth is
somewhat similar whether you live in town or in the countryside.
Secondly, we only interviewed 17 women, and it is possible that a more wide scale
study would have been able to expose a bigger divide than we managed in our study.
However, we do not believe the rather high degree of alignment between women from
urban and rural settings to jeopardize the foundation for our study. On the contrary, it
has enabled us to make more general notions about the circumstances around
pregnancy and giving birth in Zanzibar. In the following analysis, we will thus rarely
make distinctions between urban and rural circumstances but rather consider the
respondents as a homogenous group of women. If and when differences occur, we
will make sure to emphasise them.
179 cf. Chapter 5.1: Selecting respondents
73
7. ANALYSIS
7.1 Contextualising the project
According to the project document Wired Mother – use of mobile phones to improve
maternal and neonatal health in Zanzibar, the Wired Mothers intervention aims to
”improve access and shift some of the responsibility of care and referral to the health
system rather than the women and their families.” 180 In order to grasp Wired
Mothers' impact on the Zanzibarian community, it is essential to understand the
underlying motivating forces of the project. Examining the project's perceptions of its
own role by drawing on development theory, development communication and health
communication theories from previous chapters and comparing it to the local context
will explain the setting of the project and its stated objectives.
First of all, using mobile technology as the main channel of communication between
women and the health system bears witness of a recognition of the power of mobile
phones in an African context, as the technology is said to have revolutionised the
means of communication throughout the African continent. 181 Implementing mobile
technology as the communication link between the women and the health system
sends a signal that the project's use of communication channels is constructed with the
local and cultural context in mind, as mobile phones are accessible to a majority of
the population in Zanzibar and thus is the most efficient and useful way to reach
women all over the island. Having chosen a suitable frame for the intervention, the
following analysis will explore how the different media channels used in Wired
Mothers and the message mediated match the reality of the recipient.
7.1.1 Defining Health
From a Western point of view, health is a matter of science, founded on facts and
research on how to live a healthy life. The general stance seems to be that the more
modern a health system is, the better quality and living standards it brings about.
180 Appendix 1: Wired Mothers - use of mobile phones to improve maternal and neonatal health in Zanzibar 181 cf. Chapter 2: The mobile revolution
74
From this perspective, a development from traditional to modern practices is always
desirable because it enables improved treatment, care and living standards for the
people in question. When the Wired Mothers project uses communicational tools to
create a stronger link between Zanzibarian women and the health system in order to
influence more women to give birth in health facilities, the project aims to foster a
movement away from traditional standards towards more modern practices
concerning pregnancy and giving birth. In short, the assumption is that because giving
birth with skilled attendance in health facilities is the practice in the Western world,
where the maternal mortality rate is very low, increasing the number of births in
health facilities with skilled attendance is the adequate procedure to lower the
maternal mortality rate in a Zanzibarian context as well.
Health behaviour in a Western context is perceived as a mainly individual matter and
health interventions thus often revolve around changing individual health behaviour
to the better. Even in terms of the earlier mentioned increased tendency to involve the
cultural context of the individual in health interventions and campaigns in mind, a
typical Western health intervention revolves around how the individual benefits from
quitting cigarettes, eating healthier or practicing safe sex. However, in developing
countries in the global south health behaviour is generally of a much more collective
character, family, groups and community are much more included in decision making
processes regarding personal and health related issues. The individual rarely
determines it’s health behaviour solely but in accordance with the local, contextual
practices, which is why health communication theories on the matter emphasise how
the local context should always be taken into consideration, when implementing
health interventions in development projects.
From a health scientific point of view, however, there is no doubt that giving birth in
a health facility with skilled attendance is the safest option. Several research results
have stated how the way to secure safer reproductive health in the developing regions
of the world is by increased access to the health system and by providing women the
opportunity to give birth in secure settings with the help from trained, professional
health staff. 182 The objectives of the Wired Mothers project directly reflect MDG 5,
which aims to decrease the maternal and neonatal mortality by three quarters through
an increase in skilled attendance during labour and increased access to effective 24-
182 cf. Chapter 3: Case presentation
75
hour emergency obstetric care.183 Working towards making more women give birth at
health facilities and with skilled attendance is a high global priority and is thus a
constructive and relevant goal for a reproductive health development project such as
Wired Mothers. The aim of this study is not to discuss whether the objective of the
project is right or wrong, but to analyse and discuss how the objective has been
approached by the project and whether or not this is consistent with the local context.
7.1.2 Designing an intervention
There is little attempt to convey understanding through viable channels of
local belief and practice. Instead, these channels are used to disguise
imported knowledge by presenting it in the local idiom. Beliefs or
knowledge of illness and traditional health practice should become the
substance of local (or culturally appropriate) messages and interventions.184
The quotation from the UNAIDS communication framework is suitable to keep in
mind when analysing the approach to communication used in the Wired Mothers
project. To understand and analyse the project's impact it is thus essential to
investigate to which degree Wired Mothers has taken local beliefs and traditional
practices into consideration when designing and implementing, or if the project have
applied the Western, modern view on health in its communication to the women. The
fact that the communication is channelled through mobile phones, a very popular
means of communication in the local setting of Zanzibar, indicates an understanding
of “disguising imported knowledge by presenting it in the local idiom” and it is thus
important to grasp how the communication strategy has actually been designed and
implemented.
In the case of WM, the fact that the target group of the intervention is uneducated,
Muslim women in a tradition-grounded society makes it even more reasonable to
target the women's surroundings. It is very unlikely that the individual woman single-
handedly determine how the process of her pregnancy and birth should be. These
183 cf. Chapter 3: Case presentation 184 UNAIDS 1999: 37
76
circumstances make it even more crucial for the project to aim the communication
more widely than just at the women, as their local and cultural context is very likely
to influence her decisions or perhaps even her ability to make individual choices.
Furthermore, it is unlikely that the decision concerning the woman's pregnancy and
birth course will be based solely on facts and knowledge, when factors such as
traditions, religion and practical circumstances are widely dominant determinants for
people's behaviour in Zanzibar.
The Wired Mothers project documents emphasis results from research conducted by
the Ministry of Health and Welfare in Zanzibar, which state that the challenges of
reducing maternal and child mortality consist of both health system factors and non-
health system factors.185 While the health system factors can be approached within the
system, non-health system factors such as socio-cultural beliefs, gender inequalities
and inadequate health seeking behaviour are determined within the women's local
communities and must be approached by taking context, culture and tradition into
consideration. Mentioning these factors in the project documents clearly shows that
the research team was aware of the contextual determinants for the women's health
behaviour, and one would expect this knowledge to be reflected clearly in the design
and implementation of the intervention. As we will elaborate on throughout the
analysis, this has not been the case.
7.1.3 Wired Mothers’ self perception
Implementing an individually based health intervention into a development project in
an African society, Wired Mothers represents an approach to development rooted in
modernisation theories. As described in the theoretical presentation of the concept of
modernisation, Coetzee defines the essence of modernisation as a linear movement or
transition from a traditional form to a modern form with the main goal to improve the
quality of life.186 Wired Mothers presents the attitude that following modern health
practices will save lives of women and newborns in Zanzibar, and the project design
bears resemblance to modernisation theories view on development, which takes for
granted that the underdeveloped parts of the world would be best off looking like the
185 cf. Chapter 3: Case presentation 186 Coetzee 2002: 27
77
west.187
Being a society resting on traditional and religious pillars, Zanzibar cannot be
expected to share this modern view on health and health behaviour, and the women
can thus not be expected to comprehend the (in a western optic) urgency of giving
birth at the hospital. This is for instance supported by the fact that 99% of women in
Zanzibar attend their first ANC, while only 10% attend the recommended number of
ANC-visits at the clinic prior to giving birth. The official health recommendations for
pregnant women is that five ANC's are necessary to secure the health of mother and
child, but a majority of the women in Zanzibar only attend one, maybe two. This
illustrates the somewhat different views on health and health behaviour from the
system and the women respectively.
In a Zanzibarian context, health behaviour is often associated with religion, traditional
practices, superstition, and practical circumstances such as economic obstacles. As
stated in the chapter on health communication188, UNAIDS identifies five contextual
domains, which need to be taken into consideration when designing and
implementing health communication, namely government policy, socioeconomic
status, culture, gender relations, and spirituality.189 In our empirical data, these factors
also proved to play a significant role for the women's health behaviour, which we will
touch upon later on in the analysis.190
7.1.4 Providing information
Wired Mothers' communication to the women builds on one main message "Use the
health system during pregnancy and birth". The project is based on a philosophy
stating that providing knowledge about pregnancy and birth to pregnant women
through mobile phones will equip them to make an informed decision about giving
birth at a health facility. This approach leans on the assumption that lack of
knowledge is the main obstacle standing in the way of strengthening the link between
women and health system. The point of departure thus mainly rests on the grounds
earlier described as the original ideas behind the diffusion model, which aims to
187 Martinussen 1994: 53 188 cf. Chapter 4.3.5: Contextual factors 189 UNAIDS 1999: 29 190 Some will be elaborated more than others according to their relevance to Wired Mothers.
78
increase the level of knowledge by sending messages from a sender to receivers
through mass media.191 From this point of view, health communication is mainly a
matter of providing people with enough factual information for them to make
informed health decisions leading to behavioural changes.
As is also the case with the diffusion model, where innovations are distributed from
sender to receiver in a vertical form but where interpersonal communication also
plays a significant role for the spread and acceptance of the innovations, the project
encourages dialogue and involvement through the emergency phone, hoping it will
lead to a change in behaviour. In many ways, this view on communication makes the
project a classic case of a diffusion-based communication project, where the main
assumption is that behaviour change and thereby development must be triggered from
the outside, aiming to provide the women with the necessary information and
education to change behaviour. One of the advantages from the way in which the
project is designed is that the outcome is rather quantifiable and thus somewhat easy
to measure the impact of. Had the project rested on participatory strategies, the
assumption would have been that development happens from within; triggered from,
initiated and implemented by the people, the project is aiming to influence. A
participatory approach to the project would have called for another set of
communication strategies, aims and criteria for success and it would most likely have
created much less quantifiable outcomes. We will discuss how the diffusion model
and the participatory mode are or could have been used in the project in chapter 8.
To sum up, the way Wired Mothers was designed and implemented points towards a
view on development that tries to translate Western health ideals to a traditional
society. While the choice of communication channel rests on contextual
considerations of mobile technology's accessibility, prevalence and penetration in
Zanzibar, the content of the messages and communicational strategies seems to build
on a more Western perception of health and communication, hereby risking that the
impact that local and contextual factors have in efficient health communication are
overlooked.
191 cf. Chapter 4.2.1: Diffusion
79
7.2 Local context: Articulating pregnancy and birth
In order to analyse the impact of the Wired Mothers intervention, we need a thorough
understanding of how being pregnant and giving birth is articulated and perceived
within the local community of Zanzibar.
7.2.1 Family planning in Zanzibar
First of all, it is important to point out that the concept of family planning in Zanzibar
differs widely from how it is perceived in a modern Western context. From a Western
point of view, contraception puts the woman in control over her body turning
pregnancy into a carefully planned choice (for most women, anyway). For the
majority of women in Zanzibar, though a happy event for many, getting pregnant is
rarely the result of an active choice. Pregnancy just happens; it is an important part of
being a woman and more specifically of being somebody’s wife. People from rural
and remote areas only have limited or no access to contraceptive devices and religious
and cultural circumstances often stand in the way of using condoms and birth control
all together.192 Girls often marry at a very young age and for the majority of women,
their wedding night is their sexual debut. Having unprotected sex from such a young
age inevitably means that most women in Zanzibar give birth to a high number of
children in their lifetime, in average five children per woman.193 The reality for many
women in the developing world is that they have more children then they would
prefer, if they had been able to plan it. United Nations Population Fund (UNFPA)
emphasises how women in developing countries on average want two, three or four
children, which is lower than previous generations, but most women still end up
having five or six children as a result of lack of access to contraceptives and inability
to influence family planning decisions. The aim of UNFPA is thus to close the gap
between the number of women who use contraceptives and those who would like to
have more control over how many children they have and the interlude between those
children. Cultural and traditional norms, inequality between men and women, and
192 The Zanzibar prevalence of HIV and AIDS of app. 0,8 % is very low compared to Tanzania
mainland where the prevalence is close to 6 % (http://www.avert.org/hiv-aids-tanzania.htm). Using
condoms is thus not a high health intervention priority in Zanzibar compared to Tanzania mainland. 193 cf. Chapter 3.3 pregnancy, childbirth and maternal mortality in Zanzibar
80
poverty are the main obstacles standing in the way for this to happen.194
7.2.2 Privacy
Based on the women’s statements, pregnancy is perceived as a predominantly private
matter and something kept within the privacy of the closest family. The women
mainly consult doctors to confirm their pregnancy and find out when they can expect
to give birth. The woman’s husband is generally the first to know about the
pregnancy, and for the most part no big announcement is made to let the rest of the
woman’s surroundings in on her situation.
Aisha Juma Said195:
I: okay. So who was the first person, that she told that she was pregnant?
T: Her husband.
I: Her husband. Did she tell her family?
T: She didn't tell anyone. Just her husband and the family just they see
the stomach grow big and.
I: okay.
T: they say “ahh”.
I: Did she tell any friends?
T: no.
Aisha Juma Said exemplifies an approach quite different from Western cultures,
where pregnancy is a public shared topic normally discussed among family, friends,
and colleagues and touched upon in various magazines, books and tv-shows. Aisha
Juma Said’s behaviour must be seen in correlation to the local culture and norms.
Being a very religious and traditional society, the Zanzibarian community does not
invite to a public sharing of pregnancy-related topics. The fact that pregnancy is a
direct result of sexual behaviour is likely to play a significant role in the limited
articulation surrounding the matter. This would explain why Aisha Juma Said waited
for her surroundings to notice her stomach growing instead of announcing her
pregnancy. Similar behaviour is found with Tum Mosi Haji196, who also refrained
194 http://www.unfpa.org/rh/planning.htm#contraceptive 195 Appendix 6: i13 196 Appendix 6: i1
81
from telling anybody (except her husband) about her pregnancy:
T: She didn't tell anyone, she says.
I: Only her husband?
T: Only her husband. Yes.
I: So did she have any questions about being pregnant. She didn't talk to
anybody about...
T: She just went to the hospital only.... When someone asked her “Hi Tum,
how are you”, she just said, “I'm fine”.
When Tum Mosi Haji deliberately dodged to tell her surroundings about her
pregnancy and refrained from the truth about her condition, when people asked her
how she was doing, it bears witness to a general shyness and silence surrounding
being pregnant. Tum states that “she felt too shy to tell anyone… even her mother”.
And when asked to elaborate on why she refrains by repeating, “I (she) just felt shy”
clearly signalling “no further comments”. Like Aisha Juma Said, Tum left it up to
nature to reveal her pregnancy to her surroundings:
T: Yes, when she was sick and her stomach was big, she (referring to
Tum’s mother) said; “ahh, my daughter is pregnant”.
Also these statements indicates that being pregnant in a Zanzibarian context does not
hold the same special status as pregnancy is known to in most modern societies.
Having a child in Zanzibar is considered a natural outcome of two people engaging in
marriage. The growing stomach is naturally expected by a married woman’s
surroundings, and therefore there is no reason to tell the whole world that she is
pregnant. Most western women articulate their pregnancy as a gift, a long waited
miracle. For most Zanzibarian women, however, getting pregnant is simply the way
life goes - perhaps to some even her primary cause in life.
7.2.3 Seeking advice about pregnancy
The limited articulation of pregnancy also appears to translate into whom the women
go to for advice on pregnancy-related issues. Once again there seems to be no cultural
habit of sharing thoughts and feelings on pregnancy and birth with friends and family.
82
Fatma Ali Amour197
I: Okay. Can you ask her who the first person she talked to about being
pregnant?
T: her husband.
I: and did she tell her family and friends also?
T: She so secretive, she just told her husband. R laughs.
I: just her husband. And then when she was (gestures a growing stomach,
R nods, everybody laughs). Okay. So if she had any questions about being
pregnant, where did she go?
T: she just go to the hospital and tell all her problems to the doctor.
Several women state, like Fatma Ali Amour, that they took their questions to the
doctor. Although articulating this question as “if you had questions, who did you
ask”, the women generally seemed to interpret the question as “if you had any
problems, who did you ask”. This could partly be a result of translation difficulties,
but it could also describe how the women see the doctor as a problem-fixer. The
women don’t share their general thoughts on pregnancy with the doctor. They see
him/her if they feel sick.198 Aside from consulting with the doctor on health related
issues, several women refer to older women or women with experience in their
community as their primary pregnancy adviser. Even when talking to other women
about pregnancy, the gist of the conversation seems to be problem-orientated. In
Fatuma Mohammed Shabani’s case, she shared her pregnancy with her sisters. When
asked to give examples of what they talked about, she also drew on an example,
where solving problems was the centre of attention:
Fatuma Mohammed Shabani199
T: she says the first person is her husband, and after that she can... she can
also tell her sisters. Yeah.
I: mh, and then what do they talk about? Do they give each other advice?
T: yes
I: can she maybe give examples?
197 Appendix 6: i11 198 This could also explain, why only 10% of pregnant women in Zanzibar go to all five recommended
health examinations. Why see the doctor, when nothing is wrong? 199 Appendix 6: i8
83
T: she say when she got any problem she, they tell her ’please go to the
hospital'.
The respondents state that talking to other women about pregnancy is a normal
procedure, but Fatuma Mohammed’s statement, along with other similar statements
from the respondents, indicates that articulation of pregnancy is generally problem
related. They seek advice from others to clarify whether their situation is normal or if
they should pay the doctor a visit. They don’t share general thoughts or reflections
about pregnancy, neither do they share good news as known from Western societies,
where pregnant couples announce to friends and family that their latest health check
or scanning showed everything to be normal and the baby to be healthy. The way, in
which women in Zanzibar talk about pregnancy seems to be limited to practical,
problem oriented topics.
7.2.4 Knowledge about reproduction
In a traditional society founded on Islamic values, where articulation of reproduction
is kept to a minimum and pregnancy is associated with privacy and shyness, it comes
as no surprise that the official attention in Zanzibar on general reproductive education
is very limited. One staff member at the clinic in Matemwe mentions radio
broadcasting of family planning campaigns in the interview, but aside from that,
reproductive education is considered a private matter. Limited insight into ways of
reproduction were revealed in some of the interviews:
Hidaya Rashid Nasar:200
T: She says that because she was married in a very young age so when she
got pregnant she didn't know. So she just feel pain so she went to the
hospital and the doctor check her and she say that you are pregnant and so
the first person to know that she is pregnant was her mother.
In Zanzibar, sexual and reproductive education is thus something dealt with within the
private sphere, framed by traditional norms and rituals. Usually, older women in the
200 Appendix 6: i15
84
community pass on information and experiences through traditional music and
dancing, teaching young women how to act in sexual relations. Knowledge and
information about sex, pregnancy and reproduction is thus very much dependent on
passing of experience from older to younger women and is rarely based on actual
health scientific sources as we know it from the Western world. Women rely on
personal experience when they learn about pregnancy and birth; in their first
pregnancy they learn from the experience of other women, in their succeeding
pregnancies they draw on their own experience. Habiba Juma Said’s201 statement on
the matter exemplifies this tendency:
I: And when she was pregnant, if she had any questions about being
pregnant, who would she ask? Or talk to.
T: She say she didn't ask anyone question
I: Not family or friends?
T: not family, no friends
T: Because she say she has experience
I: She has experience?
T: yeah
I: ok, but so maybe the first time she was pregnant, who did she ask?
T: Her mothers
7.2.5 General relationship to the health system
The women’s usage of the health system does not seem to reflect a health behaviour
resting on either the formal health system or the traditional. On the contrary, Stine
Lund emphasises that the traditional and official health system exist side by side in
the Zanzibarian society. People in Zanzibar ‘shop’ between the two according to
which health matter they are dealing with, which treatment they find appropriate and
not least what the practical circumstances allow. The fact that 50% of all pregnant
women in Zanzibar give birth with limited or no contact to the health system should
not be perceived as a general reservation towards the official health facilities. In the
interviews conducted for this study all women stress how being within a doctor’s
reach is a “good thing”, making “them feel safe in case they have a problem” and so
201 Appendix 6: i12
85
on. Many of our respondents emphasised how the formal health system is favourable
in terms of expertise and getting medicine, while the traditional health methods are
favourable in terms of things like comfort as well as financial and practical
circumstances.202
Traditional health methods should thus not be perceived as an opponent to the formal
health system. And it should not be a case of making the women choose between the
two methods once and for all and expect them to stick with their choice. The two
health systems work side by side in the Zanzibarian society and an efficient health
initiative should thus take into consideration that the women’s health behaviour is
determined by two parallel functioning health systems instead of two rivalling ones.
7.2.6 Individual or collective?
The limited articulation and private behaviour, which our study suggests linked to
pregnancy in the Zanzibarian context, marks a peculiar paradox: The general
philosophy within health communication theories is that health behaviour and
decisions in developing countries are of a much more collective character than in the
Western world. Although few of the women (i.e i8203) claim discussing their situation
with other women, the majority of the women seek medical advise from the doctor
without involving their surroundings in the matter. Perhaps because of the private
behaviour and limited articulation surrounding pregnancy, health related decisions on
this particular topic are not a collective activity but a private decision in the
Zanzibarian context. This would indicate that communicating about pregnancy and
birth requires another approach than the one of general health communication in
development initiatives. Communicating about pregnancy and birth is a more delicate
subject than i.e. malaria or TB and that is a reservation worth making when designing
a health communication intervention to decrease maternal mortality. Seeking to
influence women’s health behaviour in a more modern direction is then not only a
matter of strengthening the link between women and the formal health system; it is
also a matter of accustoming the women to articulate pregnancy and birth through a
202 The respondents seemed to apply the title doctor as an overall designation for both health workers and doctors. Also there seemed to ben o distinction between clinic and hospital, both were referred to as hospital. 203 Appendix 6
86
new and more modern discourse.
7.2.7 Partial conclusion
Our analysis suggests that in a Zanzibarian context, pregnancy and birth are topics
perceived and articulated in ways that differ widely from the Western world.
Pregnancy and birth are perceived as mainly a private matter and the communication
surrounding the topic is thus very limited and often restricted to problems. Women
shuffle between the traditional and formal health systems during pregnancy and birth,
but they mainly keep their pregnancy, and the thoughts, questions and reflections it
may prompt, within their marriage, or they consult their doctor and their mother.
Strengthening the link between the formal health system and pregnant women through
communication thus requires a discourse and communication strategy sensitive to the
way in which pregnancy and birth is normally perceived and articulated.
7.3 Perception of danger in childbirth
She says there are a lot of problems when you give birth at home, because
if you have a problem there is no doctor to take care of you. The people
who help you they just have experience but they don't know what to do
when you got any problem.
Habibi Juma Said204
WM is trying to change a behaviour that counts for about 50% of all pregnant women
in Zanzibar. Leaning on communicational perception based primarily on elements
from diffusion theories, the way the intervention approaches this is by informing the
women about the benefits of giving birth at a hospital and aiming to eventually
persuade them into a behavioural change. To judge from the quote initiating this
section the message is received. Habibi Juma Said did in fact give birth to her Wired
Mothers child in the hospital, but so was her first child while number two and three
was born in her home with the help of her neighbour.
The informative and persuasive nature of the intervention aims to strengthen the
204 Appendix 6: i12
87
relation between woman and health system. In short the message Wired Mothers is
projecting to the women is:
Giving birth at home = danger vs. Giving birth at hospital = safe
The portrayed health perception on which WM seems grounded assumes that the
women, when enrolling in the project, are to some extent unaware of the dangers
connected to giving birth without a skilled attendant present. Another existing
assumption is that once informed and continuously reminded about the benefits of
regularly “checking in” at the health system, the women will base their health
decision on rational reason instead of tradition. However, Habibi’s history of delivery
and the respondents’ answers offer other reasons to why the women do not use the
health system as desired by the project.
But first, a quantitative look at the 17 interviews205: Out of the 17 interviews
conducted, only two women had never given birth at a hospital. Those two women
were at the time of the interviews first time mothers. Eight women, four from rural
areas and four from urban areas, have given birth both in a hospital and at home. 11 of
17 Wired Mothers children206 were delivered at a hospital, which is in fact almost
equivalent to the results published by the research team207 and well over the 50%,
which is conceived normal in Zanzibar prior to the Wired Mothers intervention.
Based merely on this quantitative count, these numbers do in fact support the project's
conclusion stating that an intervention like Wired Mthers can change a Zanzibarian
woman's health behaviour concerning pregnancy and birth. But looking at where
these women have previously given birth tells us, that seven of the women gave birth
to all their children in a hospital or clinic, which does not suggest a change in
behaviour after becoming a Wired Mothers but the remaining of status quo.
When asked to reflect on the good things about giving birth at home and afterwards
on the good things about giving birth at a hospital, all respondents answered that
giving birth at the hospital is safer. When asked why the hospital is safer, they all
answered within a category of “the doctors know how to take care of you, if you have
a problem”. This indicates an awareness of the danger of childbirth and furthermore
an ability to describe what kind of problems they could potentially face during labour. 205 Appendix 6 206 Children born during the mother’s involvement in the WM project. 207 60% of the intervention group gave birth with a skilled attendant present.
88
When asked where they would prefer to give birth, all except one208 answered “in the
hospital”. Now, as described in our methodical reflections on interviewing an
otherwise voiceless group in a society209 it is possible that the premises of the
interview situation could influence the women’s response. Still, trusting the validity
of our data, this quantitative overview indicates that the women are in fact aware of
the dangers connected to childbirth and do perceive giving birth at the hospital with a
skilled attendant present as best practice.210 This supports the project's own
conclusion stating that the WM intervention was successful. Still, the inconsistency in
the birthplace history of the women and the fact that six of the Wired Mothers
children were born at home, calls for further qualitative research. The following
suggests that the reasons for the high rate of home deliveries in Zanzibar are perhaps
not only connected to lack of knowledge but a reflection of several other factors
surrounding pregnancy and giving birth.
7.3.1 Practical circumstances
11 out of the 17 interviewed women have given birth to at least one child at home and
six out of 17 WM children were born at home despite the WM-intervention.
According to these six mothers, they all intended to go to the hospital, but when going
into labour, different practical circumstances prevented them from following through
with their intention.
Jabu Silima211:
I: Yes, and that one time where she gave birth at home, why did she choose
to give birth home?
T: She say she stay far away from her home and when she gave birth to her
second child, this clinic there is not here (I: this one?) yeah, so it’s very far
away from her home to the clinic in Kivunge, the hospital in Kivunge, and
she give birth at night (I: ok) so there is no transportation to take her to the
hospital.
208 Appendix 6: i3 209 cf. Chapter 5.5: Interviewing the voiceless 210 The question of validity will address thoroughly in chapter 9: Verification. 211 Appendix 6: i6
89
Like two thirds of Zanzibar's population, Jabu Silima lives in a rural area, where the
general living standards are considerably lower than in the urban areas. Owning a car
is far from common (also in the urban areas) and the infrastructure is very poor.
Public transportation consists of the irregular timetable of dallah dallahs (Swahili
mini-busses), taxis or catching a ride from the side of the road. To judge from Jabu
Silima's answer, factors like distance to a clinic and expected time of delivery seems
to play an important role, when deciding whether arranging transportation to the clinic
or hospital is “worthwhile” at the given time. Giving birth at night complicates the
situation further. The dallah dallah's are out of service, taxis are both expensive and
perhaps unavailable and arranging transportation based on the courtesy of a relative
with a car is often a time consuming (or non-existing) option. Jabu Silima's situation
is representative of that of the other women from rural areas, who gave birth at home.
Nyamato Vuai Hija and Mboja Mwadhini both explain how they planned to give birth
at the hospital but went into labour at night.212 In both cases the women explain how
lack of transport and great distance to the nearest health facility forced them to give
birth at home. Hadia Seif Abdalla213 and Fatma Armlani214 explain their home
delivery like this:
(Hadia) T: She give birth at home because she doesn't know what time she
give birth.
…
(Fatma) T: She say she has no... normal sickness of give birth (I: ok). Just
to... for instance, today she was sick. Maybe then she was not sick. Then
tomorrow she was sick. She didn't know the time, which time she wants to
give birth. Yeah
I: And then, all of the sudden, she had to give birth and then she did it at
home?
T: yeah.
Going into fast labour and missing the normal signs indicating that the time of
delivery is approaching, the woman had no time to prepare a trip to the clinic. This
indicates that practical circumstances tend to play large role, when the situation varies
212 Appendix 6: i3 & i9 213 Appendix 6: i2 214 Appendix 6: i10
90
from what the women perceives as normal signs of going into labour. Since none of
the two women were first-time mothers at the time, it is safe to assume, that they base
“normal” on their own previous experience.
Although presumably closer to health facilities, women from the urban areas also
point to lack of transport as a reason for their home deliveries:
Zaituna Omar Salum – interview 16
T: She say that she gave birth at home, she didn't want to give birth at
home but when she gave birth at home because it was at night and there is
no transportation from her house and up to the hospital and she say that, I
asked, you were at shamba (swahili for countryside, rural), she said no, I'm
at town but I have no I have no my own car, so it was very difficult to get
car and take me to the hospital. When car was at my place, I have already
give birth. Yeah.
As well as Zaituna Omar, Habiba Juma Said, Fatma Armlani and Aisha Juma Said
also went into fast labour and had already given birth, when the car finally arrived to
take them to a health facility.215 Whether from the rural or urban areas of Zanzibar the
same practical obstacles seem to interfere with the women's intention of going to the
hospital to give birth. Although distances are greater and therefore a more urgent
factor in rural areas, both groups mention lack of transportation and the amount of
time it takes to arrange it as practical obstacles. Furthermore, the time of day proves
to be of great significance in terms of how easy it is to arrange transportation.
7.3.2 Perception of doctors and hospitals
When asked to list any good things about giving birth at a hospital all respondents
highlight the safety of being close to the expertise of doctors if a problem should
occur. Although positive towards doctors on this particular question, quite a few
respondents characterise the more personal relationship between patient and doctor as
extremely uneven:
215 Appendix 6: i12, i10, i13
91
Tatu Juma Mawazo216:
I: How does she feel about hospitals and doctors?
T: She says, it is good for a little bit?
I: Why just a little bit?
T: Because some doctors they are rude, some are good. She say some
doctor they even hit you.
I: okay, so it is not a nice place?
T: She say, according to her it is a nice place, because it is a place of safe
for their life. But sometimes it is not good for the other side to the other
side of doctors, so some of the doctors are not good.
Like Tatu Jamu Mawazo, other women217 from both rural and urban areas describe
some doctors as “cruel, using rude language and physical abusive” towards their
patients. Fatma Ali Amour218 offers this as an explanation to why many women
choose to give birth at home:
T: She say, that they are scared of the hospitals because of the doctor. As
we said earlier they were rude, they were not use polite languages. Also
they say that if you go to the hospital if you maybe have an hour the doctor
say that “ah, this is operation, this is operation” so they don't want to go.
Some of the women stress how the doctors are only cruel and rude if the patients
themselves have a “bad attitude”. Fatma Armlani219 explains how the doctor's attitude
can change “if the person has been careless (…) didn't follow the advise from the
doctor”. Both staff members connected to the program mention rude language as
reasons to why many women neglect showing up to recommended prenatal
examinations. When asked to elaborate on this matter, they politely decline.220 When
we consulted with people from the Ministry of Maternal Health on this matter, they
all confirmed that a patronising tone, physical abuse and other forms of exploitation
within the formal health system are unfortunately quite normal practices in Zanzibar
and Tanzania mainland.
The women's statements mark an interesting discrepancy. Many of the respondents
216 Appendix 6: i7 217 Appendix 6: i1, i10, i11 218 Appendix 6: i11 219 Appendix 6: i10 220 Appenix 6: Staff Tatu Selima Vuai, Staff Mwanaisha Ilali Sheha
92
claim to have a “fine relationship” with doctors and hospitals, and although some
women point to certain critical issues, they still prefer to give birth at a hospital and
they still claim to count on the doctors' expertise in times of need, accepting the
hierarchical relationship between doctor and patient. Although we are not able to
quantitatively document to what extent these critical issues cause women to steer
clear of hospitals when giving birth or missing prenatal appointments, bearing this
problematic doctor-patient-relationship in mind, when trying (as WM's intentions are)
to strengthen the ties between the women of Zanzibar and the health system, is of
extreme importance. There seems to be no focus on this particular matter in current
descriptions of the project. We will address this in chapter 8, when we discuss and
assess the impact of and intentions of Wired Mothers.
7.3.3 A costly affair
According to staff member at the Matemwe clinic, Tatu Semila Vuai221, all women are
advised to start saving up money for pregnancy and delivery, when they attend the
first health examination of their pregnancy. Although none of the women from the
interviews mention lack of money as the primary reason for their home deliveries,
staff member at Matemwe, Mwanaisha Ilali Sheha222, points to situations where
women have pointed out lack of money as the primary reason for their home delivery:
T: She say that according to the woman who has the pregnant, when she
come to the hospital and they ask her 'why you did to, to give birth at
home' they say that because we are poor so we have no much time to go to
the hospital because in hospital we need many things just like clothes, just
like medicine, just like injections so we are poor so it's better for us to give
birth at home.
According to Fatma Ali Amour and Zaituna Omar Salum the fear of hospitals are in
some cases also connected to economy.
221 Appendix 6: Staff Tatu Selima Vuai 222 Appendix 6: Staff Mwanaisha Ilali Sheha
93
Zaituna Omar Salum: 223
T: she say, that they are scared because of the character of the doctor and
also of their condition.
I: their condition?
T: yeah. Some people they are poor so they are they didn't were not saved
the money for hospital.
I: So they are afraid that if they go in to a hospital, it's going to be
expensive?
T: yeah. Because when you go to the hospital, there are many things that
are they need to you health so they didn't have enough money.
Getting pregnant is a costly affair. Besides payment for the doctor's service, blood
samples, blood pressure measurement and medication, women and their families also
need to pay for transportation or for petroleum for the ambulance in case of an
emergency, gloves, needles and so on. Giving birth at home is cheaper, but rarely for
free as it is custom to pay the traditional birth attendant for her services.
Fatma Ali Amour:224
T: She say that this project is very nice because you first you got
everything free of charge so if you for instance you can go to the hospital
and the doctor say to you that you go to buy this one and this one and this
one. But for the Mama Mtandao225 everything you can get for free.
As Fatma Ali Amour’s statement shows, the Wired Mothers intervention obliged this
fear of unforeseen expenses by paying for certain pregnancy related services. The free
services are often highlighted by the respondents as one of the main reasons why they
liked being in the project. However, considering the stated objectives of the
intervention and the future plan of up-scale, providing women with free benefits could
contribute to some ethical implications. We will elaborate this matter in the discussion
in chapter 8.
223 Appendix 6: i16 224 Appendix 6: i11 225 Swahili for Wired Mothers
94
7.3.4 God's will vs. modern medicine
Beside practical circumstances, some women call their home delivery an “act of
God”. Tum Mosi Haji226, 21 years old, disclaims control over where she gave birth to
her first and only child. She claims that “it was just destiny and God just wanted her
to give birth at home”. Although she is aware of the dangers connected to home
deliveries and would prefer to give birth at the hospital, she is convinced, that when
the time finally comes, the decision is out of her hands: “It is up to God”. Being a part
of a religiously founded community, Tum Mosi Haji naturally puts her fate in God's
hands, believing that God had planned for her to give birth at home and not in a
hospital.
So, if women believe that everything is predetermined by God, what power to change
health behaviour could an intervention like Wired Mothers hope to have? The
fatalistic take on life in Tum's statement does in some ways undermine the very raison
d'être of WM. On the other hand, Tum Mosi Haji did accept becoming part of the
project, which indicates that she is open towards the methods of modern medicine and
with Coetzee's227 terminology moving forward on the continuum of tradition to
modern. Maua Omar Ali also touches upon the same sort of divine disempowerment,
when asked to explain why she thinks so many women in Zanzibar give birth at
home. Although living in a rural area of Zanzibar herself, she distances herself from
“the people from shamba”228 explaining how lack of education results in these people
having a bad attitude towards doctors:
Maua Omar Ali: 229
T: (…) God is everywhere and not in hospital only. (...) Yeahh, so they
want to give birth at home, because they don't believe, that when they give
birth at hospital it will be... there is no problem, there is no anything, so
they say, that if you want to got a problem anywhere, you have got a
problem. Not only at home. Even at hospital you can get a problem. So
they have a bad attitude about give birth at hospital.
226 Appendix 6: i1 227 Coetzee 2001 228 Swahili for “the countryside” 229 Appendix 6: i5
95
Despite the poor translation, Maua Omar Ali’s statement suggests that lack of
education will make people more inclined to disempower themselves in a situation
like this. Maua is insinuating, that the people of shamba are going against medical
advise and use God’s will to justify it. The same logic is displayed when Nyamato
Vuai Hija offers her explanation to why many women in Zanzibar give birth at home:
Nyamato Vuai Hija:230
T: Yeahh like a C-section. So they don't want to go to the hospital, because
they are scared of operation. For for them, they think it is better to give
birth at home.
I: Okay. And they are not scared to give birth at home... if anything goes
wrong.
T: They don't get scared, because she say Allah is <...> everything is up to
Allah. It is up to God.
This statement leaves the impression that the perception of the power of God and
modern medicine is somehow strictly divided. Within the walls of the hospital your
fate is in the hands of the doctors, while God is the one you turn to outside the
hospital. Though, as the next statement exemplifies, it does not seem as if this
perception is conscious:
Zanituna Omar Salum:231
I: so when she gave birth at home, that one time, was she more scared than
when she gave birth at the hospital?
T: she was not scared, because she say, God is there and she will, he
protect her.
I: God?
T: Yeah.
I: is God also at the hospital? Can you ask her?
T: Sorry?
I: Is God also at the hospital?
(R and T smiles)
T: everywhere God is.
230 Appendix 6: i3 231 Appendix 6: i16
96
An obstacle facing the Wired Mother intervention is an ongoing battle between
religion and modern medicine. The picture extracted from these statements is one of a
society caught somewhere halfway on the continuum of tradition and modern ways of
life. Where death in traditional societies are usually justified by dogmatic reasoning
and labelled as “God's will”, modern medicine offers the means to conduct “divined
interventions”. Remembering the points made in the theoretical review of
modernization,232 a successful adaptation will only take place when/if people
emancipate themselves from the mindset of traditional values. Seen through a
modernization lens, the presented statements suggest that the society in which our
data is collected is not quite ready to separate religion and health related issues. The
respondents have no problems accepting the knowledge of modern medicine right up
to a point where it becomes an obstacle or inconvenience to them (for example an
economical disadvantage). They then retract to fatalism, where everything that
happens is predetermined by God and is therefore out of their hands.
7.3.5 Health behaviour and health belief
Half of all pregnant women in Zanzibar give birth outside the official health facilities
and only 10% attend the five recommended health examinations during their
pregnancy. Based on findings in previous chapters, we find the four following
categories of obstacles to have significant influence on our respondents’ health
behaviour:
• Physical factors: distance to the clinic, fast labour (at night)
• Relational factors: relationship to doctors and hospitals
• Contextual factors: religion, tradition, norms, minimal articulation of
pregnancy and birth
• Financial factors: material cost at hospital, cheaper to give birth at home.
With regards to the framework of the Health Belief Model233 these factors could very
well function as central components in the subjective cost-benefit analysis conducted
by women, when cognitively deciding her health behaviour. The physical and
232 cf. Chapter 4.1.3: Modernization 233 cf. Chapter 4.3.1
97
financial factors stand out as perceived barriers prevailing women from going to the
hospital. Contextual factors can influence the women’s perceived efficacy as for
example in the case of Tum Mosi Haji234, who declines responsibility for her health
behaviour with reference to God’s will. The relational factors occupies a position as
both a perceived benefit, as most women state, how giving birth at a hospital close to
doctors are safer than the alternative, but at the same time a perceived barrier, as
several women refer to the doctors derogatory attitude and fear of physical abuse. As
described in our theoretical review of the model, the different perceptions are not of
equal importance to the chosen health behaviour, neither does that seem to be the case
in our interviews. The perceived severity of the potential health threat (of giving birth
at home) is less articulated than the discomfort, fear and financial expenses they risk
having to endure (perceived barriers) when giving birth at the hospital. What the
Health Belief model tells us is that the barriers standing in the way of the
recommended health behaviour are of both structural and emotional character.
Considering the nature of these barriers; lack of religion, money and distance, they
seem to be not only perceived, but very real and out of the hands of the individual to
control. The model was originally developed within the field of health psychology
and broadly referred to in health communication literature, where it is used to predict
behaviour and frame communication based interventions. It is based on rational
reasoning stating, that choices regarding health behaviour are determined by two
types of reflections: Subjective probabilities that a given action will lead to expected
outcomes, and an evaluation of the outcome.235 This could explain why the model
only has limited focus on external variable, which (as our analysis shows) in a
Zanzibarian context have great impact on health behaviour. Respectfully, modifying
factors such as age, gender, ethnicity, personality, socioeconomics, knowledge are
implemented in the constructing of the Health Belief model, but the actual effect of
these seem to be perceived as limited. In Health behaviour and Health education
Glanz et. al. describe how modifying factors may influence perceptions and indirectly
influence the health related behaviour.236 Our analysis show how, with regards to the
factors retrieved from the interviews, structural limitations like bad infrastructure,
giving birth at night or lack of money to pay for medicine are not merely perceived as
234 Appendix 6: i1 235 Berry 2007: 30-31 236 Glanz, Rimer & Viswanath 2008: 50
98
barriers, they are in fact barriers. In the cultural context of these interviews, the
factors are not modifying factors, but defining factors directly influencing health
related behaviour: If a woman goes into labour at night, what options does that leave
her with for changing her health behaviour? The logic of the model is perhaps suitable
in a western context, where individual health choices and subjective reflections over
personal outcome is, to a larger extend, in fact a possibility. But when planning an
intervention in a developing society in the global south, attention to context and
culture is crucial. UNAIDS five contextual domains237: Government policy,
socioeconomic status, culture, gender relations, and spirituality all seems to have had
impact on the health behaviour of our respondents. In a Zanzibarian context, external
factors like religion, traditions, distance to help and lack of money are more likely to
set external limitation to alter health behaviour denying the individual of an actual
choice. This critical notion compels the following question: When a health behaviour
to a large extend is predetermined by external factors, disabling the individual from
making a actual choice, what changes will a intervention based in communication
induce? We will elaborate on this reflection in the discussion and assessments in
chapter 8.
7.3.6 Partial conclusion
Our analysis indicates that the women are not actively deselecting go to the hospital
when going into labour. The high rate of women giving birth outside health facilities
could also be explained by the encounter with several factors, which from the
women's point of view would make the health system inaccessible.
But first and foremost it is important to remember, that how, where and when to give
birth is not a personal choice but a force of nature, which can only be planned to a
certain extent (e.g. knowing when you due date is). Once in labour, psychical,
contextual, relational and/or economical circumstances are likely to interrupt the
woman's intention of going to the hospital. Faced with these obstacles, the women
perceive the health system as inaccessible. Where practical circumstances such as
lack of transportation, money and distance to help can be characterized as physical
obstacles, the strained relationship between doctors and patient suggests that some
237 UNAIDS 1999: 29
99
women avoid the professional assistance because they perceive the authorities as
emotionally inaccessible. Another emotional barrier is God. Although not in the same
way directly preventing them from going to the hospital, trusting God's will make the
women less determined to take control over their own lives. One could argue that the
role of religion would make the hospital mentally less accessible to some women.
7.4 SMS and Emergency phone
This part of the analysis aims to explore the women's usage and perceptions of the
two communication components of the intervention, the text messages and the
emergency phone, and to analyse if it correlates with the intended communication
strategy.
7.4.1 Modes of communication
Before initiating an analysis of the recipients’ perceptions of Wired Mothers’
communication approach, it is important to keep in mind that the intervention rests on
three different modes of address: SMS from the project to the women, the emergency
phone line from women to the midwives at the clinics, and the phone line between the
local clinics and the referral hospital. The different communication levels are
presented in the following figure.238
In our analysis, we will concentrate on the SMS and the emergency phone number
between women and the clinics, as our focus is on the women's perception of the
238 Appendix 1: Wired Mothers - use of mobile phones to improve maternal and neonatal health in Zanzibar
100
communication rather than the staff perspectives. Both communication components
work towards the same goal, but with different means of communication.
In terms of communication form, the automatically generated SMS from the project to
the women represent a one-way communication mode much like the one described by
Mefalopulos.239 The SMS-driven component of the communication represents a
“classic case” of the Sender-Message-Channel-Receiver-model where communication
can be perceived as vertical and linear from a sender to receiver(s). Software
developed especially for the project would automatically generate and sent text
reminders for appointments on the clinic depending on the women’s gestational week.
Health educational messages were sent on a monthly basis and included general
advise on how to act and eat during pregnancy and after delivery. Around the
expected time of delivery, text messages were sent out, advocating for the woman to
give birth in a hospital or clinic. Frequency and content of the SMS varied depending
on how far along in her pregnancy the woman was. 240 With regards to Mefalopulos'
distinction between communication to inform and communication to persuade,241 the
SMS represent the latter, using media channels and strategic methods of information
and health education to persuade the women into using the health system during
pregnancy and birth and mentally making the health system stand out as a natural
choice.
The emergency phone (and the staff phone line), on the other hand, works as a two-
way communication channel, providing women the opportunity to contact the health
system on their own initiative. The emergency phone was a channel linking the
women and the health system on a 24-hour basis. In that sense, the emergency phone
functioned on two levels: Providing women with 24-hour access to emergency
obstetric care (as stated in MDG5 as one of the main tools to decrease maternal
mortality), and on a more general level, strengthening the link between women and
the health system by making the health care more accessible to the women.
One thing is how the project intended the different communication modes of the SMS
and the emergency phone to operate. Another thing is the women’s perception and
usage of the two types of mobile technology-based intervention, which is why we will
now turn to analyse this matter based on our respondents’ statements.
239 cf. Chapter 4.2: Development Communication 240 Appendix 4: Text messages in Swahili and English 241 cf. Chapter 4.2: Development Communication
101
7.4.2 SMS
7.4.2.1 Access to information
The text message intervention is based on a one-way communicational structure
generally associated with diffusion theories. The gist of diffusion development
thinking is that behavioural change will occur through education and access to
information. Due to several context-related factors one could question how accessible
the SMS-mediated information in fact is. Sending out a message to a mobile phone
does not automatically result in the recipient getting hold of the message content.
Once the message is sent, the sender looses control over how, when and if the
message is reaching the intended receiver.
Out of the 17 interviewed women only five of them received the messages on their
own phone. For the remaining part, the messages were send to their husband’s phone
or in one case a neighbour’s phone. Despite the previously mentioned phone sharing
culture in the local setting in chapter 2, one could argue that the relatively low number
of mobile owners amongst the respondents would reduce the odds of the messages
actually reaching the intended receiver. Obstacles such as the husband being out of
town or forgetting to pass on the information could easily prevent the message from
ever reaching the wired mother. As insinuated in Zaituna Omar Salum’s answer, there
is a possibility that the information would be withheld on purpose:
Zaituna Omar Salum:242
T: she didn't know that her husband he forgot or he do it intentionally.
I: he did it intentionally?
T: she say, that she didn't know, her husband he forget to tell her that this is
your message or she she do it in... she say that she doesn't know.
I: okay. So maybe he forgot or maybe he didn't want to tell her. Okay. Why
wouldn't he want to tell her? If that is the case?
T: you don't know. She doesn't know.
Women in the Wired Mothers project represent a marginalized group in of the
Zanzibarian society. Most of them have little education and are rarely single-handedly
in charge of their decisions. Educating women to know more about their health
242 Appendix 6: i16
102
situation and their options in terms of health behaviour could lead to a degree of
empowerment, which, as positive as it may sound in our ears, is perhaps not in the
interest of all. We will elaborate this further in chapter 8.
Furthermore, the high prevalence of illiteracy in Zanzibar243 could complicate the
access to information. Although none of the women in this study admit to not being
able to read the messages, only 8 of them have attended secondary school, 5 have
attended primary and 2 have no education. It is thus reasonable to question if basing
an intervention aiming to change the behaviour of a marginalized group in a
traditional developing society on written words is the most effective choice of the
communicational strategy. On the other hand, one of the advantages of mobile phone
communication is the easy access factors244 regarding required literacy skills. It does
not require very high reading skills to read and understand an SMS as long as the
language in the text is kept on a simple level. Sending SMS with health information to
women can thus be an adequate tool to reach women as long as the text messages are
supplemented with other communication channels as well. Basing health information
primarily on text messages is too risky, as practical factors and the women’s ability to
read and comprehend the messages can stand in the way of the message reaching the
intended recipient adequately.
7.4.2.2 The medium or the message
A quantitative count245 shows that 4 out of 17 women claim not to have received the
text messages or not to remember the content of them. These four women were all
signed up to the Wired Mothers through their husband’s phones. The remaining 13
women remember receiving text messages from Wired Mothers during their
pregnancy. When asked to repeat the content of a text message the women typically
emphasized the ones reminding them to go to health examinations or the ones urging
them to seek medical assistance in case of emergencies.246 In relation to our
methodologically considerations presented in chapter 5, we find the similarity in these
answers likely to be caused by the translator and her way of asking the question.
Perhaps her urge to help the respondents to answer the questions in a fulfilling way
243 cf. Chapter 3.2: Zanzibar 244 cf. Chapter 2.1: ICT4D 245 Appendix 7: WM registration table 246 Appendix 4: Text messages in Swahili and English
103
led her to offer them examples of SMS-content when presenting them with the
question “Do you remember, what the SMS’s were about”. On the other hand, the
respondents’ trouble to recollect the content of the SMS can also be connected to the
fact that almost a year has past since they received SMS from the project. This is
supported by the fact that some women needed us to offer them cues before
recollecting the content of the messages, as the interview with Maua Omar Ali is an
example of:
Maua Omar Ali:247
I: Ten times. Does she remember what one of them said?
R laughs at the question.
T: She forget.
I: You forgot. Okay. So does she maybe remember one of the messages
being about it was now time to go to the clinic for a health check.
T: Yes.
An important function of the text messages was to remind women about going to the
recommended health examinations during their pregnancy. Maua Omar Ali represents
a repeated attitude towards the SMS-reminders, stating that “she went because, she
got the SMS and also because she wanted to check her health”. Also Tatu Juma
Khamis248 declares, that she went the ANC’s because she wanted to know her health
and refers to the SMS-recommendations:
T: Yes, she wanted to know her health.
I: okay, did she feel sick?
T: She says, because for here, I don't know for somewhere, but for here
when you are pregnant, you must go to the hospital every month. So she
went to the hospital every month.
Results from the project conclude that the text messages had a significant influence on
the number of health examinations the women attended before giving birth.
Approximately 2-3% points more women from the intervention group attended each
247 Appendix 6: i5 248 Appendix 6: i7
104
of the five ANC than women from the control group.249 Furthermore, the project’
results show that 59% of women from the intervention group claim the SMS to have
influenced them into attending ANC’s at the clinic.250251
Although only counting 17 Wired Mothers the general attitude presented among our
respondents was that they allegedly would have gone to health examinations with or
without the text messages reminding them to attend. This discrepancy triggers a
wondering about the actual impact of the SMS. Questioning the reliability of the
women’s stated intentions is one explanation to the mismatch between information
from our qualitative interviews and results extracted from the project. The
respondents’ answers could reflect an urge to “look good” in the eyes of the
interviewer by claiming to act according to the recommendations. On the other hand,
the women becoming alert to the fact that their visits to the clinic were carefully noted
in their files could also cause the increase in ANC-visits among women in the
intervention group. This could also boost the women’s personal incentive to fulfil the
recommendations, which would question the actual influence of the SMS service on
the women’s health behaviour.
7.4.2.3 A connection
The women’s ability to remember the content of the SMS may reflect the way in
which the women used the information presented to them through the SMS. Did they
just read the SMS without further reflection and action, or did they use and pass on
the information presented to them? Some women characterize the information in the
SMS as new and educational, thus stating that they learned things about pregnancy
and birth through the SMS.252 Even women who had trouble remembering the
content, stated to have gained knowledge from the SMS at the time they received
them. If this in fact reflects the women’s true perception or if they said it to please us,
is difficult to determine. To others, like in the case of Mboja Mwadhini253, the
information was already fully or partially known. Several women from both urban
and rural areas claimed not to have passed on any information to others. Keeping the
description of the local context and culture surrounding pregnancy and birth in 249 Appendix 2: WM presentaion 2011, slide 35+36 250 Ibid 251 Based on end-of-study interviews, appendix 3, form 7 252 Appendix 6: i4, i5, i6, i8, i12, i15 253 Appendix 6: i9
105
mind,254 Zaituna Omar Salum255 offers an interesting perspective in the following
quote:
T: she say, that she didn't pass it on the information.
I: Because nobody asked or because she didn't want to?
T: Nobody asked.
Receiving text messages with information about pregnancy, birth and health related
topics is quite possibly a new and unfamiliar setting to women enrolled in Wired
Mothers. The project is articulating and communicating about subjects, which are
otherwise rarely articulated or communicated within the women’s surroundings. This
could explain the limited knowledge sharing in this case. On the other hand, several
women refer to situations where they shared the information with people around
them. In some cases “ sharing information” turns out to be merely explaining the
terms of the project. But others, like Hadia Seif Abdalla256, emphasize the educational
function of Wired Mothers and the SMS:
T: She say the Wired Mothers project is very nice because they care about
them. Any time they text a message to advice, to consult so, so for her she
say it's very good.
I: Yes? And who does she talk to that about?
T: [R still speaking] her neighbours, her friends...
I: Mh, what do they talk about then?
T: she just explain them about the project and they say 'this is good, before
we didn't know anything about this'.
Hadia Seif Abdalla’s statement points to another interesting tendency suggesting that
the information is in fact of secondary importance to the women. Hadia personifies
the project by referring to the sender as they: “Any time they text a message to
advice, to consult so, so for her she say it's very good”. Fatma Ali Amour257, who also
254 cf. Chapter 7.2 255 Appendix 6: i16 256 Appendix 6: i2 257 Appendix 6: i11
106
refers to the senders of the SMS as they, seems unaware that the SMS are
automatically generated:
I: I know she doesn't remember what it (the SMS) said, that’s fine, but
maybe you can ask her how she felt about getting the SMS.
T: she feel happy. She feel and she say “ahh, they remember me”.
I: they remember me. Okay okay. Did she.. can she maybe say a little more
about why she felt happy?
T: she just felt happy, she say that she was very happy and she felt “hi,
they remember me” you are till today, you are alive and you survived.
(T and R laugh while T translates).
To Fatma Ali Amour, the text messages derives from a “real person”, who actively
decided to send her a text to make sure she was doing okay. As we will elaborate in
chapter 7.5 the personification suggests that some women care less about the actual
information content and more about the attention provided to them by the project
through the SMS.
The statements mark a discrepancy between initial project intentions and actual
outcome. From the sender’s point of view, the primary function of the text messages
was educational: Providing women with health information enabling them to make
informed decisions during their pregnancy. As the points made in this section display,
this only happened partially.
However, the SMS-intervention was found to have unexpected results. Attempting to
strengthen the link between pregnant women and the health system, the SMS’s would
work as recurring reminders to women of the presence of the health system, making
the option of going to a clinic seem more natural. According to our respondents this
only happened to a certain extend. In fact, the actual information content seems of
secondary importance to them, and instead the genuine value was simply in receiving
an SMS dealing with the women’s pregnancy and general health. The SMS represent
a connection to something larger; the women become a part of something, a priority
to someone. That is the case with Fatma Ali Amour, who can’t recall the actual
content of the text messages, but instead she emphasizes the feeling of being
remembered. In conclusion, the text messages did in fact give rise to a stronger link
between women and the health system, although perhaps somewhat different from the
way the project initially intended it. Faced with these particular contextual obstacles,
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the SMS-based intervention only had limited influence to trigger a behavioural
change. However, it did, to some women, create a sense of continuity; a constant
reminder of the health system’s presence.
7.4.3 Emergency phone
Eight out of the 17 women we interviewed used the emergency phone at least once.258
That accounts for an emergency phone use of 47% within the group of respondents,
which is slightly higher than the average use throughout the project, where 39% of the
women used the emergency phone to call their midwife at least one time.259 Five of
the respondents who called the emergency phone were from urban settings, three from
rural areas. Five women called about emergencies; feeling sick (i1, i11), stomach pain
(i14), vaginal discharge (i5), and other problems (i10), while three women called
about non-emergencies; to inform about abortion (i4), to get more medicine (i15), and
to report her id-card stolen (i12)260. In all the cases where women called about
emergencies, they were told to come to the clinic for further treatment.
7.4.3.1 Minimizing distance
Being linked to the formal health system on a 24-hour basis was a new situation to the
women, to whom the only option to get medical advice and treatment before the
project was by visiting the clinic physically. Being a traditionally grounded society
where women rarely make decisions single-handedly, one could expect the women to
act carefully around the emergency phone and only call it after consulting their
husbands or other family members. However, to judge from the interviews, the
women widely embraced the opportunity to call the emergency phone on their own
initiative. Calling the emergency phone number was natural for most of the
respondents and didn't require much consideration. A few women discussed it with
their husbands before calling, but in most cases they would call the number if any
acute or non-acute situation occurred without discussing it with anyone first. As
Fatma Armlani's statement suggests, the barriers for the women to contact the
258 Appendix 7: Wired Mothers registration table 259 Appendix 2: WM presentation 2011, slide 38 260 Appendix 6: i1, i11, i14, i5, i10, i4, i15, i12
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doctor/midwife by phone seems to be few.
Fatma Armlani:261
I: Ok. And before she called, did she discuss with anyone if she
should call it or not?
T: She say direct she call the doctor because doctor they already
tell them that 'if you have any problem just call us'.
Generally, the women seemed well informed about the function of the emergency
phone, both via information through the SMS service and from face-to-face
communication with health staff at the clinics. Many of the automatically generated
SMS emphasized the women's opportunity to call the phone number if they felt a need
for it through messages such as:
If you have health problems at any time is very important to call
your health centre or seek medical care quickly.262
In contrast to the SMS service, which didn't always appear to be fully received or
comprehended according to the project’s intentions by the women,263 the function of
the emergency phone was clear to all of the respondents, even those who did not use
it. The women who did not use the emergency phone all stressed lack of emergencies
as the reason why they did not call the emergency number. Furthermore, they all
emphasized that they would have called the emergency phone if it had been
necessary. Only one of the respondents264 expressed unwillingness to use the phone
because she feared it would be too expensive (despite the fact that they received a
phone voucher from the project to prevent just that from being an obstacle). In that
regard, it is worth remembering how the phone voucher the women in the project
received could easily have been used for other purposes than calling the emergency
phone number. After giving women the voucher, the project had no chance of
monitoring how and when the voucher was used – or by whom. It is very likely that
persons, who in fact owned the phone, which in many cases were the women’s
261 Appendix 6: i10 262 Appendix 4: Text messages in Swahili and English 263 cf. Chapter 7.4.2: SMS 264 Appendix 6: i4
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husbands, would sometimes spend the vouchers rather than the women.
It was a general opinion among the respondents that calling the emergency phone was
a good solution to smaller problems, but if more serious problems occurred they
would prefer to come to the clinic or hospital for face-to-face communication and
treatment:
Hawa Suleman:265
T: She say, that if there is no serious problem she just talk to the doctor
over the phone but if there is a serious problem the doctor tell her to come
to the clinic and they will discuss it there.
Several women explained that they felt comfortable talking to the doctor over the
phone and found it manageable to explain their situation without seeing the doctor in
person. Generally, the women's statements reflect that the communication with
doctors and midwives over the phone was perceived as rather smooth and
uncomplicated. This impression is in contrast to the women's descriptions of how the
doctors would often act rude and cruel when communicating with them face-to-face at
a health facility. In chapter 7.3.2 we described how many of the women would use the
doctors’ rude and violent behaviour as an argument for the high number of home
deliveries in Zanzibar, because many women would feel more safe at home despite
the lack of skilled attendance home deliveries brought about266. When talking about
the doctors’ rude behaviour and language, the respondents would often use other
women as examples instead of themselves. We expect it to be a way for them to
distance themselves from the situation. Stating that some women fear doctors is a lot
easier than admitting to be one of them. Again, it should be kept in mind that the
women’s way of distancing themselves from fearing doctors could reflect an effort to
answer the questions in a way they expect to be fulfilling for us.
Hidaya Rashid, who called the emergency phone because she suffered from vaginal
discharge, explains how communicating with the doctor over the phone was a good
experience, because she felt certain that the doctor had her best interest at heart.
265 Appendix 6: i14 266 Both staff members we interviewed also mentioned the strained doctor-patient relationship as a possible reason to why women would stay home.
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Hidaya Rashid:267
I: ok. Uh, and how was it to talk to a doctor over the phone?
T: She say that she felt nice
I: She felt nice?
T: Yeah
I: like how?
T: She say that she felt nice because when she got any problem the doctor
were help them and maybe they advice her 'this problem just use this
medicine, this problem just go to the hospital and I will check you' or
'this problem just do this and this.
To judge from the women's statements, it seems that the physical distance between
women and doctors created by the phone somehow diminishes the hierarchical divide
between health staff and their patients and make the women feel more comfortable
communicating with the doctor than when seeing the doctor personally.
7.4.3.2 Feeling prioritised
The emergency phone provided the women with the opportunity to skip waiting in
line at the clinic and to always have direct access to trained health staff on a 24-hour
basis. Through the emergency phone they no longer needed to come to the clinic,
because the service from the clinic would come to them through their phone. In a
Western context, 24-hour emergency phone access to a doctor is a reality for most
people, and positive experiences from that is most likely a big reason to why it is
stated as a main tool to achieve MDG5. But for women in rural and urban Zanzibar,
24-hour access to emergency obstetric care it is a rare privilege. For that reason, it
gives the women a feeling of being prioritized by the system, which inevitably
strengthens the women's perception of the health system's accessibility.
The respondents articulate the emergency phone as being a quick and direct channel
to help. In comparison to normal practice when seeking health advice there is a
significant difference. The clinics are often located in a rather large distance from the
women's home and quite often they will have to walk to the clinic because of lack of
money and transportation. Normally there is a line of people waiting outside the clinic
from early morning to past midday. Through the emergency phone the women were
267 Appendix 6: i15
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able to skip the line and get direct access to help. To use Thompson’s words, the
medium would minimize the distance between in this case women and health
system268.
Also the two staff members we interviewed emphasized the impact of the emergency
phone on the contact between the clinics and the women. According to the midwives
at Matemwe clinic, Tatu Selima Vuai and Mwanaisha Ilali Sheha,269 the emergency
phone was an advantage for both pregnant women and for staff in their daily work.
An advantage for the women because they would get free and direct access to a
doctor, and an advantage for staff members because it would give them a better
chance to be in contact with and follow up on their patients. According to the two
staff members, they would receive somewhere between one and three calls from
pregnant women on the emergency phone every day, and they felt certain that the
increased communication between women and the clinics would make more women
visit the clinics.
Apart from making staff members busier, the emergency phone would, according to
Tatu Selima from Matemwe270, affect the way the patients perceived the staff:
T: She was pleasure about the, the emergency phone and she say they,
their patients or her, her clients were, would value her
I: Would value her?
T: yeah. So every time they call her ’we need you, we need something’, so
they tell everything about their pregnancy. So I think she, she say, she was
busy but she was very happy about it.
I: Ok. She was happy that they would call and ask her?
T: yeah
The emergency phone minimized the distance to help for women both physically and
mentally, and it is relevant to explore which modes of communication have been used
in the process.
268 cf. Chapter 4.1.3: Media and Modernization 269 Appendix 6: Staff Tatu Selima Vuai, Staff Mwanaisha Ilali Sheha 270 Appendix 6: Staff Tatu Selima Vuai
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7.4.4 Addressing the recipient
Analysing the women’s experiences leaves us with the following impression
regarding the usability and impact of SMS messages and the emergency phone: The
construction of the SMS service makes it vulnerable to contextual factors like high
level of illiteracy and limited mobile ownership among the receivers. The SMS
medium holds the potential to reach a large group at limited costs, but at the same
time you risk not reaching everyone because it is not possible to shape the
communication content according to each woman’s needs and position. In that sense,
communication through SMS works like mass communication: Its reach is wide but
rarely accurate. For these contextual reasons, decoding of the information in the text
messages only happened partially, which reflects directly on the receivers’
educational gain. Although perhaps not a success in terms of passing on information
leading to behavioural change, the SMS proved to influence the receivers on a more
psychological level. The continuity of the text messages provided some women with a
feeling of safety and importance, which could be said to strengthen the emotional link
between the women and the health system and create a feeling of connectivity.
The emergency phone seems to have worked according to the project's intentions. It
provided women the possibility to seek help directly from trained health professionals
without being forced to travel all the way to the nearest clinic. In that sense, it
provided women the opportunity to take action on their own initiative and seek the
expertise of doctors and midwives even when they were physically far away. The
women used the emergency phone when they felt a need for it, and none of them
expressed anxiety towards communicating with health staff over the phone. Also the
two members of health staff we interviewed expressed positive attitudes towards the
emergency phone as it shortened the distance to help and made more women contact
the clinics during pregnancy and birth. Distance was not just minimized physically,
the phone made it possible for the women to jump ahead in line, which made them
feel prioritized. Should the plans of an up-scale of the project to include the entire
island become a reality, this would no longer be the case. The phone as the medium
would still minimize the distance to help, but there would be no line to jump, as
everyone would have equal opportunities.
This analysis points to a tendency that the women’s behaviour is not caused by active
rejection of the health system. As our study shows, the reasons for a home delivery
are often practical circumstances preventing the woman from getting to the hospital in
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time. The success of the emergency phone has to be seen in the light of this as well.
By minimizing the distance to help, the accessibility of the health system is improved.
Being a two-way-communication form and accessible 24 hours a day, the
construction of the intervention eliminates some practical and structural obstacles.
The SMS intervention is not constructed to do so, although the emotional connection
created by the continuous flow of text messages does hold the potential to influence
the negative associations concerning hospitals and doctors in a more positive
direction.
7.4.5 Diffusion and participation in the intervention
As described in chapter 4.2.8, participatory and diffusion approaches are often
combined in practical development communication interventions. The use of the
emergency phone in Wired Mothers' communication strategy is to some extend an
example of this type of combination, all though one approach is more dominant than
the other. The emergency phone opened up two different means of communication:
Women calling the clinic with acute or non-acute questions and situations, and the
clinic staff calling staff and doctors at the referral hospitals in cases where second
opinions, a certain doctor's expertise or discussing the transfer of a patient were
needed.271
The communication mode of the emergency phone includes a more dialogical element
than the rest of the project, enabling women to contact the health system by own
initiative. The emergency phone thus to some extend represents a two-way
communication mode as described by Mefalopulos to be based on dialogue and
horizontal communication rather than vertical communication and information
transfer.272 Because women are given the opportunity to contact the health system on
own initiative, the emergency phone can be said to draw on some participatory
elements in the way it links women and the health system. It is up to the women to
determine if, when and how many times they want to be in contact with health staff,
and it is thus a way for women to take action single-handedly. This element of
participation within the project somehow leans on the notion made by Servaes
271 As our focus is on the women's perception of the hotline, we are concentrating on the first mode of communication, the one between the women and the local clinic staff. 272 cf. Chapter 4.2: Development communication
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concerning how a participatory communication initiative “is no longer attempting to
create a need for the information one is disseminating, but one is rather disseminating
information for which there is a need.”273 However, within the communication mode
brought about by the emergency phone, elements from the diffusion theories are
somewhat dominant, because the emergency phone can be said to work as a
supplement to mass communication sent out through SMS. According to the diffusion
model, a combination of mass media and interpersonal channels is the most efficient
way to generate behaviour change: A behaviour change, which must be triggered and
designed from outside the community.274 Combining automatically generated SMS
sent out to a large group of people with a two-way interpersonal communication via
the emergency phone to strengthen the impact of the intervention thus largely draws
on elements from the newer and modified diffusion of innovations approach. The
women's active, participatory role only applies within frames set by the project as part
of a communication intervention mainly drawing on diffusion elements. Furthermore,
the women in question do not in any way contribute to form or frame the
communication design, which points to a strategy building on hierarchical
communication and very little participation. The minimal level of participation
enabled through the emergency phone is similar to Mefalopulos’ notion of passive
participation in his participation ladder, allowing stakeholders to participate “only by
being informed about what has or will happen, offering (…) minimal or no level of
feedback or dialogue”.275 Women call the emergency phone because it has been made
possible by the project. They do not contribute to or question the way the
communication works or the project design in general – nor have they been invited by
the project to give inputs. They call to seek advice and information from experts, not
to exchange ideas. The communication content is still vertical, a patient seeking
expertise and advice from a doctor.
However, as pointed out in an earlier chapter,276 within health communication there is
a certain need for a vertical, hierarchical communication because successful and
effective health communication depends on the expertise from educated health staff to
be distributed. There is a crucial need for a passing of information from doctors to
273 Servaes 1996: 77 cf. Chapter 4.2.4: participation 274 Rogers 1974: 48 275 cf. Chapter 4.2.5: Levels of participation 276 Chapter 4.2.8: Combining approaches in practical development communication work
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patients in order for the emergency phone to work according to the project's intentions
to lower maternal mortality by increased access and communication. Even so, an
increased level of dialogue and participation could potentially contribute to
strengthening the link between women and the clinics, making the women feel even
more included and prioritized by the health system than they already express to do
now. The next chapter elaborates on this feeling of being included in something
bigger through the project; the so-called Wired Mothers identity brought to the
women by the project.
7.5 Wired Mothers identity
Most of the women, who are pregnant, are not involved in this project.
There are few of them. So for her, this is her golden opportunity.
Fatma Ali Amour277
All respondents expressed a positive attitude towards their involvement in the Wired
Mothers project, much like the one stated by Fatma above. Being enrolled in Wired
Mothers brought benefits to the women and gave them access to services, treatment
and care in a way, which had never before been accessible to them. Therefore, it
comes as no surprise that the women expressed a very positive attitude towards the
project. However, we aim to explore which qualities about the project were
highlighted by the women, what they felt they gained from these qualities, and if their
perception of what it means to be a wired mother correlates with the intentions of the
project. When asked to elaborate on the personal gain from their involvement the
answers generally fall in two categories: access to free services and safety in knowing
that help is near.
7.5.1 Access to free services
Although not mentioned in the project documents available to us, we know from
interviews with Stine Lund and Ida Boas that the project provided women from both
277 Appendix 6: i11
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the control group and the intervention group with free services like HIV-tests, blood
pressure measurement, free medical equipment such as needles, gloves, clothes etc.,
fuel for an ambulance if needed and not least free consultation with the doctor
throughout their pregnancy. These are all services that women would normally have
had to pay for when using the health system in Zanzibar. When asked to explain what
they liked about being a wired mother, quite a few women started by emphasizing the
free services provided to them by the project.
Fatma Ali Amour:278
T: She say that this project is very nice because you get everything free of
charge, so if you for instance you can go to the hospital and the doctor say
to you that you go to buy this one and this one and this one. But for the
Mama Mtandao279 everything you can get for free.
I: Is there any other reason why she thought it was a good idea?
T: She say, this is a better project because if you have a problem at home
so the doctor they come from hospital to your home and take you to the
hospital and for more investigation, so then she say that this is a very nice
project.
Like Fatma Ali Amour, several other women refer to the free services before
mentioning the easy access to help as the advantage from participating in the project.
Also the two staff members at Matemwe considered access to free services as
extremely important to the women enrolled in the project. Tatu Selima Vuai280 states:
T: she says many women are poor in this village or this area. So after
becoming (a part) of this Wired Mothers project, many things were free.
Also midwife Mwanaisha Ilali Sheha281 explains how many women refer to lack of
money as the main reason to why they did not give birth in a hospital:
T: According to the woman who has the pregnant, when she come to the
hospital and they ask her 'why you did to give birth at home’, they say that 278 Appendix 6: i11 279 Swahili expression for Wired Mothers 280 Appendix 6: Staff Tatu Selima Vuai 281 Appendix 6: Staff Mwanaisha Ilali Sheha
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because we are poor so we have no much time to go to the hospital because
in hospital we need many things just like clothes, just like medicine, just
like injections so we are poor so it's better for us to give birth at home.
The argument presented in chapter 7.3.3, stating that the costs of giving birth in a
hospital plays a significant role to the high rate of home deliveries, gains additional
support through the women’s emphasis on free services as the main advantage
brought to them by the project. By removing some of the financial concerns related to
pregnancy and birth, the project made the health system appear more accessible to the
women. An obstacle, that appears to have played a more important role in the
women’s perception of the health system’s accessibility than the research team
acknowledges in the project documents. The free phone vouchers are briefly
mentioned by the research team, stating, that “to ensure access the pregnant women in
the intervention cohort will receive a voucher with phone credit”.282 However, free of
charge access to services, consultations and medical equipment are not mentioned,
although, as stated by the respondents, this had a significant effect on the women’s
perception of the project and its advantages. The financial intervention in the
women’s health seeking behaviour could turn out to have influenced the outcome of
the project to a higher extent than the project documents express, which would
question the level of success. We will return to this in our discussion and assessment
in chapter 8.
7.5.2 Somebody cares
Apart from free services, the majority of our respondents express how the project
made them feel safer. Hidaya Rashid Nasar and Tatu Juma Khamis express how being
a wired mother brought help closer to them through statements such as: “If you have
any problem, the doctor can take care of you”283 and “they call the doctor and they
give advice and when they need anything, they just tell the doctor”.284 From the
282 Appendix 1: Wired Mothers - use of mobile phones to improve maternal and neonatal health in Zanzibar: 2 283 Appendix 6: i15 284 Appendix 6: i7
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women’s point of view, the doctor becomes more available because of their
involvement in the project – they become a priority, as Fatma Armlani puts it:285
T: For instance when they want to give birth, so they show their card so the
doctor say 'Ah this is from mama Mtandao' so the doctor they take care of
her.
When enrolling in the project, the women received a laminated identification card
with the number for the emergency phone printed on the back. The card was the only
visible evidence to the women's participation in the project. Fatma Armlani’s
statement bears witness to the symbolic significance of the ID-card: It becomes a
membership card, opening the door to a club only accessible to a selected group.
Fatma Ali Amour286 refers to the project as “her golden opportunity” and Tatu Juma
Khamis287 “felt proud”, when her surroundings asked her, how she benefited from the
project.
In addition to becoming a priority to the doctors, Aisha Juma Said288 describes how
the WM project gave her a feeling of being taken care of. As mentioned in connection
to the SMS-intervention, Hadia Seif Abdalla289 likes the project “because they care
about them”. To Aisha and Hadia, the Wired Mothers-status provides them with a
sense of security: If something goes wrong during their pregnancy, they have
someone to turn to.
7.5.3 Empowerment
Aside from free services and privileges to consult a doctor at any time, the women
also commented on the way the project changed their perception of themselves: It
made them feel proud, as a source to knowledge and a priority to the health system.
Although not a stated objective of the intervention, these analytic points call for a
brief reflection on the potential of empowering outcomes of the intervention.
Empowerment is a buzz-word used broadly in most development initiatives today
285 Appendix 6: i10 286 Appendix 6: i11 287 Appendix 6: i7 288 Appendix 6: i13 289 Appendix 6: i2
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and, though often not articulated as an explicit target, many development projects,
whether containing elements of participation or not, hope to bring about some sort of
empowerment. Empowerment is often referred to in connection with women, as the
general idea is that empowerment of women and advocacy for women’s rights will
bring about development in the global south, where equality between the sexes is
often absent. Being a project revolving around women and their health behaviour, it is
thus natural to examine which, if any, aspects of empowerment Wired Mothers
brought about.
Also the research team behind Wired Mothers has shown interest in empowerment
aspects of the project. When we met with Stine Lund before going to Zanzibar to
collect our empirical data, she articulated an interest in finding out whether the project
enhanced the women to make their own decisions to a higher extend than before,
which is very much a question of whether the project set forth a general
empowerment of women within their families and social surroundings.
A stated objective for participatory interventions is to attain empowerment for the
people and communities in question, however, as we discovered earlier, most of the
project design in Wired Mothers rest on a diffusion approach, where empowerment is
not as much of a explicitly stated objective. The goals for diffusion interventions are
often more quantifiable and though empowerment is a welcomed side effect, it is not
an aim in itself, as it is the case within participatory approaches. The success of the
project has thus mainly been measured through quantifiable targets, answering
questions like: how many women gave birth with skilled attendance before and after
the project was launched. Had the intervention rested more on participatory elements,
the criteria of success would most likely have been less quantifiable, such as did the
women’s perception of the health system’s accessibility change due to the project?
7.5.3.1 Practical realities
WM can potentially have triggered empowerment by increasing women’s knowledge
about health behaviour during pregnancy and birth. Once women have gained
knowledge, they are more likely to use that knowledge in other pregnancies as well.
And though the women’s knowledge is not brought about through participatory
methods, a high level of education on a topic like the one in question can still prompt
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some level of empowerment, because it equips women to make informed decisions.
However, our study identifies obstacles that stand in the way of a sustainable
empowerment of the women enrolled in Wired Mothers. If empowerment is about
enhancing the capacity of making choices and acting according to these choices, as
stated in the World Bank definition of empowerment in chapter 4.2.4, our study
emphasises that improvement of structural obstacles regarding the women’s health
behaviour decisions is crucial, if the increased capacity is to result in actual actions
and empowerment. However, the ground pillar of empowerment is that people are
empowered to make their own decisions and it is very questionable if the project in
fact left it to the women to make their own health decisions. It is not truly an
informed, independent health behaviour decision, when the project has already told
the women what they should choose. Furthermore, and as we established in chapter
7.3.1, practical circumstances rather than rational choice is often the determinant
factor as to where the women end up giving birth.
Additionally, the financial benefits provided to the women by the project can also be
said to have had a significant impact on the women’s decision-making competences.
One thing is to decide to go to an increased number of ANC’s during pregnancy when
it is not going to be a financial burden to the woman and her family, as the financial
aspect of the project enabled. It is quite another thing to decide to use the health
system on a more regular basis if it affects the financial foundation of the woman’s
family. A financial foundation, which in many cases depends on the husband’s
income and means that the woman will often need to turn to her husband for approval
and money before she can go. And if it is a choice between paying for a doctor’s
consultation without feeling sick and to buy food or clothes for your other children,
most women are in fact not able to choose the health system. For most women in
Zanzibar that is reality, and the project only changed that for a limited number of
women during a limited time-span. With the way Wired Mothers worked as a
temporary financial benefit to the women enrolled, it is doubtful that the project has
been able to prompt empowerment of the women’s outside the time-span of the
project. Despite of good intentions, providing women with free benefits in the short
lifespan of the project can have caused to trip the empowerment potential rather than
trigger it.
To answer Stine Lund: Wired Mothers is perhaps able to change the women’s
perception of themselves and to educate them about their options. But as to whether
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or not the project is able to enhance the capacity of decision-making, the structural
inaccessibility and the financial obstacles of the health system stand in the way for
fully exploited empowerment potential.
7.5.4 Partial conclusion
The “membership” brought to the women by the project changed the women’s status
and perhaps also self-perception: For a limited period of time they became VIP’s in
the club called Wired Mothers, they got free services and they became a priority to
the doctors and in some cases a source to knowledge to women around them. This
Wired Mother identity can be perceived as very small empowering steps, enhancing
the women’s desire to participate more actively in (their own) health related
decisions. However, the empowering outcomes in the long run are greatly limited by
the structural obstacles standing in the way of decisions being brought to action and
the financial obstacles, which hinder the women to access the health system outside
the lifespan of the project.
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8. DISCUSSION AND ASSESSMENTS:
FITTING THE SOLUTION TO THE PROBLEM
8.1 The future of Wired Mothers
As described in the case presentation in chapter 3, Wired Mothers was a pilot project
running from January 2009 to December 2010 functioning as the case study for Stine
Lund’s Ph.D. in Global Health from University of Copenhagen.290 Since the pilot
ended, people behind the project have expressed interest in an up-scale, making the
project cover the entire islands of Zanzibar, making Wired Mothers a long term and
sustainable possibility for pregnant women in Zanzibar.
Up-scaling the pilot requires sustainable funding and collaborations. According to
Stine Lund (and Ida Boas) initial steps have already been made to attain these
requirements, although it is a rather slow process. The pilot project was mainly
funded by Danida’s general health sector support to Tanzania and Zanzibar and
through financial support to Stine Lunds’ Ph.D, and it was thus resting on a rather
short-term financial foundation291. Were an up-scale of the project to happen, a more
sustainable financing plan would be necessary. Furthermore, the project would need a
much higher degree of local initiative and ownership. The people behind the project
are currently negotiating with Zantel, Zanzibar’s largest telecommunications operator,
about making them responsible for the technological aspect as well as partly funding
of the project, while they are waiting for Ministry of Health and Social Welfare in
Zanzibar to take political and operational ownership of the project. Stine Lund and the
rest of the research team seem very aware of the fact, that if Wired Mothers is ever
going to be a permanent intervention, it needs to be run by local forces and, at least
partly, funded through other sources than international aid assistance. However, little
progress has been made since the pilot project ended in late 2010, and in our meeting
with Stine Lund she expressed doubts about whether an up-scale of Wired Mothers
will in fact ever become a reality, mainly due to lack of sufficient local ownership and
fundings.
290 Stine Lund is currently on maternity leave and will finish her Ph.D., when she returns. 291 cf. Chapter 3, Case Presentation
123
8.2 Intention vs. reality
However, lack of local ownership and funding are not the only problems facing the
potential up-scale of WM. Our analysis points to several areas, where the project’s
intentions fail to match the reality of the people it is designed to help. The following
chapter presents a critical assessment of the intervention’s design as well as
recommendations on how to adjust the communicative aspects and make them more
suitable for up-scale.
Firstly, the Wired Mothers intervention is perceived as a success by both the research
team behind the project and women involved in the project. However, the two implied
stakeholders seem to have different perceptions of, which aspects of the project
constitute its success. Based on quantitative results retrieved from the clinics, the
Wired Mothers project declares itself successful in fulfilling the aim to increase the
number of births with skilled attendance, as the data shows that 60% of women from
the intervention group gave birth with skilled attendance as opposed to 47% of
women from the control group. Quantitatively, the project is thus assessed to have had
significant impact on women from the intervention group’s health behaviour.
Furthermore, using mHealth as framework for the intervention is perceived as an
innovative and successful solution. In the concluding remarks of a Wired Mothers
presentation made by Stine Lund and her research team, mHealth is considered a
recommendable approach in developing projects concerning maternal health, stating
that:
Mobile phones may contribute to saving women’s and newborn lives and
towards achievement of MDG5.292
The respondents’ perception of the project’s success is though somewhat different.
While the project focuses on quantitative results indicating that the intervention
succeeded in fostering a significant health behaviour change within the intervention
group, qualitative responses from our respondents indicate that the women’s
enrolment in Wired Mothers shed of side effects of a more psychological and long
term character, rather than it influenced where and how they gave birth. In the
women’s perspective, the project’s success seems closely related to increased access
292 Appendix 2: Wired Mothers ppt presentation: slide 46
124
to the health system brought to them mainly by free services and consultations with
doctors. Furthermore, the women emphasize how the project made them feel that
somebody was showing interest in their pregnancy, describing it as becoming part of
a prioritized club. This perception bears witness to an inherent empowerment
potential within the Wired Mothers mHealth intervention as described in chapter 5 of
the analysis. Through our processing of the project we found indicators suggesting
that the women’s health behavioural change was only partially brought forward by
education and information. Particularly structural and practical circumstances proved
to be of great importance to the women’s use of the formal health system, challenging
the project’s very point of departure.
The different perceptions of the project’s success invite us to ask whether the
intervention in fact fits the problem. When dealing with both system-related and non
system-related obstacles, in what ways is an mHealth intervention the appropriate
approach to affect behaviour, and where does it fall short?
8.3 Project premises
Based on our analysis, we find two general problems in the construction of the Wired
Mothers intervention.
First, the problem, to which to projects aims to create a solution, is perceived as being
caused primarily by lack of knowledge. However, as our analysis suggests, lack of
knowledge is not the main reason why pregnant women do not attend the
recommended number of ANC's and why about half of them end up giving birth at
home in stead of at a health facility. On the contrary, most of the respondents
expressed a profound insight into the benefits of visiting the clinic on a regular basis
and giving birth with help from trained health staff. Furthermore, given the choice, all
of them293 would prefer to give birth in a health facility. Although some of the women
stated to have gained knowledge about pregnancy and birth through the SMS, none of
them claimed the SMS to be determinant factors to where they gave birth. Based on
that notion, it seems reasonable to assert that lack of knowledge is in fact not the main
reason to why so many women in Zanzibar give birth at home.
293 Except Nyamato Vuaij Hija, appendix 6: i3
125
Secondly, and closely linked to the first point of critique, the solution fails to
adequately adapt the cultural context into the intervention design. The project is based
on a scientifically grounded health view, advocating regular contact with the formal
health system and giving birth at a hospital as the best solutions to decrease maternal
and newborn mortality in Zanzibar. This health view is based on the conclusions of
several research projects stating that the way to secure safer reproductive health in
developing regions of the world is by increased access to the health system and by
providing women the opportunity to give birth in secure settings with the help from
trained, professional health staff.294 While we by no means aim to question the
legitimacy of this health view, our analysis raises a critical remark to this particular
subject. From our point of view, the initial thoughts on how to operationalise these
scientific conclusions are limited by a far too narrow perception of how to change
health behaviour: A perception, which lacks sufficient relation to the cultural context
in question.
The main focus of the project has been to create a change of location, so to speak,
focusing to a large extend solely on making pregnant women to move from A to B,
from home to hospital. As our analysis shows, health system and non-health system
factors are likely to stand in the way of this to succeed. The project thus relies on a
linear movement, which could be illustrated as: Home ! Hospital. We believe the
sustainability and impact of the project would benefit from changing this linear
perception of the intervention into the more dynamic and circular perception of
Home "! Hospital, including external factors more actively into the intervention
design. In the project’s own communication model, a two-way communication form
is actually incorporated in the intervention, giving health staff at the clinics a
possibility to follow up on defaulting or critical patients.
294 cf. Chapter 3.1: Maternal mortality in the developing world
126
However, in practice, the two-way communication was only carried out between the
primary health care units and the referral hospitals. In its original form, the requested
change in health behaviour is determined by women physically coming to the
hospital. However, providing women with the opportunity to give birth in secure
settings can also be obtained by bringing the health system to the women, both
figuratively and physically speaking. We will return to this matter later in this section.
8.4 Determining obstacles
Returning to the first point of critique. If knowledge is not the decisive element for
the women’s health behaviour, then what is? According to our analysis, four
categories of structural and practical obstacles can been identified as main
determinants for the weak link between pregnant women and the formal health
system.295
1. Physical obstacles; distance to the clinic, going into labour at night, lack of
transportation etc.
2. Contextual obstacles: religion, tradition, norms, articulation of pregnancy and
birth.
3. Relational obstacles; perception of hospitals and doctors.
4. Financial obstacles; the costs of giving birth at health facilities versus the
costs of giving birth at home.
Common for all of obstacles is the notion that the women's perception of the health
system's accessibility is a key factor. Health system factors as well as non-health
system factors are in fact mentioned as influential factors to health decisions in
“Roadmap to accelerate reduction of maternal, newborn and child mortality in
Zanzibar”296, but still, the construction of the intervention fails to provide these
factors the necessary attention. We will discuss each obstacle and give
recommendations on how to approach these obstacles in order for the intervention to
meet the women’s needs and adapt the cultural context to a higher extend than is the
295 cf. Chapter 7.3.5: Health behaviour and health Belief 296 Report by Ministry of Health and Social Welfare in Zanzibar: 1
127
case in the original intervention design.
8.4.1 Physical obstacles
Through interviews with our 17 respondents, we learned that no matter how
successful the communication intervention of the project is, a noticeable number of
women will inevitably end up giving birth at home, mainly due to practical
circumstances such as bad infrastructure and limited access to transportation.
Psychical obstacles like lack of transport, bad infrastructure and distance to clinics are
non-health system factors and beyond the scope of this study to address thoroughly.
Even so, they are essential realities for women in Zanzibar during pregnancy and
labour, and in order to reach more women, it is important for the project not to
underestimate this aspect. All in all, the project would benefit from embracing
practical circumstances that will inevitably sometimes stand in the way for women to
reach a clinic or hospital in time for labour. If lack of transportation is a main reason
for women’s place of delivery, what can be done to target this obstacle? Is it a matter
of buying and ambulance, hire local drivers to be Wired Mother-drivers, whom the
women can call on the emergency phone, or is it to equip women and their birth
helpers to conduct safer home deliveries for instance by providing them with a home-
delivery-kit with gloves, medical tools and a step-by-step guidebook?
Where the practical circumstances cannot be controlled, they should be complied
with. In order for this to happen, the project needs to change its perception of the
health system from a static institution that women must physically visit to get help,
into a dynamic institution meeting the women half way. The construction of the
emergency phone proves as example of how media can effectively downplay the
influence of physical obstacles on women’s health behaviour. Through a 24-hour
phone service the health system moves closer to its patients, appears more accessible
and provides pregnant women with the opportunity to consult professional staff on
more or less acute health matters. However, as stated by many of the respondents, the
emergency phone line is mostly useful in terms of smaller problems and questions,
and in times where consultancy via phone is not sufficient, the project would benefit
from a more purposeful targeting of the physical obstacles separating women and the
health system.
128
8.4.2 Contextual obstacles
As stated throughout the theoretical and analysis chapters, taking into account the
local context of a health communication intervention is crucial if the intervention is
going to have sustainable impact.
However, in our analysis, we have elaborated on some cultural and social factors of
great importance to the women’s health behaviour and perception of the project.
Although the research team behind Wired Mothers has been aware of the points made
about health system factors and non-health system factors challenging reduction of
maternal and newborn mortality in Roadmap to accelerate reduction of maternal and
newborn deaths297, we note, based on our analysis, that these factors seem to have
been downplayed when designing and implementing the project.
Before proceeding, we find it important to emphasize that the people behind Wired
Mothers have large insight to the local conditions in Zanzibar; the research team
consists of mainly local Zanzibarians, while Stine Lund and her Danish colleagues
have worked and lived in Zanzibar over a long period of time and are accustomed to
the local context. They know how the system works, they have been in continuous
contact with the women in question, and they have visited all the clinics enrolled in
the project. They are by no means just a group of foreigners who have come to the
island to implement a project on their own terms without taking local conditions and
needs into account. On the contrary, they seemed very aware that the more locally
rooted the project was, the more successful it would be.
Still, we base the following assessment and recommendations on the notion that this
knowledge was not sufficiently reflected in the design and implementation of the
Wired Mothers project. We will thus elaborate how the women’s contextual reality
including traditional birth helpers, power structures within her domestic sphere, and
articulation of pregnancy and birth should be taken into account in the project design.
8.4.2.1 Traditional birth helpers
Once again we emphasize how practical circumstances should be taken into
consideration when they cannot be controlled. First of all, a lot could be gained by
297 Report by Ministry of Health and Social Welfare in Zanzibar: 1
129
joining forces with the existing traditional health system, starting by acknowledging
the role traditional birth helpers play in the community. No matter how much more
safe it is to give birth with help from a trained midwife or doctor, reality is that more
or less untrained birth helpers from the women’s community, often mothers,
neighbours, aunts etc., are in charge of almost half of all births around the island.
Acknowledging that home ! hospital is not always an option in Zanzibar, the
project should apply time and resources to establish closer collaborations between the
traditional and formal health systems. This could for instance include educational
initiatives aimed at traditional birth helpers, making them better equipped to attend
labour in cases, where women end up giving birth at home, and thus secure higher
standards for home births. Including the traditional birth helpers more actively in the
intervention design will help strengthen both the general and specific targets of the
project: On a specific level, it would secure safer deliveries with trained birth helpers
and hopefully decrease the maternal mortality in the long run. On a more general
note, it would make the traditional birth helpers ‘part of the team’, working towards
inclusion of the community, which earlier chapters have proved to be crucial in order
to affect health behaviour in developing countries.
To help this collaboration on the way, it would be profitable to provide the traditional
birth helpers with access to the emergency phone number, enabling them to contact
the clinic or the referral hospital if an emergency occurred during a home-delivery. In
the same way that the project has contributed to a stronger link between the local
clinics and the regional referral hospitals, a similar link could be made between the
traditional helpers and the clinics and hospital and finish the circle of communication
between births attendants, so to speak. According to the project’s initial design, it was
part of the strategy to hand out vouchers and ID-cards to the traditional birth helpers
as well, but the intentions were never brought to life.298 According to Ida Boas299, the
project shelved that part of the strategy because it would be too difficult to monitor.
Including the traditional birth helpers and acknowledging their contribution to the
local community could shift the project’s health communication perception from
being mainly influenced by elements from the modernization theories towards a more
298Appendix 1: 3 299 Research assistant in Wired Mothers
130
including, participatory approach to maternal health, encouraging local ownership,
participation and empowerment.
8.4.2.2 Domestic power structures
While empowering women to be more in charge of their own decisions through
participation in the project is considered a positive side effect of the project, it also
needs to be seen as something that would potentially foster new dynamics within the
women’s families and domestic power structures, which could potentially appear
intimidating to the women’s husbands and other community authorities. In the Wired
Mothers inclusion form300, filled out by pregnant women when enrolling in the
project, several questions touch upon the power structures within the women’s
marriage, indicating that women need permission from their husbands before
engaging in communication with the project via (often the husband’s) mobile phone.
Some of the questions directly aim at learning if it is likely that the husband will show
his wife text messages from the project received on his phone and if he will allow her
to use the emergency phone number. These considerations in the project design
strongly suggest that the project’s ability to reach women depends on the husband’s
perception of the communication content and his willingness to let his wife engage in
the communication. It is thus recommendable to more explicitly take into account the
husband’s role in and attitude towards the project. So far, the husbands have not been
included in the project and their only role seems to be to own a phone, which allows
the project to reach the women. A stronger degree of inclusion of the husbands would
be in the interest of all parties. It would enable the project to learn if the husbands are
predominantly positive towards the intervention or if they somehow feel that the
project interferes with their domestic territory. Including the husbands’ point of view
in the project design could potentially strengthen the participation and empowerment
of the women and their communities and thus strengthen the link between pregnant
women and the health system.
300 Appendix 3: form 3: Inclusion form
131
8.4.2.3 Articulation of pregnancy and birth
When preparing the interview guide, we included questions about how pregnancy and
birth was commonly articulated and discussed within the local community. Initially,
we asked these questions hoping to learn to what extend some sort of knowledge
sharing on the matter was taking place among women. However, our interviews bear
witness to very little communication on the subject, and it is thus relevant to ask:
How do you fit a communicative intervention to a subject, which is normally
approached with privacy and silence?
Addressing the subject of articulation of pregnancy and birth in our analysis301 we
found that the subject is only shared with the woman’s closest family and her doctor,
not necessarily because it is a taboo subject, but because it is simply not something,
which is discussed in public in the same way, as we know it from the Western world.
For the same reason, we sometimes struggled to make our respondents express their
thoughts and feelings about their own pregnancy, and the questions regarding
practical and pragmatic subjects were clearly easier for the women to answer than the
ones of more emotional and personal character. There is thus a risk that our struggle
to make the women engage in a proper dialogue on the matter has caused the subject
to appear even more private and secretive than it in fact is in the women’s everyday
lives. Even so, we got a strong impression that pregnancy is approached and
articulated in a more pragmatic matter in Zanzibar than in Western countries where
having a baby is commonly an emotional and publicly shared matter. When designing
the intervention to revolve around communication related to pregnancy and birth, the
project must then be sensitive towards the private nature of the subject in the local
context. If an SMS ticks in on a neighbour’s phone or the woman’s husband receives
it on his phone, it might not be a natural act to pass along the message when the
content of the message is not something people within the community normally share
with one another.
It brings light to a paradoxical matter regarding health communication and pregnancy:
If all health communication theories and practitioners emphasize how inclusion of the
local context is crucial in order to bring about sustainable health behaviour change,
301 cf. Chapter 7.2 Local context: Articulating pregnancy and birth
132
how should it be dealt with when the health behaviour in question is surrounded with
silence and privacy?
We assess the most important task of the intervention is to make the formal health
system more available to the women and her surroundings and thus to make it a
natural and obvious choice to seek help from skilled health staff. The project’s stated
objective to strengthen the link between women and the health system is thus to a
large degree spotting the epicentre of the problem. However, the project often lacks
an active consideration of traditional and religious forces influencing women and their
decision-making competences. If women, like Tum Mosi Haji302, believe that their
fate is in “God’s hands”, they cannot be expected to base their health behaviour
strictly on rational reasoning. Once again, we emphasize how the women do not
actively deselect the formal health system, but that it often simply just happens
because the formal health system in not perceived as an obvious choice. It is our clear
assessment that the more flexible the health system appears, meeting women halfway,
for instance by involving the community to a higher degree, the stronger a link will be
built to the women.
8.4.3 Relational obstacles
Several of the women we interviewed mentioned the doctors’ rude language and
violent behaviour as a main reason why they or other women do not like to visit the
clinic and/or hospital. Keeping in mind that the doctors and midwives are the faces of
the project, and the ones, which the project aims for the women to trust and visit more
often, the women’s perception of doctors is an important determinant of where they
feel safe giving birth. Even though all the respondents recognize the increased level of
medical safety when giving birth at a health facility compared to a home delivery,
several of them emphasize how the tone in the clinics and hospitals are contributing
factors to why many women (although often referring to “other women”) risk their
safety in order to give birth in what is considered a more comfortable environment to
them. A general strengthening of the doctor-patient relationship could very well have
a psychological impact on the women’s perception of the health system’s
accessibility. While staff members at the clinics seem well informed about the
302 Appendix 6: i1
133
practical elements of the project, it is less certain how much they actually have been
told about the underlying thoughts about the project. A more thorough introduction of
the project concept to the doctors could trigger a better delivery of the project
components from doctor to patient. The project could thus consider conducting staff
training at the clinics, teaching doctors, nurses and midwives about the importance of
a strong doctor-patient communication and encourage them to engage in better
dialogue with pregnant women. These relational obstacles are deeply rooted within
the cultural context, and while breaking down the general hierarchical divide between
doctors and patients is beyond the reach of the Wired Mothers project, our analysis
indicates a stored potential of the intervention to influence relational factors within
the health system. As stated in chapter 7.5 of the analysis303, the intervention did in
fact lead to positive reflections on the health system in general among the respondents
who felt cared for and prioritised, and most of the women expressed to have had
positive experiences communicating with health staff over the phone. Although not a
spoken objective of the SMS and emergency phone, the potential of this
psychological effect must not be underestimated. Wired Mothers’ task is to remove as
many obstacles as possible between women and the health system and equip, or
empower, them to seek medical help when they feel a need for it. Ensuring that the
doctors’ attitudes do not make up a psychological obstacle is crucial for a strong link
between women and the health system.
8.4.4 Financial obstacles
The fact that Wired Mothers secured women with free benefits such as free
consultations, blood samples, phone vouchers, and fuel for the ambulance was by
several women emphasized as their main gain from the project. However, the project
does not mention the free benefits as a decisive factor in neither their introduction nor
evaluation of the project. Still, our analysis suggests that it has in fact played an
essential role for the project’s success rate. The incentive to provide women with free
benefits was to secure, that financial obstacles would not account for the main reason
why women in the project would stay away from the formal health system. Women
303 cf. Chapter 7.5 Wired Mothers identity
134
from both the control group and the intervention group received free benefits to
prevent financial circumstances from determining the difference between the two
groups of women within the project. And while free benefits were without a doubt
helpful to the women and maybe even a good tool for the project to measure the
outcome of the intervention, it compromises the sustainability of the project (and the
future plans to up-scale). The way in which the project was designed to pay for
women’s expenses gave the wired mothers a privilege compared to other pregnant
women in Zanzibar: They were given the chance to skip the line to a doctor’s
consultancy and they got many services for free, which women not included in the
project would still need to pay for. To achieve the same significant change in
behaviour among pregnant women in an up-scaled version of Wired Mothers, the
services provided by the project would have to involve all pregnant women in
Zanzibar. This would account for an enormous expense to the official health system,
which could jeopardize the political incitement and support. Secondly, a sustainable
future for the project would be forced to eliminate the privilege of jumping the line at
the expense of others, since the services would be equal for all pregnant women in
Zanzibar.
If the project fears that financial factors will be an obstacle for a strong link between
women and the formal health system, it would be appropriate to work out other, more
sustainable ways to narrow the economic divide between women and the clinics. For
instance, money that would otherwise be spent to pay for services for each individual
woman could be pooled and spent to buy a Wired Mothers-ambulance from which all
pregnant women on the island would benefit. Alternatively, the money could be spent
to generally lower the costs of ANC’s in local clinics. However, that would be a
political decision and beyond the scope of this study to fully examine the impact of.
8.5 Why mHealth?
Using mobile phones to reach pregnant women in Zanzibar has shown to be effective
in the case of Wired Mothers, however, the two communication components of the
initiative, the emergency phone and the SMS, have proven to play very different roles
and with different levels of success. While the emergency phone played a very active
role in strengthening the link between women an the health system by making
135
treatment, care and advise accessible to the women on a 24-hour basis, the SMS had a
less direct effect on the women’s behaviour. The SMS created a sense of continuity,
reminding women of the health system as an option to them, but it is doubtful that
receiving continuous SMS-reminders played a major role in the women’s actual
health behaviour. Our clear assumption is, that even without the SMS, the number of
births with skilled attendance would have risen to the same level in the intervention
group, mainly due to the free goods and the emergency phone.
It is thus reasonable to consider how the Wired Mothers intervention could be
designed to suite the criteria of an mHealth project, exploiting the communication
potentials within the mobile communication channels.
8.5.1 participation through SMS
The SMS communication’s limited effect on the women’s health behaviour patterns
can partly be explained by the before mentioned obstacles, limiting the women’s
possibility to act according to health advise from the SMS. Furthermore, we believe it
can be partly explained by the way in which the SMS content was designed and
distributed. A way that could have made use of the possibilities the media channel
brings to a higher degree than in the original design.
The way in which the SMS worked as continuous reminders for women to use the
formal health system by entirely one-way communication left no option for the
women to bring a contribution to the communication in question. While the SMS-
service worked as an efficient way to reach a large group of women, the way in which
the SMS communication was used in the pilot project did not fully exploit the
participatory potentials within the communication channel. Roughly speaking, Wired
Mothers’ use of SMS almost worked in the same way as if the project had handed out
posters or flyers to women and their families: As a one-way information leaflet,
educating women to act according to the project’s recommendations. The SMS
channel contains communication and participation potentials far beyond that.
As described in the introduction to this study304, several mHealth projects have used
SMS to engage their recipients and bring about participation, education and a degree
of empowerment. The mHealth project Text for Change in Uganda used an SMS-quiz
304 cf. Chapter 2. The mobile revolution
136
to generate knowledge about HIV and Aids and thus enabled recipients to participate
in a dialogical, two-way communication with the project. After finishing the quiz,
participants received information on where the nearest HIV testing and counselling
unit was. The project raised awareness on a serious subject through mobile phones,
using both educative and entertaining tools to engage their recipients, which we
earlier described as Edutainment.305 This method did not only raise people’s
awareness and knowledge on the subject, it also encouraged more people to go for
free testing and counselling, because the SMS communication helped demystify HIV
and AIDS.
Involving the recipients in a more dialogical and participatory communication
through SMS is an option for Wired Mothers as well, for instance by following the
experiences from Text for Change. If the SMS could be implemented to engage
women to a higher extend, it would potentially play a more significant role in
changing the women’s health behaviour patterns through edutainment and
empowerment communicational tools.
8.6 mHealth by coincidence
So, is Wired Mothers even suited to be an mHealth project if many of the reasons for
the weak link between women and the health system lie within practical and structural
frames?
In our meeting with Stine Lund she explained how Wired Mothers entered the
mHealth tradition somewhat by coincidence. The people behind the project spotted a
need for women to give birth with skilled attendance, and they assessed mobile
phones to be an adequate tool to make it happen because of the large mobile
penetration in Zanzibar, and because they were curious to learn what effects mobile
technology could potentially have on health behaviour. At that time, the research team
was not aware of the concept of mHealth.
The project does sometimes bear the mark of being designed without a pre-
determined communication strategy. First of all, the mission seems to be to uncover
the possibilities in using mobile technology to decrease maternal and child mortality
305 cf. Chapter 4.2.7 Entertainment-education
137
in Zanzibar, without ever really questioning whether an mHealth initiative is in fact
the right solution to target the problem, or if other more urgent challenges are at stake.
Secondly, and in continuation of the first notion, it seems as if the project did not
always manage to take the local context into consideration in a sufficient way when
designing the different elements of the intervention. Thirdly, the project contains
some sustainability weaknesses, which could challenge the lifespan of the project,
should it one day be up-scaled to cover the entire island. Especially the financial
privileges brought to the women by the project are problematic, because of its
distorting effects on the local setting.
As much as it would satisfy our communication hearts to conclude that
communication through mobile phones can foster a decrease in maternal and newborn
mortality in Zanzibar, reality is that there is a much higher need for practical and
structural solutions to strengthen the link between pregnant women and the health
system. Something, which mobile phones can help to achieve but only as a
supplement to practical and structural changes on a community and political level.
8.7 Upscaling mHealth - a reoccurring struggle
The effectiveness of health education is dependent on the quality
of the planning process.
We begin this final section by quoting Gerjo Kok306 and his rule thumb, which
appears logical in theory, but somehow difficult to execute in practice and which has
proven valid for the Wired Mothers project and its challenges to create sustainable
impact.
Wired Mothers is far from the only mHealth initiative facing a potential struggle to
create sustainable and long-lasting solutions despite promising results in the pilot
phase. In fact, potential up-scales seem to be a general challenge within the field.
mHealth is a popular trend within development work, especially because of mobile
technology’s potential ability to reach groups of people who are normally outside the
scope of a classic health initiative. But including mobile phones into an intervention
306 cf. Chapter 4.3.1 Effective health communication
138
does not ensure successive results. In fact, the challenges of up-scaling mHealth
interventions was the main theme at the annual United Nations mHealth summit in
Washington where organizations, experts and stakeholders were gathered to discuss
the field.307 A report composed by the organization Advanced Development for
Africa (ADA) titled Elements necessary for the successful scale up of mHealth in
developing countries, addresses just this struggle:
Despite the strong promise demonstrated by mHealth tools and applications,
the current landscape of mHealth development in developing country
contexts is characterized by a proliferation of unsustainable pilot projects
that often expire once initial funding is exhausted.308
The ADA report is meant as a constructive guide for people involved in mHealth
related projects, constructed mainly through examples on successfully up-scaled
mHealth projects and field expert interviews. Still, the report addresses several of the
same issues as presented in this study. To secure best practice, the report emphasises
how “sustainability and scalability factors must be built into the program from the
beginning”.309 Translating this into a Wired Mothers context, the financial benefits to
women included in the Wired Mothers pilot would not be sustainable on a broader
scale, neither practically nor financially. The ADA report also stresses how local
conditions such as existing health care infrastructures, mobile network signal reach,
literacy levels, language requirements and local practices can have significant impact
on the success of a project; factors very similar to the before mentioned notion of
health-system and non-health system factors. In the ADA report it is recommended to:
“…acquire a concrete understanding of the health system environment and
norms within which the system will be operating. This includes identifying
both cultural and social norms that affect patient behaviour and uptake of the
mHealth intervention, as well as the political and policy environment that
affects implementation and scale up of the intervention. For example, if there
is a gender gap in mobile phone ownership, this may render an intervention
307 Representatives from Wired Mothers were in fact invited to speak about the project at the summit, because of the project’s promising results, but they were not able to attend. 308 http://www.adaorganization.org: mHealth White Paper: 12 309 http://www.adaorganization.org: mHealth White Paper: 12
139
ineffective if its target audience – women – do not have regular access to a
mobile phone.”310
Although the research team behind Wired Mothers were aware of the system related
and non-system related factors contributing to the statistics of births outside the health
system, this knowledge was not put to substantial use during the planning of the
intervention.
Regarding a future up-scale of Wired Mothers, other ADA recommendations are of
interest. For example, the report emphasises the importance of “educating and
engaging end-users and target beneficiaries in the development of the mHealth
intervention and Identifying what motivates the end-users, not just what the objectives
of the program are”, which suggests boosting the participatory elements in
interventions by activating all involved parties in the process.
Though mHealth is still a relatively young field, the ADA report, UN’s mHealth
report and the theme of the annual mHealth summit 2011 all demonstrate attention to
the problems at hand within the field. We present this study as a relevant contribution
this debate - not just regarding the future of Wired Mothers – but to the development
of mHealth and M4D in general.
310 310 http://www.adaorganization.org: mHealth White Paper: 12
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9. VERIFICATION
Applying the trinity of verification; validity, reliability and generalisation, which
originally belongs to the positivistic founded disciplines seeking one objective truth,
to qualitative based results, is not without difficulties. However, the context in which
our interviews were carried out has throughout the duration of this study given rise to
important reflections and discussions concerning the veracity of the data. Finding
these discussions relevant to the overall comprehension of the conclusions in this
thesis, we will present them here, using Steinar Kvales’ reconceptualization of the
trinity.311
9.1 Reliability
A reoccurring concern to us was how much information was lost in translation due to
the presence of a translator with limited English skills. This choice of using a local
translator has unquestionably lead to some degree of simplification or unintended
misinterpretations in the questions and answers. Also, there were (although few)
situations were our translator, Fatma’s personal beliefs and perceptions seemed to
interfere with her translation. As described in chapter 5 these factors can be said to
have contaminated the reliability of the data. However, since those were the terms for
our field trip and our best option to collect the data, we repeatedly tried to minimize
the influence of the translator. Besides limited English skills, Fatma lacked basic
insight into the construction of qualitative interviews. Given these different
circumstances, the quality of our interviews would have benefited from her being
more trained into understanding the framework of qualitative research. Unfortunately,
that was beyond the time and financial span of this study.
In addition, we were faced with other unforeseen obstacles in terms of several cultural
barriers complicating the interview situation. In chapter 5 we describe struggles trying
to balance between distancing ourselves from the project when interviewing, while at
the same time relying on the team behind the project to make the interviews possible.
Although being constantly alert to the possible complications of our somewhat two-
311 Kvale 2005: 225-246
141
faced role, it is hard to determine to what extend we succeeded in making the women
feel comfortable enough to speak their mind to us. A relaxed and friendly atmosphere
accompanied most interviews, but surprisingly few critical remarks were uttered. We
often found it difficult to get beneath the surface and when we pushed for elaboration
of answers, a common response was “I don’t know”. Whether this was due to the
quality of our questions or cultural barriers out of our control is hard to determine.
However, our analysis is not just limited to the 17 qualitative interviews but based on
an insight into the culture of the region, which gives us reason to believe, that our
difficulties are mainly related to the habit of Swahili people to almost never talk
negatively or critically about things, the women and the translator not comprehending
the premises of qualitative interviews, and most importantly women’s position and
confidence to speak their mind in a traditional society.312 In hindsight, one could
argue that conducting focus group interviews would have taken some pressure off the
respondents, however we believe the translation would suffer severely from this
construction and we would have very limited control over the flow of the interviews.
With regards to the later point, the uncertainties facing the reliability of this study is
the price you pay, when attempting to give a voice to a usually voiceless group of
people. In our case, we were aware of the difficulties, dealt with them to the best of
our abilities and on those terms retrieved the best possible material. Weakness found
in the data must be weighed in correlation to the conditions set by the context.
9.2 Validity
According to Kvale, the best way to ensure valid results is to reflect upon the validity
of a study throughout the entire process and not just assess the final product.313 As
described in chapter 5, we tried to eliminate subjective interpretations while
condensing and categorising by cross-examining our results.
A more overall assessment of the validity of this study would address the question ‘do
we examine what we set out to do’. To this question we find a discrepancy between
the focus in our initial intention and the final conclusion. Before leaving for Zanzibar
our recognition of interest was to uncover women’s experience and their personal
312 We spent one month in Tanzania and Zanzibar. Before that Johanne lived and worked in Tanzania for a period of eight months 313 Kvale 2005: 231-233
142
development lead forward by the intervention, differentiating between change of
attitude and behaviour change among the women. While processing the data our focus
shifted from being mainly a recipient analysis of the project’s impact on the
recipients’ health behaviour, to focus on whether the project’s intentions are in fact
consistent with the recipients’ reality. Although not resulting in extensive alternations,
this minor shift in focus, brought forward by the inductive nature of our process, did
mean that the interviews only sought reflections from women submitted to the
intervention. Given the essential role the women’s local context came to play in the
analysis, one could argue that abandoning our initial deselecting and including
women from the control group (or other women from outside the intervention) would
strengthen the points of the analysis. Since the interviews were conducted in
Zanzibar, the possibility of conducting a series of follow-up interviews was not an
option, and furthermore, it would be beyond the scope of this thesis to take both
perspectives into account.
Throughout this study we have addressed the Wired Mothers project as an mHealth
intervention despite the fact that the research team only became aware of the
existence of the field during implementation of the project. Furthermore, we have
sought to address the communicational aspects of a research project originated within
health science where communicational aspects are not the primary concern314. In
doing so, we have in some way removed the project from its ontological foundation.
Although not affecting the validity of our study, this reflection is important to
remember in order to understand the premises on which the project is build.
9.3 Generalisability
To which extend the present results transfer to a larger, more general scale is not the
crucial question when working with qualitative interviews. Our list of respondents
was not a result of a random selection, but chosen based on their enrolment in a
specific case and certain criteria set by us. The goal was not to find a general truth but
to extract detailed information from a limited number of respondents in a specific
314 The project is carried out by Stine Lund, who is a doctor and currently writing a Ph.D. in global health.
143
context. Still, the following presents a short evaluation of the statistic and analytical
generalisability of the study.315
17 interviews set a natural limitation to the statistic generalizability of this study.
It is questionable how much it is possible to say in general terms based on 17
interviews. However, supporting the reliability of our selection of respondents, we
conducted a number of quantitative comparisons between our respondents and results
from the Wired Mothers project’s own statistical data. These results showed that the
history of our respondents was an acceptable match to that of the 1311 women from
the intervention group in terms of parity, number of births with skilled attendance,
number of women calling the emergency phone etc. This supports the statistic
generalisation of our study.
Based on the analysis, we suggest that up-scale of the current version of Wired
Mothers would be difficult due to significant health system and non-health system
obstacles. Aside from the study at hand and the theoretical backbone it stands on, we
support these statements by extensive mHealth research including numerous examples
of failed attempts of up-scaling other projects due to miscalculations of structural
obstacles. This knowledge suggests that our results, though very context related, can
in fact transfer to a larger scale, which proves the analytic generalisability of our
study.
In conclusion, despite these concerns we leave the study with an overall content
feeling about the validity and reliability.
315 Kvale 2005: 227
144
10. SUGGESTIONS TO FURTHER RESEARCH
Considering the different participants affected by the Wired Mothers intervention, our
chosen limitation of the study leaves the role of the midwives at the PHCU free to
submit to further research. Besides hoping to create behavioural change among
pregnant women, the intervention also changed the working conditions for health
workers at the PHCU and referral hospitals.
For one thing, the emergency phone diminished psychical limitations caused by
women’s distance to clinics and thus changed the premises of staff communicating
with patients. Before the project, patient contact was limited to face-to-face
interaction, but during the project the consultations were conducted over the phone.
This changed the general ways of patient interaction as well as the working conditions
for staff members.
Although mentioning how the emergency phone increased their workload, both staff
members from Matemwe spoke positively about the change the intervention had
caused. For instance, as stated in chapter 7.4.3.2, staff member Tatu Selima Vuai316
points to a sort of personal enrichment by feeling “more valued” by her patients,
which would be interesting to pursue with further research.
Secondly, both Ida Boas and Stine Lund emphasised how they received positive
feedback (in terms of both personal and professional gain) from staff at the PHCU’s
concerning the communicational connection to the referral hospitals. The local PHCU
had a direct number to the referral hospitals in case of emergencies and a need for
consultancy from a doctor. Further research on the mobile phones’ potential influence
on the relational power structures between midwives and doctors would also be
interesting to pursue.
316 Appendix 6: Staff Tatu Selima Vuai
145
11. CONCLUSION
When our translator, Fatma, during our very first interview, stated how giving birth at
home is ”just a lucky gamble”, she captured the essence of the problem Wired
Mothers is facing. For women in Zanzibar, the course of pregnancy and delivery often
lacks the luxury of choice. Instead, women find themselves depending on external
circumstances granting them a bit of luck. Our analysis found the mHealth
intervention Wired Mothers to have only partly managed to change the terms on
which women in Zanzibar enter the gamble.
As stated in the preface, the objective of this study was two-fold: We aimed to
analyse the communicational aspects of Wired Mothers, partly by focusing on the
project’s impact on pregnant women’s health behaviour, and partly by assessing how
the project’s intentions consist with the reality of the women it was designed to help.
Processing our qualitative interviews showed the two parts of our analysis to be
mutually reliant and difficult to separate: The impact of Wired Mothers is deeply
dependent on the project’s ability to comply with the practical and contextual
circumstances forming the women’s reality.
In terms of impact, the project did succeed to influence women’s health behaviour,
but only when structural obstacles were naturally absent, diminished or artificially
abolished by the project itself, for example by removing the financial burden a
doctor’s consultation would otherwise cause the women. The project’s two
communication components, the SMS service and the emergency phone, did
contribute to a stronger connection between pregnant women and the health system.
Through continuous information flow, the SMS service created a feeling of
connectivity (what we call the Wired Mothers-identity), while the emergency phone
brought the health system to the women’s assistance on a 24-hour basis. However, as
soon as structural circumstances interfered with the women’s ability to determine
their own health behaviour, it was beyond the reach of the project to influence the
course of pregnancy and birth via communication.
Resting mainly on the theoretical grounds of diffusion, the Wired Mothers
intervention works from the assumption that access to information and education on
how to engage in safe pregnancy and childbirth will leave pregnant women more
inclined to act according to the project’s intentions, choosing the formal health system
over traditional practices. However, our analysis shows that lack of knowledge is not
146
the main issue separating women and the formal health system, nor are the women
actively deselecting the health system in favour of traditional home-births. On the
contrary, our respondents demonstrated profound insight into the dangers of
unattended childbirth, and given the choice, almost all of them claimed to prefer
going through labour in a health facility rather than at home. However, we found a
general inconsistency in the women’s history of delivery, usually brought about by
structural circumstances, which made the health system appear inaccessible to the
women. The determining structural obstacles hindering women to reach the health
system falls into four categories: physical, contextual, financial and relational. To
bring about sustainable behavioural change, it is crucial to approach these structural
obstacles standing in the way of a strong link between women and the health system.
To improve the health system’s accessibility we recommend to reassess the
relationship between women and the health system into one of more dynamic and
flexible character, enabling the health system to reach women despite structural
obstacles rather than depending on the women to come to the health system. Joining
forces with key players in the local community and foster a higher degree of
participation within the women’s surroundings would pose a strong foundation for
this relationship. Regarding the future plans of scaling up of Wired Mothers, we
emphasise the necessity for more sustainable and less distorting project components
than in the pilot, enabling all women to join the intervention on equal terms.
Mobile phones are effective tools to create a stronger link between women and the
health system, but the communication channels should work as a supplement to
structural improvements. Until these physical, relational, financial and contextual
obstacles are integrated more thoroughly into the intervention design, women’s course
of pregnancy and delivery will depend on practicalities, timing and luck rather than
informed decisions through mobile phone communication. Mobile phones do not save
lives. The way in which they are integrated into a local context does.
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BIBLIOGRAPHY
Bartholomew, L. Kay et.al: Intervention Mapping – Designing theory- and evidence-
based health promotion programs, Mayfield Publishing Company, 2001
Berry, Dianne C.: Health Communication - Theory and Practice, Open University
Press, New York, 2007
Coetzee, Jan Karel: “Modernization Theory – a model for progress” in Development:
Theory, policy and practice, Oxford University Press, 2001
Drotner, Kirsten et. al.: Medier og Kultur – en grundbog i medieanalyse og
medieteori, Borgen/Medier, 2005/1996
Figueroa et. al.: “Communication for Social Change - An Integrated Model for
Measuring the Process and its Outcomes” in Communication for Social Change
Working Paper Series no. 1, The Rockefeller Foundation, 2002.
Glanz, Karen, Rimer, Barabara K. & Viswanath, K: Health Behavior and Health
Education – theory, research and practice, fourth edition, Jossey Bass, 2008
Hemer, Oscar & Tufte, Thomas: Media and Glocal change: Rethinking
Communication for Development, Nordicom & CLASCO, 2005
Chapter 4: Waisbord, Silvio: Five Key Ideas: Coincidences and
Challenges in Development Communication
Chapter 5: Servaes, Jan & Malikho, Patchanee: Participatory
Communication: the new paradigm?
Chapter 7: Morris, Nancy: The diffusion and participatory models: a
comparative analysis
Chapter 8: Cadiz, Maria Celeste H.: Communication for empowerment:
The practice of participatory communication in development
148
Chapter 9: Tufte, Thomas: Entertainment-education in development
communication: Between marketing behaviours and
empowering people
Chapter 13: Obregon, Rafael and Mosquera, Mario: Participatory and
cultural challenges for research and practice in health
communication
Henrik Kaare Nielsen: “Modernitet og massemedier – med udgangspunkt i Anthony
Giddens’ sociologi” in Mediekultur volume 10 no. 22, 1994
Inkeles, Alex & Smith, David H.: Becoming Modern – Individual Change in Six
Developing Countries, Heineman, London, 1974
Kok, Gerjo: “Health education theories and research for AIDS prevention” in Hygie –
vol X 1991/2 1 (u.s.)
Kvale, Steinar: Interview – en introduktion til det kvalitative forskningsinterview.
Hans Reitzels Forlag 2005/1997
Martinussen, John D.: Samfund, Stat og Marked. En kritisk gennemgang af teorier om
udviklng i den 3. verden, Mellemfolkeligt Samvirke, 1997/1994
Martinussen, John D.: Teorier om Samfund og Udvikling i den 3. Verden,
Mellemfolkdelig Samvirke, 1995/1994.
Mefalopulos, Paulo: Development Communication Sourcebook - Broadening the
Boundaries of Communication, The World Bank, 2008
Mefalopulos, Paulo & Tufte, Thomas: Participatory Communication, a practical guide
in World Bank Working Paper no. 170, The World Bank, 2009
Nutbeam, Don: Health Promotion Glossary, World Health Organization,
WHO/HPR/HeP/98.1, Geneva, 1998
149
Rogers, Everett M.: “Communication in Development: The Passing of the dominant
paradigm” in Communication Research, http://crx.sagepub.com, 1976
Rogers, Everett M.: Diffusion of Innovations, Fifth edition, Free Press, New York
2003/1995 (1962, 1971, 1983)
Rogers, Everett M. & Singhai, Arvind: Entertainment-Education – a Communication
Strategy for Social Change, Lawrence Erlbaum Associates, 1999
Rostow, W.W: The Stages of Economic Growth, Cambridge University Press
1971/1960
Servaes, Jan: “Participatory Communication (Research) from a Freirean Perspective”
in Africa Media Review Vol. 10 No. 1. 1996: 73-91
Thompson, John B.: Medier og Modernitet – en samfundsteori om medierne, Hans
Reitzels Forlag, Polity Press, Cambridge, 2001/1995
Wilkins, Karin Gwin: Redeveloping Communication for Social Change. Theory,
practice and power. Rowman & Littlefield Publishers Inc., 2000
REPORTS, PROJECT DOCUMENTS
Advanced Development for Africa: Scaling Up Mobile health: Elements necessary
for the successful scale-up of mHealth in developing countries, Advanced
Development for Africa, ADA, December 2011
James, Jeffrey & Versteeg, Mila: Mobile Phones in Africa: How much do we really
know?, Soc Indic Res (2007) 84:117–126 2007, Springer Science + Business Media
B.V, 2007
150
Ministry of Foreign Affairs, Denmark, Danida: Strategy for promotion of
reproductive health and rights – strategy for Denmark’s support, May 2006
Ministry of Health and Social Welfare, The Revolutionary Government of Zanzibar:
Roadmap to Accelerate the Reduction of Maternal, Newborn and Child Mortality in
Zanzibar (2008-2015), Reproductive and Child Health Program, May 2008
Ronsmans C, Graham W J. Maternal Mortality: Who, When, Where, and Why. The
Lancet Maternal Survival Series, Lancet 2006; 368:1189-200
Tanzania Commision for Aids (TACAIDS) et al.: Tanzania Hiv/Aids and Malaria
Indicator Survey 2007/08, November 2008
The Revolutionary Governement of Zanzibar (RGoZ): Zanzibar Strategy for Growth
and Reduction of Poverty 2010-2015 (ZSGRP), Mkuza II – a successor to Zanzibar
Strategy for Growth and Reduction of Poverty 2007-2010, October 2010
UNAIDS: HIV/AIDS and Communication for Behavior and Social Change:
Programme Experiences, Examples and The Way Forward, 2001, Geneva,
Switzerland, 2000
Vital Wave Consulting: mHealth for Development: The Opportunity of Mobile
Technology for Healthcare in the Developing World. Washington, D.C. and
Berkshire, UK: UN Foundation-Vodafone Foundation Partnership, 2009.
WEBSITES
http://www.enrecahealth.dk/archive/wiredmothers/
www.tanzania.um.dk
http://www.jordemoderforeningen.dk/tidsskrift-for-
jordemoedre/singlevisning/artikel/mobiltelefoner-redder-liv/
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International Telecommunication Union:
http://www.itu.int/net/pressoffice/stats/2011/03/index.aspx
http://www.un-gaid.org/
www.mhealthalliance.org
UN mHealth Summit 2011:
http://www.mhealthsummit.org/about_attending.php
Millenium Development Goals:
http://www.un.org/millenniumgoals/
Safe motherhood initiative WHO:
http://www.internationalmidwives.org/Partners/WHO/tabid/554/Default.aspx
World Bank, empowerment:
http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTPOVERTY/EXTEMP
OWERMENT/0,,contentMDK:20272299~pagePK:210058~piPK:210062~theSitePK:
486411~isCURL:Y,00.html
HIV & Aids in Tanzania:
http://www.avert.org/hiv-aids-tanzania.htm
UNFPA:
http://www.unfpa.org/rh/planning.htm#contraceptive)
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LIST OF APPENDIXES
The relevant appendixes accompanying the study are enclosed in digital form on a
CD.
Table of content:
Appendix 1: “Wired Mothers - use of mobile phones to improve maternal and
neonatal health in Zanzibar”, Project proposal, Lund, Stine 2009.
Appendix 2: “Wired Mothers - use of mobile phones to improve maternal and
neonatal health in Zanzibar”, Power Point-presentation, Lund, Stine
2011.
Appendix 3: Wired Mothers project forms:
1. Consent form
2. Registration form
3. Inclusion interview
5. Delivery form
6. PNC form
7. End of study interview
Appendix 4: Text messages in Swahili and English
Appendix 5: Interviewguide
Appendix 6: Transcription of 17 interviews with Wired Mothers + 2 staff interviews
Appendix 7: Wired Mothers registration table
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RESUMÉ
Mobiltelefoner er blevet allemandseje, og mediets udbredelse til selv de fattigste dele
af verden betegnes ofte som en mobil revolution, som har åbnet døre for interaktion
mellem mennesker, der hidtil har været uden for rækkevidde. Den mobile revolution
er ikke gået det internationale udviklingsmiljøs næse forbi. Under fællesbetegnelsen
Mobile Phones for Development (M4D) udspringer stadig flere udviklingsinitiativer,
der har mobilmediet som omdrejningspunkt for social forandring. Også indenfor
sundhedsområdet er mobilteknologi et anerkendt udviklingsredskab, og begrebet
mHealth bruges bredt om sundhedsprojekter, som benytter mobilbaseret
kommunikation til sundhedsfremmende interventioner.
Et eksempel er projektet Wired Mothers på Zanzibar, Tanzania, der fungerer som case
for dette speciale. Projektet forsøger via mobilteknologi at styrke linket mellem
gravide kvinder og sundhedssystemet med det mål nedbringe antallet af kvinder, der
føder hjemme uden assistance fra uddannet sundhedspersonale. Som ’wired mothers’
modtager gravide kvinder løbende SMS beskeder fra projektet med påmindelser om at
møde op til sundhedstjek, gode råd til kost og livsstil og gentagende opfordringer om
at føde i sikre omgivelser med hjælp fra uddannet sundhedspersonale. Kvinden
udstyres desuden med et akuttelefonnummer til den lokale klinik, som hun kan ringe
til døgnet rundt i tilfælde af problemer i større eller mindre grad.
Kvantitativt set bliver projektet, som kørte på prøvebasis fra 2009 til 2010, opfattet
som en succes, fordi man opnåede en stigning i antallet af fødsler med hjælp fra
uddannet sundhedspersonale. Dette speciale anlægger imidlertid et kvalitativt fokus
og undersøger modtagerens opfattelse af projektet og dets indflydelse på deres
sundhedsadfærd samt en vurdering af sammenhængen mellem projektets intentioner
og kvindernes virkelighed.
I alt 17 interviews med såkaldte ’wired mothers’ samt to med jordmødre tilknyttet de
involverede sundhedsklinikker udgør således undersøgelsens empiriske fundament i
dette speciale, hvis teoretiske forankring bevæger sig indenfor paradigmerne
udviklingsteori, udviklingskommunikation samt sundhedskommunikation.
Bygget på analyser af 1) projektets selvforståelse, 2) den lokale kontekst omkring
graviditet og fødsel, 3) kvindernes opfattelser af farer forbundet med graviditet og
fødsel, 4) SMS-beskedernes og akuttelefonens rolle og effekt samt 5) den følelse af at
154
være prioriteret, som projektet skaber hos kvinderne, vurderer vi, at projektet kun
delvist har haft den tilsigtede effekt hos de implicerede kvinder.
Det skyldes især, at projektets opfattelse af problemets kerne ikke stemmer overens
med kvindernes virkelighed. Projektet anser problemet som værende forårsaget af
manglende viden omkring faren ved at føde hjemme, og vurderer at kvinderne derfor
vil ændre adfærd, hvis de får løbende adgang til viden, vejledning og behandling fra
sundhedssystemet. Vores analyse viser imidlertid, at det ikke er manglende viden, der
afholder kvinderne fra at opsøge sundhedssystemet, men derimod manglende adgang.
Strukturelle omstændigheder i form af fysiske, kontekstuelle, relationelle og
økonomiske faktorer får sundhedssystemet til at fremstå utilgængeligt for kvinderne.
Disse omstændigheder er af mere afgørende betydning for kvindernes forhold til
sundhedssystemet, end kommunikationsinterventionen i sin nuværende form
anerkender, og mange af disse strukturelle omstændigheder kan ikke løses gennem
kommunikation. Vores vurdering er, at for at en intervention som Wired Mothers kan
have den tilsigtede, langtidsholdbare effekt på mødre- og børnesundheden på
Zanzibar, er der behov for en kommunikationsstrategi, der i højere grad
imødekommer kvindernes virkelighed og de strukturelle forhindringer, den indeholder
for på den måde at give kvinderne en større chance for at tage hånd om eget
graviditets- og fødselsforløb.
