Bobbi Be Best: the development and evaluation of an audio program and discussion guide to promote exclusive breastfeeding in Cameroon,Central Africa

Abstract

One risk factor for infant and childhood morbidity is not exclusive breastfeeding (EBF) during the first six months of life. Entertainment Education (EE) is a communication strategy consisting of placing educational information into television, movies, and radio programs. In developing countries this form of behavioral change communication has proven effective in addressing health-related issues; however, no research has determined if EE is effective in promoting EBF. The objective of this research was to develop an EE audio program and discussion guide and to determine if a series of four 15-minute episodes and post-listening discussion improved knowledge, perceived benefits, self-efficacy, and intention and decreased misconceptions and perceived barriers toward EBF in the Kumbo West Health District, Cameroon. Pregnant women and their partners were assigned to either the control group (N = 116; 74 women, 42 partners) or intervention group (N = 148; 99 women, 49 partners) based on expected date of delivery. All control and intervention group participants completed a questionnaire prior to listening to the first and after the last episode. Pre- and post-listening questionnaires were used to determine changes in the EBF knowledge, misconceptions, perceived barriers, self-efficacy, and intention variables as a result of exposure to the audio program. The Wilcoxon Sign Rank test showed significant improvement in all of the variables, except perceived barriers, within the intervention group (p < 0.05) and the Mann–Whitney test indicated significant differences between the control and intervention group in all of the variables (p < 0.05), indicating that using an audio program and discussion guide based on the EE model is an effective tool for promoting EBF in this setting. The strength of this approach is that it goes beyond simply telling women about what constitutes EBF, but addresses misconceptions and perceived barriers that may prevent women from practicing EBF for six months.

Keywords

health promotion maternal health behavior Entertainment Education exclusive breastfeeding

Introduction

A leading risk factor for infant and childhood morbidity is not to exclusive breastfeed during the first six months of life (1). Exclusive breastfeeding (EBF) is defined as providing breast milk to the infant as the sole form of nutrition (2). Adhering to this practice potentially saves 1.3 million lives worldwide each year (3). Since 2003, the World Health Organization (WHO) has recommended EBF for the first six months of life because of immunologic, psychological, social, environmental, and economic benefits; however, EBF for the recommended time frame is low, even in countries with high rates of breastfeeding initiation (4).

Entertainment Education (EE) is a mass-media communication strategy consisting of placing educational or motivational information into entertainment media, such as television programs, movies, books, and radio programs (5). EE programs are characterized by an ongoing story line with several concurrent plots linked together by the character’s personal relationships (6). In developing countries this form of behavioral change communication has proven effective in addressing health-related issues such as condom usage (7), family planning (6), prevention of HIV/AIDS (8), prevention of mother-to-child transmission of HIV (9), and HIV testing (10). However, no research has determined if EE is effective in promoting EBF. The objective of this research was to develop an EE audio program and discussion guide and evaluate if a series of four 15-minute episodes and post-listening discussion improved knowledge, perceived benefits, self-efficacy, and intention and decreased misconceptions and perceived barriers toward EBF in the Kumbo West Health District, Cameroon, Africa.

Materials and methods

Study population

Cameroon is a sub-Saharan African country bordering Nigeria, Chad, the Central African Republic, Gabon, Equatorial Guinea, and the Congo. Recent estimates suggest that 21% of children less than six months of age are exclusively breastfed (11,12). In the Northwest Region of Cameroon, approximately 90% of women initiate breastfeeding; however, only 34% of these women exclusively breastfeed for the recommended six months (13,14).

This study was completed in the Kumbo West Health District, Northwest Region of Cameroon, between February 2011 and February 2012. The district serves 173,911 inhabitants who belong primarily to the Banso and Fulani ethnic tribes and identify themselves as Christian, Muslim, or Animist. Based on G*Power calculations of an effect size of 0.25, an alpha error of 0.05, with 80% power for comparing means for non-parametric tests, a sample size of 134 members per group were needed (15). Between July and December 2011, four nurses trained in the research protocol and human subject protection recruited 384 people (294 women, 90 partners) from five antenatal clinics at three health centers and two hospitals. The recruitment sites were purposely chosen to represent the religious, ethnic, and rural/urban diversity within the Kumbo West Health District.

The first 150 women and their influential partners were assigned to the dose-matched control group based on their estimated delivery date. A total of 116 people (74 women, 42 partners) gathered once a week for all four weeks to listen to a unique 15-minute episode about injection safety and then participate in a post-listening discussion led by health workers.

After all the listening sessions for the control groups were completed, the remaining women, as well as those who could not participate in the control group, were assigned to the intervention group. A total of 148 participants (99 women, 49 partners) gathered once a week for four weeks to listen to a unique 15-minute episode about EBF and then participate in a post-listening discussion led by local health workers. Based on power calculations, there were enough people in the intervention group to detect statistical differences in EBF knowledge, misconceptions, barriers, and benefits.

One hundred and eighteen women were recruited, but did not participate in the control or intervention group because of sickness, movement out of the health district, change in contact information, lack of transportation, or late stages of pregnancy.

Influential partners were defined as a woman’s husband, partner, or other influential family members and were recruited because of their known influence on women’s infant feeding decisions (13,16 –18), although they are not traditionally included in breastfeeding health education (18). Table 1 provides demographic characteristics of the study participants. The demographic characteristics represent this area of Cameroon, but are not representative of the whole country. Research approval came from the Cameroon Baptist Convention Health Board and Loma Linda University Human Research Committee. All participants provided informed consent.

Table 1.

Percentage of participants with selected demographic characteristics.

	Women		Influential partners
	Control (n = 74)	Intervention (n = 99)	Control (n = 42)	Intervention (n = 49)
Age
20 and younger	13.3	17.8	4.8	12.5
21–25	33.3	26.7	9.5	18.8
26–30	25.3	24.8	14.3	12.5
31–35	17.3	17.8	9.5	12.5
36–40	8.0	7.9	19.0	18.8
41–44	2.7	3.0	16.7	14.6
45-older		1.0	21.4	10.4
Marital status
Single	21.3	22.8	21.4	27.7
Polygamous marriage	8.0	5.9	21.4	8.5
Monogamous marriage	69.3	67.3	50.0	59.6
Divorced/separated	1.3	3.0	2.4	4.3
Pregnancy trimester*
First	4.0	11
Second	55.4	30
Third	29.7	45
Recently delivered	10.8	14
Gender**
Male			73.8	56.3
Female			21.4	43.8
Religious beliefs*
Muslim	16.0	13.9	19.0	16.7
Catholic	36.0	8.9	26.2	39.6
Protestant	45.3	21.8	47.6	41.7
Other	2.7	4.0	2.4	2.1
Number of pregnancies
0–2	49.3	46.5
3–5	33.3	42.6
6 or more	16.0	8.9
Occupation
Farmer	58.7	50.5	69.0	52.1
Teacher	4.0	7.9	2.4	4.2
Tailor	5.3	14.9	2.4	4.2
Shop owner				2.1
Nurse/doctor	2.7	4.0
Other	28	21.8	19.0	37.5
Education
None	1.3		4.8	2.1
Primary	53.3	44.6	64.3	62.5
Secondary	29.3	39.6	19	25
High School	12	8.9	2.4	8.3
University/Vocational	2.7	6.0	4.8	2.1

Significant differences between the female control and intervention groups, p < 0.05

Significant differences between the influential partner control and intervention groups, p < 0.05

Audio program development

Previous research indicates that a mother’s attitude, knowledge, social support, and self-efficacy are significantly associated with EBF intention (19 –24). Fishbein and Yzer (25) advise that before developing a health behavior communication strategy, it is paramount to first determine if the target population’s intention toward the behavior is under attitudinal, normative, or self-efficacy control Therefore, before developing the audio program and discussion guide, the underlying beliefs, social norms, attitudes, self-efficacy, and strength of intention toward EBF amongst the target population were explored through formative research.

The result of the formative research suggested women have a high degree of knowledge and intention toward EBF; however, misconceptions and perceived barriers often prevent them from EBF for six months (26), suggesting that the intention toward EBF is primarily under attitudinal (misconceptions, perceived barriers) control. These findings, discussions with local health professionals, and previous research (6,8,27) led to the following objectives for the audio program: increase knowledge, raise awareness, correct misconceptions, and increase self-efficacy to overcome perceived barriers in order to increase intention toward exclusively breastfeeding. These objectives were incorporated into an hour-long audio program consisting of four 15-minute episodes. Each episode focused on two or three of the overall objectives; thus, all of the objectives were covered by the conclusion of the program.

The program followed the EE model by utilizing an ongoing story line with concurrent plots linked together by the characters’ personal relationships (8). There were a total of eight main characters, including one that was a positive role model, Beri, one that was a negative role model, Litika, and one that was transitory, Aisha. Before the script was recorded, all research staff members reviewed the content. Voice actors from the region were hired and the program was recorded in Pidgin English, the language most commonly spoken throughout the region. In coordination with the audio program script, a four-part discussion guide was written to reinforce the message for each program episode. Table 2 provides a list of the objectives, role modeling, and discussion points for each episode.

Table 2.

Description of Bobbi Be Best audio program.

	Episode one	Episode two	Episode three	Episode four
Objectives	• Clarify definition/duration of exclusive breastfeeding • Emphasize the advantages of exclusive breastfeeding to the baby • Emphasize the advantages of exclusive breastfeeding to the mother	Correct false knowledge: • Colostrum is dirty and not good for the baby • Palm wine/alcoholic drinks stimulate milk flow • Breast milk is not enough for the baby • Sperm spoils breast milk and slows growth • Breast milk gets bad after skipping a day without breastfeeding • Cannot breastfeed while pregnant • HIV positive mothers cannot breastfeed	Empower women to overcome barriers that prevent them from exclusive breastfeeding: • Pressure from family to give complementary foods • Fear of baby refusing other foods later • Strenuous and tiring leading to ill health of the mother • Baby cries too much despite sucking • Inconvenience of taking baby to farm and other activities • Problems with breast or nipple • Husband hates smell of breast milk during sex Fear of sagging of breast and getting old.	• Sensitize to the need for family planning while breastfeeding • Educate on different birth control methods • Reiterate the benefits of exclusive breastfeeding • Encourage self-efficacy to exclusively breastfeed
Role modeling	• Beri patiently provides Litika and her husband with correct information about exclusive breastfeeding • Beri explains to other women the advantages of exclusive breastfeeding	• Aisha learns about the importance of giving baby colostrum • Aisha learns that sex does not spoil breastmilk • Aisha learns that exclusive breastfeeding can prevent diarrhea	• Aisha talks to her husband and mother in law about the benefits and importance of exclusive breastfeeding • Beri explains to her mother in law the importance of exclusive breastfeeding • Litika refuses to exclusively breastfeed because of fear of sagging breasts and her baby is always sick	• Beri and her husband go to the family planning clinic where they learn about the different methods of family planning • Aisha explains to her friends and husband the benefits of exclusive breastfeeding • Beri explains to other women the various methods of family planning
Discussion	• Reasons why family members are unsupportive of exclusive breastfeeding • Approaches to convince others to support exclusive breastfeeding	• Other cultural beliefs that influence exclusive breastfeeding practices	• Brainstorm options to exclusively breastfeed in the midst of barriers	• Different methods of family planning • Family planning and pregnancy

Description of intervention

This research used a quasi-experimental design. To reduce threats to internal validity, including contamination between groups, time-series and exposure matched comparison groups were used (28). A total of 116 people (74 women, 42 partners) came every week for four weeks to listen to a unique 15-minute episode about injection safety and caring for sick children and then participate in a post-listening discussion led by health workers. Participants in the control group listened to an audio program entitled The Sick Child of Batibo, a four-episode series on injection safety, also based on prior formative research.

After the listening sessions for the control group were completed, 148 people (99 women, 49 partners) gathered once a week for four weeks to listen to the intervention audio program, Bobbi Be Best, which means Breast is Best in Pidgin English. Participants listened to a sequential, unique 15-minute episode about EBF and then participated in a post-listening discussion led by health workers. All control and intervention group participants completed a questionnaire prior to listening to the first episode and then completed the same questionnaire after listening to the last episode in the fourth week. Figure 1 demonstrates how data was collected from the control and intervention groups.

Figure 1.

Data collection procedures.

Measurement

The results from the pre- and post-listening questionnaire determined changes in EBF knowledge, misconceptions, perceived barriers, self-efficacy, and intention as a result of exposure to the audio program. The content of the questions came from the formative research phase and objectives from the EBF audio program. The questionnaire was pilot-tested with a group of pregnant women and it was reviewed for content validity by an expert panel. All participants completed the same questionnaire regardless of being in the control or intervention group. Women were asked additional questions about EBF self-efficacy and intention.

Knowledge of EBF was measured using multiple-choice questions. The answers to the four knowledge questions were added together for a score ranging between 4 and 10: 4 indicating inaccurate knowledge and 10 indicating accurate knowledge. The misconceptions, perceived benefits, perceived barriers, and intention variables toward EBF were each measured using a five-point Likert scale (strongly disagree to strongly agree). The answers to the six misconception questions, the six perceived benefit questions, and the six perceived barrier questions were individually added together to create a distinct misconception score, a perceived benefit score, and a perceived barrier score each ranging between 6 and 30. A higher score (30) indicated more misconceptions, perceived benefits, and perceived barriers. A lower score (6) indicated fewer misconceptions, perceived benefits, and perceived barriers. The answers to the four self-efficacy questions were added together for a score ranging from 4 to 20; a higher self-efficacy score indicated a woman’s stronger self-efficacy toward EBF. The content for the self-efficacy questions was adapted from the Breastfeeding Self-Efficacy Scale Short Form (29). One intention to exclusively breastfeed question asked if mothers were planning to give their next baby only breastmilk for the first six months; a higher score indicated stronger intention to exclusively breastfeed for six months. Cronbach’s alpha was used to determine the internal validity of the Likert scale questions and ranged from 0.63 to 0.89.

Analysis

Data analysis included chi-square, the Wilcoxon Signed Ranks Test, Mann–Whitney, and Binomial Logistic Regression using SPSS version 19 (SPSS, INC., Chicago, IL, 2010). Non-parametric tests were used because the data was not normally distributed. Chi-square measured differences in demographics between the control and intervention group. The Wilcoxon Signed Ranks Test measured changes in women and their partners’ EBF knowledge, misconceptions, perceived barriers, and perceived benefits scores and in women’s self-efficacy and intention scores between the pre- and post-listening questionnaires within the control and intervention groups. Differences between the control and intervention group EBF knowledge, misconceptions, perceived barriers, perceived benefits, and women’s self-efficacy and intention post-listening questionnaire scores were compared using the Mann–Whitney statistical test. Binary logistic regression analysis determined if women in the intervention group compared to the control group were significantly more likely to intend to exclusively breastfeed for six months. The primary independent variable was treatment group and the other independent variables, including age, education, occupation, tribe, pregnancy trimester, number of pregnancies, number of delivered children, number of family members in the house, HIV status, the sum of the economic indicators of ownership of a radio, electricity, television, motorbike, and car, and the post-listening knowledge, misconceptions, barrier, benefit, and self-efficacy scores were individually added using the enter method to the unadjusted model. If any of these covariates significantly contributed to the predictive power of the model (p < 0.001) they were included in the adjusted regression model using the forward stepwise method. The final adjusted model included the perceived barriers, perceived benefits, and pregnancy trimester covariates.

Results

Regression model

Based on chi-square tests, statistically significant more Catholics, more women who had previously delivered fewer children, and more women in their third trimester were in the intervention group compared to women in the control group. For the influential partners, significantly more female family members were in the intervention group compared to the control group. However, of these differences in demographics, only pregnancy trimester significantly contributed to the regression model and was included in the adjusted model. The binomial logistic regression model demonstrated that women in the intervention group were significantly more likely to intend to breastfeed (p < 0.001, OR 21.53, CI = 8.70–52.99), even after for controlling for the pregnancy trimester, perceived barriers, and perceived benefits covariates (p < 0.001, OR 35.74, CI = 11.92–116.02) (Table 3).

Table 3.

Treatment group and intention to exclusively breastfeed regression model.

Variable	Unadjusted		Adjusted^a
	OR	95% CI	OR	95% CI
Treatment group	21.53*	[8.7, 52.99]	35.87*	[11.92, 116.02]

OR: odds ratio; CI: confidence interval.

Adjusted for pregnancy trimester and exclusive breastfeeding benefits and barriers, and post-test score.

p < 0.05.

Knowledge score

There was a significant improvement in EBF knowledge score between the pre- and post-listening questionnaire for the intervention group (p < 0.001) (Table 4). The difference in knowledge scores between the control and intervention group when measured at the post-listening was also significant (p < 0.001) (Table 5).

Table 4.

Knowledge, misconceptions, perceived barriers, perceived benefits, self-efficacy, and intention score in pre and post–listening questionnaire for intervention group.

Parameter	n	Median pre–listening questionnaire	n	Median post–listening questionnaire	z	p-value	r
Knowledge^a	148	10	135	10	–3.618	0.000**	–0.30
Misconceptions^b	148	14	135	10	–6.400	0.000**	–0.52
Barriers^c	148	6	135	6	–1.917	0.055	–0.16
Benefits^d	148	26	135	30	–6.000	0.000**	–0.49
Self-efficacy^e	99	20	94	20	–2.434	0.015*	–0.24
Intention^f	99	5	94	5	–2.850	0.004*	–0.29

Note: z indicates Wilcoxon signed rank test. r indicates effect size.

Total knowledge score out of four multiple-choice questions.

Total misconception score on six 5-point Likert scale questions from strongly disagree to strongly agree.

Total barrier score on six 5-point Likert scale questions from strongly disagree to strongly agree.

Total benefits score on six 5-point Likert scale questions from strongly disagree to strongly agree.

Total self-efficacy score on four 5-point Likert scale questions from strongly disagree to strongly agree for pregnant women only.

Total intention score on one 5-point Likert scale question from strongly disagree to strongly agree for pregnant women only.

The mean change between the pre- and post-listening questionnaire was significant, P < .05.

The mean change between the pre- and post-listening questionnaire was significant, P <.001.

Table 5.

Difference in post knowledge, misconceptions, perceived barriers, perceived benefits, self-efficacy, and intention rank score between control and intervention groups.

Parameter	Control group		Intervention group		U	p-value	r
Parameter	n	Median post-listening questionnaire	n	Median post-listening questionnaire	U	p-value	r
Knowledge^a	100	10	135	10	5007	0.000**	–0.49
Misconceptions^b	98	14	135	9	3179	0.000**	–0.69
Barriers^c	99	6	135	6	4510	0.000**	–0.45
Benefits^d	100	26	135	30	3571	0.000**	–0.69
Self-efficacy^e	62	20	94	20	2301	0.000**	–0.41
Intention^f	62	5	93	5	2570	0.04*	–0.27

Note. U indicates Mann–Whitney test statistic. r indicates effect size.

Total knowledge rank score out of four multiple-choice questions.

Total misconception rank score on six 5-point Likert scale questions from strongly disagree to strongly agree.

Total barrier rank score on six 5-point Likert scale questions from strongly disagree to strongly agree.

Total benefits rank score on six 5-point Likert scale questions from strongly disagree to strongly agree.

Total self-efficacy rank score on four 5-point Likert scale question from strongly disagree to strongly agree for pregnant women only.

Total intention rank score on one 5-point Likert scale question from strongly disagree to strongly agree for pregnant women only.

The mean difference between control and intervention group was significant, p < 0.05.

The mean change between control and intervention group was significant, p < 0.001.

Misconception score

When comparing the pre- and post-listening questionnaires, both the control and intervention groups had significant decreases in EBF misconceptions (p < 0.05, < 0.001) (Tables 4 and 6). Yet when comparing the EBF misconception score at the post-listening, there was a significant difference between the control and intervention group, suggesting a greater change amongst the intervention group participants (p < 0.001) (Table 5).

Table 6.

Knowledge, misconceptions, perceived barriers, perceived benefits, self-efficacy, and intention score in pre- and post-listening questionnaire for control group.

Parameter	n	Median pre-listening questionnaire	n	Median post-listening questionnaire	z	P-value	r
Knowledge^a	116	10	100	10	–0.367	0.714	–0.03
Misconceptions^b	116	18	98	14	–3.374	0.001*	–0.31
Barriers^c	116	12	99	10	–1.658	0.097	–0.15
Benefits^d	116	27	100	26	–1.038	0.299	–0.10
Self-efficacy^e	74	20	62	20	–0.134	0.894	–0.02
Intention^f	74	5	62	5	–0.415	0.678	–0.04

Note: z indicates Wilcoxon signed rank test. r indicates effect size.

Total knowledge score out of four multiple-choice questions.

Total misconception score on six 5-point Likert scale questions from strongly disagree to strongly agree.

Total barrier score on six 5-point Likert scale questions from strongly disagree to strongly agree.

Total benefits score on six 5-point Likert scale questions from strongly disagree to strongly agree.

Total self-efficacy score on four 5-point Likert scale questions from strongly disagree to strongly agree for pregnant women only.

Total intention score on one 5-point Likert scale question from strongly disagree to strongly agree for pregnant women only

The mean change between the pre- and post-listening questionnaire was significant, p < 0.05.

Perceived barriers score

There was no significant change in the perceived barrier score between the pre- and post-listening questionnaire for either the control or intervention group (Tables 4 and 6). However, post-listening questionnaire scores were significantly lower for the intervention group compared to the control group, signifying intervention group members perceived lower barriers toward EBF at the conclusion of the program (p < 0.001) (Table 5).

Perceived benefits score

There was a significant increase in the post-listening questionnaire perceived benefits score toward EBF for the intervention group (p < 0.001) (Table 4). When comparing perceived benefits at the post-listening, the intervention group also had a significantly higher perceived benefit score than the control group (p < 0.001) (Table 5).

Self-efficacy score

For participants in the intervention group, there were significant improvements in their self-efficacy score between the pre- and post-listening questionnaire (p < 0.05) (Table 4). This improvement was also significant for the intervention group participants when comparing the post-listening questionnaire scores with control group participants (p < 0.001) (Table 5).

Intention to exclusively breastfeed score

In the intervention group there was a significant improvement in women’s intention to exclusively breastfeed score between the pre- and post-listening questionnaire (p < 0.05) (Table 4). The scores were also significantly different between the control and intervention group when measured at post-listening (p < 0.05) (Table 5).

Discussion

Our short-term outcomes indicate using an EE audio program is effective in improving knowledge, perceived benefits, self-efficacy, and intention and decreases misconceptions toward EBF in this area in Cameroon. In addition, the program successfully engaged and maintained the attention of our participants throughout the study period as we had a reasonably high retention rate with 82% (61) of women and 88% (37) of the influential partners in the control group and 89% (88) of the women and 82% (40) of the partners in the intervention group attending all four sessions and completing the post-listening questionnaire.

The improvement in knowledge in the intervention group is surprising considering that women already had a high degree of knowledge about the definition of EBF and other EE interventions had been unsuccessful in improving health behavior knowledge (6,27). The greatest improvement in knowledge was exhibited in the question about at what age to give the child water, suggesting that prior to the intervention many knew about EBF, but did not know some of the behavior practicalities, such as avoiding giving the child water for the first six months.

During the formative research many mis-conceptions were identified that negatively influence EBF practices. Although there was also an unexpected significant decrease in the misconception score within the control group, more of the individual mis-conception questions changed within the intervention group compared to the control group, signifying that Bobbi Be Best was effective in addressing and correcting misconceptions about EBF.

It is surprising that there was no significant change in perceived barriers toward EBF between the pre- and post-listening questionnaire for the intervention group. Although the perceived barrier questionnaire score at the post-listening was sig-nificantly different for the intervention group compared to the control group, the lack of significant change between the pre- and post-listening for the intervention group implies health education needs to be augmented to counsel breastfeeding women in finding creative solutions to overcome barriers, instead of simply telling them to give their baby only breastmilk for the first six months of life.

There was a remarkable improvement in perceived benefits toward EBF within the intervention group between the pre- and post-listening questionnaire; the post-listening score for the intervention group was significantly higher compared to the control group. This was an unexpected finding as the majority of participants in the formative research acknowledged many perceived benefits associated with EBF. This extraordinary change in perceived benefits may be because it was emphasized in episodes one and four, suggesting the importance of repetition when introducing a new idea or concept within this population.

The significant change in self-efficacy within the intervention group is similar to findings in other EE interventions (6,8,27) and is possibly related to the characters’ role modeling of the health behavior. During the formative research phase participants were asked how they overcome obstacles that prevent them from exclusively breastfeeding and their advice was then incorporated into episode three, thereby making the situations and solutions relative to this context.

Other research suggests that intent to breastfeed is a significant indicator for EBF for six months (30,31). Since data on long-term EBF practices were not collected at this time, the intent to breastfeed variable was used as a proxy for EBF practices. The significant improvement in intention to exclusively breastfeed within the intervention group, even after controlling for covariates, is noteworthy and a possible predictor that women who listened to Bobbi Be Best will exclusively breastfeed for six months.

As previously mentioned, Fishbein and Yzer (25) suggest that when developing a health communication intervention for behavior change it is essential to determine if the intention toward the behavior is under attitudinal, normative, or self-efficacy control. The results of the formative research and the regression model indicate that in this population, intention to exclusively breastfeed is influenced by the attitudes of perceived benefits and barriers. Furthermore, Fishbein and Yzer suggest that if the intention is already high, then the intervention should be directed toward skill building and/or overcoming constraints. Since the results of this intervention indicate significant improvement in intention, future interventions should focus on helping breastfeeding women overcome barriers either through more episodes, role modeling, and/or group discussions.

After the project was finished a press conference was held with local policy makers and media outlets to share the results of our study. During the press conference suggestions were provided for possible next steps. These included designing a video of the program, broadcasting the drama as an interactive program, developing and/or changing curriculum for health care workers about EBF, and sharing policy briefs with the media. Following the conference, the research team acted upon two of these suggestions—an interactive program was recorded and broadcast and policy briefs were developed and shared with the media. Future funding will be used to develop and/or change curriculum for health care workers to encourage them to recognize and address the cultural barriers and perceived barriers that prevent women from EBF.

Limitations

A potential limitation of this study was the helpful subject effect, in which individuals may have felt that they should have learned something as a result of participating in a program and varied their answers in the post-listening questionnaire to reflect a change to please the researchers and the nurses who facilitated the listening sessions. This phenomenon, coupled with a training effect from completing a pre- and post-listening questionnaire within four weeks, could possibly explain why there was a significant change in the misconception score between the pre- and post-listening questionnaire for both the control group and modify the results in the intervention group. Also, because the study is based partly on the theory of diffusion of information, in which participants will talk with their neighbors or family members about what they learn, it is possible that the control group may have been contaminated. However, because the control group participants completed their pre- and post-listening questionnaire before the intervention group began, this is unlikely. Furthermore, due to time limitations, participants were assigned to either the control or intervention group based on estimated delivery date, creating possible bias. In the future an experimental study design with random allocation could be used to minimize recruitment bias.

Conclusion

The significant improvement in overall EBF knowledge, perceived benefits, and self-efficacy and decreases in misconceptions within the intervention group indicates that using a theory-driven audio program and discussion guide based on the EE model is an effective tool for promoting EBF in a Cameroonian rural setting. The strength of this approach is that it goes beyond simply telling women about what constitutes EBF, but addresses misconceptions and perceived barriers that may prevent women from exclusively breastfeeding for six months and does so in a culturally congruent modality, as many rural Cameroonians do not yet own TVs, but listen to radios. In fact, 41% of control group participants and 53.5% of intervention group participants indicated they owned a radio.

We found that using formative research was essential in designing the audio program to identify the best approach for the intervention, as well as gaps in knowledge, misconceptions, and perceived barriers toward EBF that were then addressed in Bobbi Be Best characters through role modeling. Furthermore, by encouraging participants to discuss characters’ behaviors, instead of their own in a post-listening discussion, it created a forum to discuss issues that might otherwise be considered taboo, thus enabling the new behavior of EBF for six months to spread throughout a community. Future studies are needed to determine the long-term effects of Bobbi Be Best in promoting exclusively breastfeeding and the interaction between misconceptions, perceived barriers, perceived benefits, intention, self-efficacy, and EBF duration.

Footnotes

Conflict of interest statement

None declared.

Funding

Research was funded by the Nestle Foundation.

Notes

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