Acceptability, Comprehensibility and Reported Influence - BRAC ...

Working Paper No. 21 

Acceptability, Comprehensibility and 

Reported Influence of Behaviour 

Change Communication Tools: 

Experience from MNCH Programme in 

Nilphamari District of Bangladesh 

Atiya Rahman 1 , Margaret Leppard 2 , Hashima-E-Nasreen 1 , Sarawat Rashid 1 

1 BRAC RED, Bangladesh, 2 University of Aberdeen, UK 

May 2011 

Research and Evaluation Division, BRAC, 75 Mohakhali, Dhaka 1212, Bangladesh 

Telephone: (88-02) 9881265-72, 8824180-7 (PABX) Fax: (88-02) 8823542 

E-mail: research@brac.net, Website: www.brac.net/research

Working Paper No. 21 

Copyright © 2011 BRAC 

May 2011 

Published by: 

BRAC 

75 Mohakhali 

Dhaka 1212 

Bangladesh 

Telephone: (88-02) 9881265-72, 8824180-7 (PABX) 

Fax: (88-02) 8823542 

Website: www.brac.net/research 

Printing and Publication 

Altamas Pasha 

Cover design 

Md. Abdur Razzaque 

Design and layout 

Md. Akram Hossain 

BRAC/RED publishes research reports, scientific papers, monographs, working 

papers, research compendium in Bangla (Nirjash), proceedings, manuals, and other 

publications on subjects relating to poverty, social development and human rights, 

health and nutrition, education, gender, environment, and governance. 

Printed by BRAC Printers at Tongi, Gazipur, Bangladesh.

Abbreviations 

AIDS 

ANC 

BCC 

BHP 

E-E 

HIV 

IEC 

IPC 

MDG 

MNCH 

NHW 

PNC 

SS 

SK 

VD 

Acquired Immune Deficiency Syndrome 

Antenatal Care 

Behaviour Change Communication 

BRAC Health Programme 

Entertainment Education 

Human Immunodeficiency Virus 

Information, Education and Communication 

Interpersonal Communication 

Millennium Development Goal 

Maternal, Neonatal and Child Health 

Newborn Health Worker 

Post-natal care 

Shasthya Shebika 

Shasthya Kormi 

Village Doctor 

Behaviour change communication tools: experience from MNCH programme 

iii

Glossary 

Behaviour Change Communication 

Behaviour change communication (BCC) is a research-driven approach for promoting 

and sustaining behaviour change in individuals and communities, and is implemented 

though the development and distribution of specific health messages via a variety of 

communication channels. 

Entertainment Education 

“Entertainment-Education is the process of purposely designing and 

implementing a media message to both entertain and educate, in order to 

increase audience knowledge about an educational issue, create favorable 

attitudes, and change overt behavior” (Singhal and Rogers, 1999. Entertainment 

education: a communication strategy for social change. L.Erlbaum Assoc.) 

Mass Media 

Mass media include radio, television, print media (newspapers and magazines), and 

other forms of traditional media, which may reach large numbers of target audience. 

iv RED Working Paper No. 21

Acknowledgements 

We are indebted to Dr. Kaosar Afsana, Associate Director, BRAC Health Programme 

(BHP) for giving us the opportunity to work in the rural Maternal, Neonatal and Child 

Health (MNCH) programme area. We are also thankful to Mr. Hasan Shareef Ahmed, 

Chief, Editing and Publications, BRAC Research and Evaluation Division for editing 

the final draft of the report. We acknowledge the support of research assistants 

during fieldwork. We want to thank the countless interview respondents and other 

assistants at the community level without whom effective data collection would not 

have been possible. We are also thankful to Shasthya Kormis (SK), Shasthya 

Shebikas (SS) and all other providers involved in this study for answering our 

questions. 

The Research and Evaluation Division (RED) is supported by BRAC's core funds and 

funds from donor agencies, organizations and governments worldwide. Current 

major donors of BRAC and RED include AED ARTS (USA), Aga Khan Foundation 

Canada, AIDA (Spain), AusAID (Australia), Bill and Melinda Gates Foundation (USA), 

BRAC-USA, Campaign for Popular Education (Bangladesh), Canadian International 

Development Agency, Department for International Development (UK), DIMAGI (USA), 

EKN (The Netherlands), Emory University (USA), European Commission, Family 

Health International (USA), Fidelis, France, Government of Bangladesh, GTZ 

(Germany), Hospital for Sick Children (Canada), ICDDR,B (Bangladesh), Institute of 

Development Studies (UK), Inter-cooperation Bangladesh, Karolinska University 

(Sweden), Land O Lakes (USA), Manusher Jonno Foundation (Bangladesh), 

Micronutrient Initiative (Canada), NORAD (Norway), OXFAM NOVIB (The Netherlands), 

Oxford University (UK), Plan International Bangladesh, Rockefeller Foundation (USA), 

Rotary International (Bangladesh), Save the Children (UK), Save the Children (USA), 

Scojo Foundation Incorporation (USA), Stanford University (USA), Swiss Development 

Cooperation (Switzerland), The Global Fund (USA), The Population Council (USA), 

UNICEF, University of Leeds (UK), World Bank and World Food Programme. 


v

Abstract 

This operational research aimed to assess the acceptability, comprehensibility and 

reported influence of behaviour change communication tools such as interpersonal 

communications (IPC), print materials, and entertainment education (E-E) used in the 

Maternal, Neonatal and Child Health programme of BRAC. A qualitative study was 

conducted during March-April 2010 in two unions in Nilphamari Sadar upazila of 

Nilphamari district in northern Bangladesh. Data were collected by using semistructured 

questionnaire, key informant interview, focus group discussion, and 

document review. Respondents were selected using snowball sampling technique. 

Data were analyzed using framework and content analyses. Findings reveal that faceto-face 

IPC was unanimously accepted by the community members. The 

respondents requested increased frequency of IPC. Community members identified 

some inconsistencies in some of the pictures and messages on maternal danger 

signs. Other communication channels such as folksongs and street theatres were 

perceived to play strong supporting role in communicating the key messages. The 

community people made limited use of television and radio, although where 

accessible, community members perceived television as a useful medium to support 

adoption of new knowledge in certain groups of the viewers. Overall, the study 

reveals that well integrated IPC, use of modified printed materials, and E-E have 

potentials for motivating and supporting families and other community members to 

take healthy decision for birth planning and maternal and neonatal care-seeking. 

vi RED Working Paper No. 21

Introduction 

In Bangladesh the maternal mortality ratio in 2007 was 322 per 100,000 live births, 

infant mortality rate was 57 per 1,000 live births, and neonatal mortality rate was 37 

per 1,000 live births (1, 2). But irrespective of these positive trends to achieve 

Millennium Development Goals (MDG) 4 and 5, the issues of Maternal, neonatal and 

child health (MNCH) remain a major national concern. The recent Bangladesh 

Demographic Health Survey (BDHS) shows that most births occur at home without 

skilled attendants (2). Thus, almost 80% of neonates do not receive post-natal care 

(PNC) from a trained provider within six days of births. The poor health outcomes of 

the mother and children are associated with a number of factors including poverty, 

poor social status of women, low education levels, limited rights and freedoms, and 

cultural practices associated with pregnancy, childbirth, and the post-partum period 

result in mothers and babies being secluded in their homes and not permitted to 

leave home, even to seek appropriate care for problems and sickness (3-10). Overall, 

there is poor use of modern healthcare services by women, especially the rural and 

younger women, in Bangladesh. About 13% of the deliveries in rural areas are 

attended by medically trained providers. Additionally, trained traditional birth 

attendants (TBA) assist in 11% of deliveries and, more than 75% of births in rural area 

are assisted by untrained TBAs, relatives, friends, and others (2). 

During the last quarter of the twentieth century, there had been notable trends in 

public health communication. The issues addressed include population and family 

planning, primary healthcare, maternal and child health, HIV/AIDS, water and 

sanitation, and other communicable and non communicable diseases. 

Communication approaches have progressed from health education through 

information, education and communication (IEC) to behavior change communication 

(BCC). Overall, the role of communication in public health programme has been well 

established (11). However, researching the association between health communication, 

practice of healthy behaviours, and improved health is complex because of 

the extent and variety of confounding factors. Nonetheless, there is some evidence 

that public health communication affected health behaviour (12-17). Since the mid 

1990s and following the model of development communication, many donors, 

government, communication scholars and institutions have designed, implemented 

and evaluated innovative communication programme to achieve behaviour change 

rather than simply informing and educating. Lantican (undated) citing Piotrow and 

Rimon (1999) highlighted some of the problems of lack of strategic approaches. It 

includes lack of audience segmentation, poor pre-testing of messages and materials, 

little application of communication theory, poorly developed indicators for assessing 

the effectiveness of programme and messages that are not coherent with services. 

With the development of communication technology the use of the Internet and text 

messaging are increasing (18). Nonetheless, Lantican concludes that the 

interpersonal channels are important as individuals and small groups analyze the 


1

information garnered from various sources and apply what they have learned from 

their own lives. Increasingly we understand the role not only of mothers but also 

husbands and other important kin in the family. In Bangladesh, husbands, mothersin-law 

and elder brothers of the women play a major role in decision making 

especially in the case of health problems (19, 20). 

Targeting behaviour change strategies, that address specific barriers and target 

segmented audiences, can play a significant role in increasing safe motherhood. In 

order to provide quality care at the community level and promote appropriate use of 

referral facilities, BRAC has initiated MNCH programme in rural Bangladesh in 2006. 

The aim was to reduce maternal, neonatal and child mortality and morbidity with 

especial focus on the poor and deprived people (21). 

Effective communication involves transmission of health knowledges through 

messages that can be readily understood, accepted and practiced by the audience. 

The communication strategy of MNCH programme uses existing social and cultural 

norms and traditions that offer culturally appropriate ways of enhancing the 

communication strategies in a comprehensible and credible form. 

Major BCC initiatives of BRAC MNCH programme 

The project currently covers four districts (Nilphamari, Gaibandha, Rangpur and 

Mymensingh) and has planned to scale up in six more districts (Kurigram, 

Lalmonirhat, Faridpur, Magura, Madaripur and Rajbari). In order to achieve improved 

maternal and neonatal health, the programme gives importance to not only pregnant 

and lactating women but also to others intimately involved in decisions about their 

well-being. These include mothers-in-law, husbands of primary target audience, 

community health workers (CHW), BRAC staff, government staff at union health 

centre (UHC), Upazila Health and Family Welfare Centre (UHFWC), district hospital 

(DH), and Maternal and Child Welfare Centre (MCWC). In addition, the MNCH 

communication strategy seeks to reach other local government bodies, village elites, 

school teachers, village organization (VO) members and other community ‘movers 

and shakers’, and local representatives of non government organizations (NGO) and 

national and international agencies concerned with improvement of MNCH. 

BRAC seeks to increase communication between community members and 

healthcare providers with the medium-term objective of increasing the accountability 

of local health system for better and wider access of disadvantaged women and 

children to quality health services at community and facility levels (21). 

The communication component of the MNCH programme involves grassroot level 

healthcare providers like Shasthya Shebika (SS), Shasthya Kormi (SK) and newborn 

health worker (NHW). These health cadres provide a wide range of services at 

household levels encompassing: early identification of pregnancy and antenatal care 

(ANC), attendance at delivery, newborn care, post-natal care for mothers and 

neonates, under-five care, detection, management and referral of MNCH 

complications to hospitals and family planning centres. They provide both information 

2 RED Working Paper No. 21

and support for behaviour change through interactive communications, such as, 

face-to-face interpersonal and group communications. SKs and SSs educate 

mothers and family members using pictorial messages (Annex 2 and 3) including 

pregnancy care such as effects of nutritious food, taking rest, heavy work load, 

antenatal check-up, cleanliness, etc., delivery preparedness, introducing maternal 

danger signs during pregnancy, delivery and post-partum, using cell phone number 

in case of emergency. In addition they also talk about newborn care and danger 

signs of newborn. 

Flip charts are used by the SKs during group discussion with families and other 

community members (Annex 2 and 3). A poster depicting danger signs of maternal 

and neonatal complication is posted on the wall of women’s house to reinforce 

knowledge about danger signs and what to do if such complications arise (Annex 2 

and 3). The publication of POs’ cell phone numbers encourages women to call BRAC 

health providers when needed. Stickers list neonatal and maternal danger signs; 

PO’s cell phone number and what to do if such complications arise; the importance 

of effect of extra food intake during pregnancy and post-partum period (Annex 4). 

The programme also hosts advocacy workshops in the community to build 

awareness, support the roles of local elites in advocating improved health services, 

and empower the community people about MNCH care and practices. The BRAC 

regional manager (RM) and PO conduct the workshop with local elites at every year 

in each union. The participants includes the chairman and members of the union 

parishad, teachers, imams (religious leaders), government and alternative healthcare 

providers, MNCH committee members and other local influential people. 

Local song in the form of folk music (jaarigan) and street theatre (naatak) are 

organized from time to time in the community to reach rural people. The folk music 

initiative offers messages specifically on ANC, safe delivery, post-partum care, family 

planning, and infant and child health. The street theatre introduces the SSs and SKs, 

and their role in ANC, birth preparedness including the selection of skilled birth 

attendant; newborn care and PNC. The street theatre also demonstrates how the 

practice of traditional beliefs held by elderly women in the family can compromise 

pregnancy outcomes. 

BRAC MNCH programme information especially about maternal and neonatal danger 

signs is also periodically broadcasted on radio and television in national and private 

channels. Because of contamination and confounding factors, it is difficult to design 

research that describes the association between programme interventions and 

behaviour change. Therefore this study focused on the acceptability, comprehensibility 

and reported influence of the BCC tools used in the BRAC MNCH programme. 


3

Objectives 

Broadly, the objective of the study was to investigate the application of BRAC MNCH 

BCC tools in the form of IPC, print materials, and E-E. The specific objectives were 

as follows: 

1. To identify acceptability of different BCC channels to the target audience 

2. To assess the comprehensibility of different BCC tools by the target audience 

3. To assess the reported influence of messages in MNCH health-seeking and 

health- related behaviour of the target audience; and 

4. To identify the barriers to acceptance of BCC messages regarding MNCH by the 

community. 


Methods 

Study design 

The study was exploratory in nature. Data were collected using qualitative methods 

including key informant in-depth interview (KII), interview with semi-structured 

questionnaire, and focus group discussion (FGD). Documents, for example, flipcharts 

on care of pregnant and lactating women and newborn care, posters and stickers 

about maternal and newborn danger signs were reviewed (Annex 2 and 3). 

Research setting 

The study was conducted in two unions of Nilphamari district. BRAC health 

programme (BHP) initiated MNCH programme in Nilphamari in 2006 (21). BRAC has 

had other three core programmes in all over Bangladesh including Nilphamari namely 

microfinance, health and education. The MNCH intervention, with specially trained 

SSs, SKs and NHWs was implemented in addition to these core programmes. BCC 

tools were used as communication channels to convey messages to the target 

audiences. MNCH baseline and follow-up survey data show that the pilot activities in 

Nilphamari had positive effect on knowledge and practice in many indicators 

especially in ANC, family planning, birth preparedness, delivery care, post-natal care, 

newborn care practice, and immunization (21). It was perceived that BCC activities 

influenced people’s attitude and behaviour in relation to maternal and neonatal 

health. Considering this Nilphamari district was selected for the study. 

Study population 

The study population consisted of the primary target group of MNCH programme 

comprising pregnant women, mothers of newborns and under-5 children. Mothersin-law, 

husbands of a pregnant women/father of a newborn/under-5 children of the 

primary respondents were also included as study population (Table 1). 

Study sample 

Respondents were purposively selected from two unions of Nilphamari Sadar in 

Nilphamari district. From these two working areas four SKs were selected randomly. 

The initial 50 respondents were selected from these areas using snowball sampling 

techniques for conducting semi-structured interview. Participants for KII and FGD 

were selected from the initial 50 respondents. Thus, a total of 12 KII and 8 FGD 

sessions and informal group discussions (IGD) were conducted for data collection 

(Table 1). 


5

Table 1. Types of interviews by respondent’s categories 

Group Type of respondents Semi-structured KII FGD IGD 

1 Pregnant women 8 3 2 

2 Mother of neonate and 

child under 5 years 

15 

3 2 

3 Mother-in-law 15 3 2 

4 Father of neonate/child under 12 3 2 

5/Husband of pregnant women 

5 SS and SK 3 

Total 50 12 8 3 

Tools and techniques 

A checklist was followed for KII and FGD. An interview guide was used for semistructured 

interview, with a range of topics included knowledge and practice 

regarding maternal, neonatal and child care; memorization/recall messages given by 

SSs/SKs; memorization/recall messages from print materials and E-E; frequency of 

visits by SSs/SKs at last one month before data collection, during pregnancy, and 

post-partum, acceptability of the BCC tools; barriers to acceptances and 

communication with the providers. 

To test the comprehensibility of the messages of print materials the respondents 

were asked several questions like-please tell me what do you see in this picture 

What is your opinion about this picture What does it look like to you and why Do 

you have any recommendation to improve this picture, or is the picture 

comprehensible to you Furthermore, we sought to discover how respondents did 

relate messages with own real life experiences. 

Triangulation 

Two types of triangulation has been made to check and establish validity (22). These 

includes data triangulation (includes pregnant women, mother, mothers-in-law, and 

men) and methodological triangulation (includes semi-structured interview, FGD and 

KII). 

Data collection, management and analyses 

Data were collected during March-April 2010. Notes were taken by the researcher 

during the field interview. The interviews were recorded on tape by research 

assistants. Verbal consent to use the tape recorder was obtained from all 

participants. The notes and recordings were used to produce a complete naturalized 

transcript of each interview in Bangla (23). Data were analyzed by content and 

framework analyses. Data from semi-structured interviews; each transcript was 

analyzed using framework analysis technique. Five steps including familiarization, 

identifying a thematic framework, indexing, charting and mapping, and interpretation 

of the meaning were used as a process (24). The interview transcripts were read 


epeatedly and were coded by various themes according to the meaning. Emerging 

themes were compared and modified with each and every independent transcript. 

Furthermore, all themes were categorized under broader category. Each main theme 

was charted by completing a table where each case has its own row and columns 

representing the sub-topics. Cells contain relevant summaries from the data set. The 

process of analysis are described in Annex 1. 

Content analysis included several rounds of manual coding of the transcripts and 

discussions with the entire research team and listing of key themes (25-27). An 

example of an emerging theme from framework analysis and content analysis are 

present in Table 2 and 3 respectively. 

Ethical considerations 

The research was approved by the Bangladesh Medical Research Council. Verbal 

consent was obtained from all study participants. The respondents were informed 

that the participation was voluntary and that confidentiality would be ensured 

throughout the research process. All procedures were approved by technical 

advisory group of the rural MNCH programme of BRAC. Technical Advisory group 

included members from BRAC, Bangladesh and University of Aberdeen, UK. 

Table 2. Examples of matrix table of one theme from framework analysis of 

sources of information about MNCH print materials 

Main Theme: Sources of information about MNCH print materials 

ID 

Sources of 

no 

information 

Type of 

respondents 

22 Pregnant 

mother 

SS and SK 

from BRAC 

Printed 

material 

seen 

Perceived 

understand 

ability 

Content recall Reasons for 

liking (with 

quote) 

Yes Yes 5 maternal 

danger signs, 

pic e.g. 

headache, 

bleeding, 

convulsion, 

fever, babies 

hand/leg 

come out first 

I like all; these 

are for our 

well being. If 

someone get 

pregnant she 

could see 

these, follow 

and can be 

well 

Reasons 

for 

disliking 

(with 

quote) 

Nothing to 

dislike 


7

Table 3. Examples of matrix table of one theme from content analysis of 

difficulty to reach messages to the women through entertainment education 

Transcript/Meaning unit 

All family members went 

there except 1 or 2. They had 

work in the home. Para was 

big so most of the women 

were there because it was 

near to their home (ID: R) 

Women of this village 

watched the programme of 

local song. They said local 

song was performed by 

BRAC. Apa (SS) asked to join 

there. I could not enjoy due 

to household work.(ID: R) 

Sub-category/ 

possible closest 

meaning 

Most of the women 

can watch street 

theatre if the 

settings is near to 

their household. 

Women could not 

enjoy due to her 

work. Although SS 

informed her 

previously 

Category Sub-theme Theme 

importance of 

settings and 

distance for 

street theatre 

Traditional 

norms of 

household 

work is barrier 

to not 

watching local 

song 

Barriers to 

watching 

street theatre 

Barriers to 

watching 

local song 

Difficulty 

to reach 

messages 

to the 

women 

through 

entertainm 

ent 

education 


Findings 

Source of information about MNCH 

To explore the attention of the audience towards messages and materials on 

maternal, neonatal and child care, the respondents were asked about their 

knowledge on MNCH and how they had become aware of the danger signs during 

pregnancy, delivery, and post-partum period. The respondents were fully cognizant 

of the MNCH programme and BCC tools used by the BRAC programme. All were 

familiar with door-to-door home visits and face-to-face IPC with SSs and SKs; the 

flipcharts which are used by the SKs, and the posters and stickers given to them 

during IPC. 

Most of the respondents knew about the jarigaan (folksong) and the street theatre. 

They reported of getting key information about MNCH-related messages from these 

communication tools. The respondents also reported that the government produced 

entertainment television drama called Shukhi Paribar (The happy family) as another 

source of messages regarding maternal and child health and more general health as 

well. 

Majority of the female respondents cited Shishu Mongol-the MCWC as another 

source. As village doctors (VD) were easily accessible in the community, some 

respondents said that they got messages from VDs too. Besides, neighbours, 

friends, co-workers, and elder members of the family were other sources of 

information and advice about maternal and newborn healthcare. 

Interpersonal communication (IPC) as most acceptable channels by 

community people 

According to the SSs/SKs and study participants, one-to-one IPC was commonly 

used by SSs and SKs through regular home visits to pregnant women’s house. The 

SKs and SSs reported that sometimes they tried to arrange a group meeting with 

pregnant womens, neighbours, elderly and other female members and talked with 

several aspects of pregnancy and delivery care with the help of flipchart and posters 

of maternal danger signs. The community people liked SS and SK and had 

acceptability in the community. 


9

Box 1. 

Muslema (19) has no education. Her husband is a mason and has a daughter aged 

13 months. She consulted a SS when her baby had diarrhoea. SS gave oral saline 

but the diarrhoea did not stop for 3 days. Then SS took the mother and baby to 

Sadar hospital. Her baby was examined by a MBBS doctor and had given some 

medicines including 4 injections. After 4 days her child’s diarrhoea got cured. 

Box 2. 

Tajul Islam (30) had completed higher secondary education. He went to the SS’s 

house for consultation when his wife had urine infection during pregnancy. The SS 

not only gave advice but also took his wife to an MBBS doctor. The doctor gave 

some medicines and soon his wife was cured from urine infection. 

KII with the mothers, mothers-in-law and husbands reveal that the SSs and SKs have 

good relationship with pregnant women, family members and neighbours also during 

the antenatal visits. Community people were asked whether they could directly 

communicate with SS if necessary. Because the SS resides in their localities and 

verbal communication was easy for them. Therefore, the respondents felt that they 

could ask any question if they did not understand the messages during antenatal 

visit. As noted in the cases of Muslema and Tajul (Box 1 and 2), they got services 

from SSs and the SKs in case of complications due to SSs and SKs effective IPC 

skills. 

Community people, especially pregnant and lactating women, mostly liked this faceto-face 

IPC because of the easy access to health services delivered to their home. A 

key informant lactating women mentioned, 

“Don’t you think there is a difference between verbal communication by 

home visit and voices over mike To me this one is better (face-to-face). 

Suppose you have come, talking with me and I am listening to you.” 

According to the community people and SSs, and SKs they used local dialect. 

Therefore, the messages were easily understood by the community people. This 

process was comprehensible to the community members because the SKs used 

flipchart during message delivery. That is why they could easily recognize the 

terminology applied to the maternal complications (Table 4). In the semi-structured 

interview a pregnant woman said, 

“As we can ask question without any hesitation, they speak like us. I do not 

have any problems to recognize their language.” 


Table 4. Local term used by community people and health workers 

Local term Approx. Bengali term used Approx. English term used 

Shabalika Shorir kharap First menstruation 

Gaye theka Gorvoboti hoa Being pregnant 

Jhika jhiki Khichuni Convulsion 

Chechuni Khichuni Convulsion 

Osh nama Shorire pani asha Oedema 

Okto Rokto Bleeding 

Khalash kora Proshob Delivery 

Jhar Gorvoful Placenta 

Dai Dhatri TBA 

Dhattani Dhatri TBA (who cut the cord) 

Ghorshon dhari Dhatri TBA (who delivered the baby) 

Tej Atirikto roktokhoron Excessive bleeding 

Joraur mukh bhanga Joraur mukh khola Open the mouth of uterus 

Kachra Moyla Dirty object 

Napak Opobitro Impure 

Dushi gorvo Mora Bachha prosob Stillbirth 

Frequent visits by SSs and SKs were another noticeable factor associated with 

acceptance of face-to-face IPC. Some of the pregnant and lactating women reported 

that generally SSs and SKs visited their home twice and once in a month, 

respectively. The respondents desired more home visits by the SSs and SKs. 

Because the respondents perceived that with more regular visits from the SSs and 

SKs, they could memorize the massages more. A semi-structured interview with the 

pregnant day labourer said, 

“If the Shasthya Kormi apa comes frequently and makes us understand then 

we will memorize more. They come once in a month. That is why we could 

not memorize those (messages).” 

The respondents, however, did comment on what could be improved. Some of the 

community people mentioned that, SSs and SKs concentrated more on the pregnant 

women and newborn but relatively the frequency of home visits was less for neonate 

and child. A lactating women reported, 

“When I was pregnant they (SS/SK) came again and again, but after that we 

did not hear anything from them.” 

FGD and semi-structured interviews with all types of respondents reveal that IPC with 

group discussions by SSs and SKs did not seem to be structured. Several 

respondents urged that CHWs should talk to the community in group settings. Most 

of the respondents mentioned that they followed the messages given by SS and SK 

in their activities of daily life but they wished to share their experiences in group 

meeting. Most of the respondents agreed with this pregnant women’s opinion, 


11

“They (SS and SK) did enough. Still they should come and teach frequently. 

They can call a meeting, gather people and then talk and give advice”. 

In the eyes of local people, the presence of higher officials coming from head office in 

the group meetings brought more credibility to local workers. It was the common 

demand of most of them. A typical comment, during semi-structured interview of a 

husband of a pregnant woman, 

“The group meeting should take place once in a month and will be better if 

higher officers come and conduct these meetings other than Shebika or 

Kormi.” 

A few respondents were of the opinion that higher class people question about SSs’ 

capacity to detect health problems. According to them, the community people 

believed that due to their lower level of education and social status the SS was less 

well accepted in their society. It was reported that these higher status people such as 

economically solvent villagers felt that the SS training was not sufficient to enable 

them to adequately support the pregnant mother. Therefore, some people felt that 

they could not depend on them for pregnancy management. As noted in the case of 

Rokeya (Box 3), she claimed they (SS/SK) could not identify the problem of the baby 

during her pregnancy. A husband of a pregnant woman said, 

“Rich and higher educated person (in the village) think that SSs/SKs do not 

know anything. They do not have faith in their training. So they ignored 

them.” 

Another male respondent who was a VD also pointed out that, 

Box 3. 

“They (BRAC) should hire educated SS like at least HSC or SSC 

completed…..” 

Rokeya (32) has no education. She was pregnant for three times and has two living 

children. Her last delivery was at home with the help of a dai (TBA). During this 

pregnancy she had an ultrasonography and found the baby in reverse position 

(malpresentation). According to her, SK came each month for check-up but she 

(SK) could not find the abnormality. She reported that her water (amniotic fluid) 

broke 3 days before delivery. During delivery the baby’s leg came out first and then 

they called the SS. It took time to get baby’s head out, but the baby was dead by 

then. A village doctor was also called but it was too late. Baby had died before he 

came. 


Entertainment education as powerful channels to disseminate the messages 

The majority of the respondents were aware of folksong and street theatre, but few 

had the opportunity to actually listen to or watch those. People liked to listen to 

folksong and watch street theatre as those were both entertaining and informative. 

According to the community people, folksong and street theatre were mostly listened 

to or watched by children and women of all ages. They felt that the medium of 

folksong could get people’s attention very quickly; it could disseminate many 

messages in a short time and in an amusing way which was reported to be attractive 

to community members. Most of the pregnant and lactating mothers felt that the 

messages conveyed through folksong could easily reach the community people of 

different ages. They also reported that when a SS or SK visited their home, most of 

the time their children either teenager or adult, household head and other family 

members were not present. Therefore, because this show was arranged in open 

place, these family members could enjoy and learn without any restriction. A 

pregnant woman cited that, 

“…..different types of people including young, adult, and married, unmarried 

like jaarigan. Shebika visits and talk only with pregnant women. But jaarigan 

is understandable to all whether men and women”. 

Most of the respondents recognized the value of watching street theatre because it 

not only have the voice but also the visualization. They found it was both spellbinding 

and captivating and watching along with others offers the opportunity of mutual 

support and learning. A lactating woman mentioned, 

“Drama is performed in front of us. It is understandable. It is performed so 

nicely. Many people come and watch together, and if I forget any point of the 

drama other people could help me to remember. That is why I like drama 

than other media.” 

Most memorable part of the drama 

Women who had watched the drama had good memorization of the messages. 

Some of the pregnant and lactating women concentrated only on those messages 

commonly refuted by mothers-in-law such as, taking rest, ANC and giving extra food 

during the pregnancy. Mothers reported that often the mothers-in-law forced 

pregnant women to do heavy work. They do not allow SS and SK to give advice to 

their daughters-in-law about ANC. As a result the women had given birth to a 

stillborn baby. Most of the pregnant and lactating women showed good 

comprehension of the messages. They urged that more attention should be paid to 

communicating with elderly people. Because they felt that, elderly people did not give 

importance to these matters rather they followed traditional views. 


13

Frequency of watching/hearing folksong and street theatre 

The respondents considered that frequent watching of street theatre or hearing the 

folksong can be more useful for memorizing the messages. Many participants 

reported they have heard folksong 1 to 2 times but theatre was rarely seen by them. 

Community people suggested a change in programming of folksongs and theatre. 

They wanted to hear folksong and watch theatre more frequently. The IGD 

participants also reveal that community people wanted to see these show’s once in 

every quarter. 

Inappropriate time and location as barriers to enjoy 

Semi-structured interview, KII and FGD with all groups reveal that folksongs and 

street theatres are ahead of IPC in terms of enjoy ability, but they were far behind 

from IPC in terms of knowledge dissemination coverage because of timing and 

location. Most of the pregnant women, lactating mothers and mothers-in-law could 

not watch folksong because it was arranged at the hours when they were busy with 

their household works. As a mother-in-law said, 

“No, I did not listen to jaarigan, I was busy with my cooking but I wanted to 

listen to.” 

Furthermore, they had no advance notice of the show. Most of the time it was 

arranged hurriedly and within short time it was finished. A lactating mother said, 

“We were not informed about it (jaarigan) beforehand. It was arranged 

hurriedly. One day unexpectedly a Shebika came and told about the show… 

if she had informed us previously many people would be there.” 

The timing of folksong and theatre was also not suitable for men. Because men 

would work during daytime, thus they were absent during the show time. Most male 

respondents mentioned that they were aware of folksong, for example, that it was 

arranged by BRAC and was about MNCH, but they were not concerned about the 

subject matter. A husband of a pregnant woman said, 

“I did not give attention, I just heard music from distance, I could not tell what 

they were saying.” 

Distance from home was another most important barrier to attend the folksong. In 

addition, for women it was important that they had their husbands’ consent to 

attend. If anyone contravened these traditional norms they would to face unusual 

comments of the community. A pregnant woman mentioned, 

“I did not go there as my husband was not at home. Women from 

neighbourhood also did not go. If I go there people would talk bad about 

me.” 


Therefore, when the folksong or drama was arranged near their homes or with 

adequate notice then it was more easily accessible to the women. 

Perceptions about pictures of posters/stickers/flipcharts 

Posters with smiling face of mother and child were reported to be very attractive to 

the respondents. After identification of the pregnancy SKs gave the posters of healthy 

mother and healthy child which had the contact number (cell phone number) of the 

BRAC CHWs. Mothers also have had interest especially in this poster. A pregnant 

woman said, 

“I have lost this (healthy mother and healthy child) poster at my previous 

pregnancy. But now I wanted it from SS.” 

Respondents unanimously stated that they liked all those pictures as well as 

messages. To them pictures could explain those messages better. It also helped 

them to memorize the messages. A male respondent said, 

“Those pictures are better than words; pictures help us to memorize which 

word alone cannot do.” 

Community people liked the messages because they thought that those were for 

their betterment. These pictures and messages would alert them about any danger 

before its occurrence and would help them prepare for taking action. A mother- inlaw 

said, 

“They (SS/SK) came and gave these,…I glued it in my home. Whoever 

comes can see these and these can be noticed all the time, which will help 

us to be alart. If any problem occurs can be taken to the hospital. By seeing 

these pictures we can memorize these well.” 

A husband of a pregnant woman stated, 

“When my wife started bleeding during her pregnancy, I instantly recognized 

it as danger because I had seen the picture of danger signs before and 

Shebika apa gave the message too.” 

However, some of the community people perceived poster’s pictures of maternal and 

neonatal danger signs might be a cause of ‘bad fate’ for both the mother and child. 

Interestingly the notion of bad fate derived from the fear that treatment of 

complications would be unavailable to them because of economic reasons. 

“We do not have money. How we feel good in the case of such danger I am 

scared of these if it happens to me. From where and how can we manage 

money How will we be saved” said a pregnant woman. 


15

During the antenatal visits SKs told women to glue the posters/stickers in a suitable 

place to enable other family members to easily see and read messages of the 

pictures. However, there were various reasons given for not displaying the stickers 

and posters openly. Some of the pregnant and lactating mothers felt that displaying 

the pictures of maternal danger signs inside their room, where they could be seen by 

the male relatives and parents-in-law, would be a shameful thing. Some, therefore, 

glued the posters or sticker of maternal danger signs either at the corner of the room 

or on the back of the door where they were not immediately obvious. A pregnant 

woman mentioned, 

“What will he think, if a man (purush manush) comes and sees these 

pictures I feel shy. That is why I glued this picture to the back of the door.” 

Women also kept the sticker and poster of maternal danger signs inside the drawer 

of the table because their husbands had objection towards the posters. Women also 

perceived these poster and stickers were only for the pregnant women. 

“I have three children. I do not need to take more babies. That is why I do 

not need to hang the sticker up. So, I kept it in my drawer.” 

According to SKs, elderly people did not like open display of the stickers inside the 

room. Elderly and some of the more pious community members believe that prayer 

(namaj) is impossible if the posters illustrating human beings would have been hung 

inside the room. In some cases, children of the household also removed the posters 

from the door. 

Easy access to help given by the display of health workers’ cell number on 

posters and stickers 

Most of the respondents perceived that poster or stickers containing cell phone 

number of BRAC CHW gave community people assurance about the accessibility of 

help. They believed that in any complication, if they made a phone call (phone 

number mentioned in poster), BRAC staff would be there to help. A lactating mother 

described the circumstances of her delivery as follows, 

“When I was in excessive bleeding (in local term ‘Tej’) during delivery, Monju 

Apa (SS) feed me a tablet (misoprostol). Then we called [telephoned] Shonali 

Apa (SK). She came very soon after calling her.” 

Some women reported to seek help from SK by using the cell phone numbers as 

shown in the case of Muslema (Box 4). 


Box 4. 

Muslema (19) lives in the central part of the study site. She has no education. Her 

pregnancy was being monitored by SS and SK. From them she got the cell phone 

numbers of BRAC. She was advised by SK to call any of these cell phone 

numbers on the posters in case of emergency. At night of the expected day of 

delivery the SK waited at her home for long time. When there was no signs of 

delivery, apa (SK) was called. She came and gave an injection that help to regain 

the pain but that did not work. Then in the next afternoon the village doctor came 

to try with no effect. Finally, she was taken to the hospital at night by the help of 

SK. Doctor gave injection and saline and then at 4 a.m. she delivered the baby. 

Sharing messages with family members/neighbours by community people 

Women cited that generally they would like to talk about the messages given by SSs 

or SKs with their neighbours and same age groups. Men had the same desire for 

message sharing process as reported from FGD and semi-structured interview. 

However, women also reported that they shared about the danger signs with their 

husbands. A pregnant woman said, 

“I pasted the sticker/poster of maternal danger signs in my home. Later, I 

requested my husband to look at these pictures and thereby learn about 

these danger signs. Men, including you, do not know these things.” 

However, it was particularly difficult for pregnant and lactating women to share 

knowledge or new messages with elderly people within the family or in the 

community because they hold their own traditional views on that. KIIs with pregnant 

and lactating women reveal that elderly women often do not want to accept new 

ways of pregnancy care such as necessity of taking rest, avoiding heavy workload, 

and having more nutritious and extra food during pregnancy. 

“Elderly people do not give importance to new messages rather they wish 

women would follow traditional practices,” said a pregnant and lactating 

woman. 

Reaching family members with messages through community health 

workers 

IGDs with SSs and SKs reveal that usually they tried to contact with family members, 

especially elderly people and husband, during antenatal visits because they 

considered them as important persons involved in the healthcare decisions such as: 

• seeking routine care during pregnancy or any other preventive care, 

• increasing or changing women’s diet during pregnancy and post-partum period, 

additional rest for the pregnant and lactating women, 

• birth planning or birth preparation, 


17

• referring women or baby with problems or sickness to health facilities, and 

• family planning. 

However, SSs and SKs reported that usually they failed to contact the husband 

because they were absent in the home during SS and SKs’ home visits. None of the 

pregnant or lactating women reported that the SSs and SKs had talked with their 

husbands. Most of the time the women themselves informed their spouses about the 

visits of the SSs and SKs, and they also shared the messages with their husbands. 

Women mentioned that when their husbands saw the posters of maternal danger 

signs only then they asked where from they got these. A pregnant woman said, 

“SK left the sticker on the table. My husband saw it and asked ‘who gave 

this card Why’Then I said, ‘Monoara apa (SK) gave this’. But he did not 

say anything about this matter.” 

Another pregnant woman said, 

“My husband read the messages of the posters/stickers and said to my 

mother-in -law that we have to go to hospitals if any danger sign appears. 

My mothers-in-law did not know these things beforehand.” 

Women also talked about the BRAC MNCH services to their neighbour and relatives. 

The advice they gave to their relatives and neighbours was that which they received 

from SSs and SKs during their pregnancy. A lactating woman said, 

“If anybody is pregnant I tell them to contact Monju apa (SS) and Shonali apa 

(SK). When I was pregnant they advised me on maternal danger signs, ANC, 

PNC, Newborn care etc. So you also communicate with them”. 

Clarity and comprehensibility of the pictures of posters/stickers/flipcharts 

To assess the respondents’ level of understanding we showed them existing pictures 

of flipcharts and asked them to describe the pictures and tell us what message they 

were getting from them. Most of those pictures were correctly described by the 

participants and also they could recount the exact message (Annex 1). However, they 

experienced some difficulty in recognizing certain pictures and messages, e.g. 

maternal danger signs. They could not recognize the state of the mother that is, 

whether it was before and after delivery. But the respondents knew that these danger 

signs could occur during pregnancy, delivery, and after delivery. They also suggested 

that it would have been easy to understand if there was a baby lying beside the 

mother in those pictures indicating maternal danger signs after delivery (Annex 2). 

Some of the participants found the pictures of cutting the baby’s cord with germ-free 

blade and the message on exclusive breast feeding for six months not clear. They felt 

that the pictures were not informative. They understood them because SS explained 

the messages. The respondents articulated the same opinion about the picture of 


irth asphyxia. They indicated that the picture did not communicate the message 

properly. 

Almost all pictures of both the flipcharts about maternal and newborn care, sticker 

and posters of maternal and newborn danger signs were comprehensible except 

few, e.g prolonged labour, use of a sanitary pad, cleanliness during pregnancy, 

assistance during delivery, retained placenta, one should not put anything to baby’s 

cord, baby’s eye infection, examination of baby’s breathing. Respondents had 

difficulty in grasping messages from these pictures (Annex 2). 

The pictures of poster, sticker and flipchart were supposed to be explained to the 

community people by SK in a group meeting or at each antenatal visit. The women 

stated that sometimes CHWs were in a hurry to explain and show poster only once. 

The respondents felt that if CHWs avoided hurriedness and would show the posters 

repeatedly, people could memorize it easily and communication would be more 

effective. Some of the respondents also mentioned that SK left the posters for 2 days 

at the house of pregnant women to see the pictures. That was why they could not 

understand some of the pictures. One pregnant woman said, 

“(She) showed it (flipchart) once and it was with me for 2 days. I had no 

ability to understand myself. After 2 days she returned the flipchart with her. 

And again when she came for ANC then made me understand the pictures.” 

Another pregnant woman also mentioned, 

“(She) did not show anything rather just gave some advice. She gave me the 

card (stickers of maternal danger sign) and said whatever you are seeing, try 

to maintain[do this].” 

Even the messages about newborn care were not accessible to the pregnant 

women. Most of the pregnant women did not see the flipchart of newborn care. Here 

are some comments. 

“Apa did not show this book” 

“No, it was not showed to me” 

“This book (She) did not show this picture book” 

“No, I did not see (this book)” 

KII with the mothers reveals that women did not disclose the extent to which they 

understood (or failed to understand) the messages of the pictures. Women asked 

CHWs about any queries related to pregnancy and delivery, but actually they were 

not always able to understand. A pregnant woman said, 

“That which I understand I say I understand it and that which I don’t 

understand, I say I understand that too.” 


19

Another pregnant woman also provide the same response, 

“I asked her please make me understand the pictures. She responded but I 

could not remember. Apa (SK) talked but I did not give effort to remember 

those things.” 

Accessibility, acceptability and comprehensibility of the messages from 

mass media 

Television was more accessible to the community people rather than radio. Pregnant 

and lactating women liked to watch television at their own house or in a neighbour’s 

house. Generally they enjoyed a variety of shows here, but a health-related drama 

‘Shukhi Paribar’ was very acceptable to them. According to them this national 

television drama was a good source of information on MNCH and general health as 

well. Generally, household female members, neighbours and children enjoyed the 

drama show together. They felt the stories which were based on rural communities, 

actor and actress speak rural accent, their movements, attire, attitude everything was 

similar to them. That is why they feel closely with the television drama show. A 

pregnant mother said, 

“I like this television drama because it represents our words (views). I can 

relate the situation with my real life by watching this programme”. 

Most of them had ability to recall the messages of this drama. It was found that 

visualization of drama helped pregnant and lactating mothers to understand the 

messages given by SSs/SKs. For example, they accurately recounted messages 

about ensuring pregnant women take extra food, rest and proper sleep during 

pregnancy and about colostrum feeding. 

A lactating mother also had the ability to recall the dialogue of this television 

drama, “Duti sontaner beshi noe, ekti holey valo hoe (Having no more than 

two child, but one is better).” 

Though this television show had good acceptability to the pregnant women most of 

the lactating mothers could not watch the show regularly because of their household 

work and nurturing the baby. Men had no interest in watching this. Most of the 

pregnant women mentioned that their husbands generally watched other shows in 

television but not Shukhi Paribar. Husbands perceived that the show was just for 

women only. A pregnant woman said, 

“What will we discuss (about the shukhi paribar) He does not like this 

programme rather he likes hindi movie. He has no interest in this programme. 

That is why I do not tell him anything about it.” 

A husband of a pregnant woman also said, 

“I watch TV only when the football or other matches are shown.” 


But other male respondents mentioned that they did not have enough time to watch 

television due to their workload. 

“I worked outside. When I came (at home) all of a sudden I watch TV. 

Otherwise I do not have time to watch TV.” 

Influences of messages on attitudes and practices 

Increasing awareness of mother-in-law 

Though elderly people have traditional beliefs on healthcare and seeking care about 

pregnancy and post-partum, findings reveal that some elder community members 

actually perceived the urgency of ANC and health promoting practices for the 

pregnant women. Some of the women mentioned that their mothers-in-law took 

initiative for ANC for their daughters-in-law. 

“When I was in the third month of pregnancy, my mothers-in-law talked with 

Monoara apa (SK) and brought her to my house. From then she (the SK) 

came to check-up regularly at every month.” 

Increasing realization about importance of pregnancy care 

Community people could easily recall those messages which were related with their 

real life experiences, for example antenatal check-up, tetanus toxoid (TT) vaccination, 

birth preparedness, delivery danger signs, and use of cell phone number. 

Growing demand for MNCH services 

Community people received messages positively. They mentioned that the messages 

raised awareness. Most of the community people now know about facilities available 

to them through health workers communications, posters, stickers and also local 

songs and street theatres. Now they felt it was their responsibility, and that if they 

could not follow the instruction given through the messages, maternal and neonatal 

health would never improve. Overall, the respondents considered that people were 

more aware now a day and they did what the CHWs told them to do. A mother of an 

under-five child stated, 

“Now we keep clean ourselves and take good care of our babies what we 

did not do before. Earlier we did not maintain any health rules that we do 

now and it makes our lives healthy and better.” 

Not only had that but community people realized the importance of healthcare during 

pregnancy. An SS mentioned that pregnancy identification was becoming easier than 

previously and the IGD with SSs reveal that not only was there improving 

consciousness about health among community members but among CHWs too. 


21

Improving health consciousness 

According to different types of interviews with the respondents there is a reported 

change regarding the accessing of health facilities. People have become more 

sensitized about danger signs in delivery. People now know different health-related 

problems, what causes them and their remedies. They also know what to do, where 

to go for proper treatment, and they were practicing it. They did not even depend on 

CHWs now; they would go to the health centres by themselves. Several respondents 

cited that they called SS first then the village doctors in case of danger during 

pregnancy and delivery. A father of a child under one year said, 

“If we need any kind of treatment we would like to go Shishu Mongal 

(MCWC). For diarrhea and fever we like to go to the SS. If not cured, we 

prefer the village doctor because he is accessible to us.” 

Another woman stated, 

“Before if any problem persists, we just sit in the house and do nothing, 

nowadays if we face any problem, we go to shebikas and whenever the 

problem is serious we would go to hospital.” 

Taking right decision by mutual understanding 

During the KIIs with the women it was found that the messages had some sort of 

influences on community member’s attitude that leads them to make health 

promoting decisions. A lactating mother went to enjoy the street theatre with her 

husband. After the end of the show, her husband told her about the importance of 

the healthcare, 

“Let’s drop the mistakes which we made before, the mistake which has 

occurred during our marriage, just let bygone be bygones. We watched, 

heard, and whatever learnt we will implement. We will not repeat the same 

mistakes in the case of our child.” 

Message application in personal life by health workers 

Health workers reported that they follow these messages in their own life for their 

own sake. They believe that they should practice these first before disseminating 

those messages and give advice to others to practice, otherwise they would not 

listen to and practice. One SK stated, 

“When we started giving de worming tablets to pregnant women there was 

confusion about its safety among women. At that time I was pregnant too 

and I took the tablet to prove and assure them that it was safe.” 


Discussion 

This research found that face-to-face IPC strategy by SSs and SKs was reported to 

influence community members to change their attitude and behaviour with respect to 

maternal and child healthcare. IPC channels have been most successful in influencing 

community’s knowledge, attitudes and motivating behaviour change, while mass 

media i.e, street theatre, folksong (jarigaan) and television were also important 

credible sources of information. In order to increase comprehensibility of the 

messages from print materials we identified revisions are need to reprint the BCC 

materials. 

A review of selected interventions in South Asia shows that IPC seems to be the 

strongest form of BCC in this region (28). In 2007, Hirondelle Foundation found that 

informal face-to-face communication was the most reliable source of information in 

the Timor-Leste (29). This study shows that in the community, IPC make it possible 

for people to exchange information, express their feelings, obtain immediate 

feedback, and respond to questions for removing doubts and misconceptions and to 

support one another as they implement new knowledge. Reasons for acceptability of 

IPC include common language, mutual understanding of cultural issues, rapport 

building, easy way of asking questions, and ability to direct communication with 

providers. Furthermore, from a gender perspective, female health workers (SS and 

SK) were key in communicating with pregnant women and lactating mothers 

because women have some kind of fellow feeling with SS and SK as the latter come 

from within the community with more or less similar socioeconomic background. 

Leventhal noted that during IPC that the communicator can ensure receiver 

comprehension by asking questions and observing where understanding is faulty 

(30). Thus, this two-way interaction is essential for identifying the level of readiness for 

change and for convincing and supporting individuals to adopt health-prompting 

behaviour (31). This challenge and support can be delivered in one to one situations 

in highly customized way by the SS and SK although it was found that they are often 

hurried in their house to house visits. This is likely to limit the degree of 

personalization of the messages delivered and according to our findings, limits the 

extent to which they take feedback about whether messages are understood. MNCH 

programme should address the skill of taking feedback as part of the ongoing inservice 

training for SSs and SKs. 

On the other hand, the respondents also advocated for increased use of group 

meetings. The study further shows that the mechanisms by which effective 

communication was achieved included the fact that here both recipients and 

providers could contribute essential information and ideas. For example, both spoke 

and listened to, both were asked questions, expressed opinions, and exchanged 

information, and both were able to fully understand what the other was trying to say 


23

(29). A community member who felt that they did not understand or could not 

remember a message could ask a peer for clarity. 

Factors such as the degree of privacy, time selected for encounters, comfort, and 

waiting time can also inhibit or enhance individual/group-provider interaction (29). 

Results reveal that messages did not effectively reach secondary audiences such as 

men and elderly due to their unavailability in the household at the time of visit of the 

SSs and SKs and because of the persistence of traditional beliefs and attendant 

resistance to modern healthcare systems. There was little evidence that men and the 

elderly engaged in peer support. In Tanzania, under the KINSHAI project, eight peer 

support groups were established to provide HIV/AIDS education to the community. 

Each group consists of 25 members aged at least 60. From each group four 

individuals were trained by KINSHAI. Members of the groups have reported reduced 

stigma from their communities and a greater sense of hope and well-being (32). 

MNCH programme may arrange group meeting with both the mother-in-law and 

daughter-in-law about their role and relationship in pregnancy and delivery care. 

Flash cards including men’s role in pregnancy and delivery care of his wife, 

importance of ANC, delivery preparedness can be distributed to increase men’s 

comprehensibility in these issues. There is also room for more targeted 

communication with older members of the community. 

Effective communication programme could explore new ways to use peer groups to 

convey messages and also reinforce the practice of the key messages in their real 

life. However, depending on intervention site, peer educators are often illiterate, which 

especially in our study areas where there was discrimination against lower status and 

poorly educated SSs and SKs could be considered to be a disadvantage to the peer 

education method (33). 

It was found that community had a perception of SSs and SKs as poorly educated 

and of low status. To overcome this perception, programmes should give importance 

of effective training which may increase rapport-building, communication and 

negotiation skills. While SSs and SKs are given foundation or some basic training on 

MNCH and essential healthcare. Regular refresher training is also given for one day 

every month. If they are adequately trained and exposed to identify health problem, 

they will have adequate skills to assess, manage and take right decisions to save 

mother and newborn lives. However, the technical medical skills listed should be 

buttressed by further training in assertive communication. There are many 

programmes that report successful training of CHWs (34, 35). Soloman et al. found 

that in the Ghananian community health volunteer’s drug management skills were 

good, the response of the community was positive. In Ghana, community volunteers 

were trained for 7-18 days on diagnosis of trachoma, the use of azithromycine, and 

side effect of the drugs. After training, each volunteer was asked to examine the 

member of household in the presence of doctor and ophthalmic nurse (35). 


It was revealed that village doctors still play an important and, at times, perverse role 

in the care of mothers and neonates. So, non-professional healthcare providers may 

also be included in the effective training on MNCH care. 

In the case of BRAC, MNCH committee could perform a significant role. As per rules 

and regulation MNCH committee members introduced the SSs as healthcare 

providers in the community. The process of introducing SS should be credible to the 

community. 

The flipcharts and posters were found to be popular materials, because the 

community people considered it for easy memorization of the danger signs, and 

getting cell phone numbers for emergency of help. Religious and cultural reasons 

were found to be the barriers to adopt the pictures of maternal danger signs. 

Biologically each individual are unique, but culturally they belong to same ground 

where their beliefs stands for. Pictorial forms of communication have been 

considered by many NGOs and the government as the best way to address people 

at the rural level, because if well designed and adequately pre-tested this 

communication medium is easy to understand (33). Our findings reveal that 

community people had their own perceptions regarding the photos of flipchart and 

posters. As most of the community people were not literate, CHWs should be 

capable of teaching them effectively taking account of their perceptions. The pictures 

which were misunderstood or found culturally unacceptable by community people 

should be revised. Our flipchart mostly gives one message per page. However, there 

is evidence that people could more easily understand the pictures if it contains some 

stories and parables. In Niger, a popular flipchart tells the story of two characters, 

Aicha and Mariama, who have opposite experiences with nutrition and family 

planning. The village women used to discuss their stories as this flipchart was so 

popular to them (36). 

Effective and sustainable posters are essential for different target groups. In Nepal, a 

variety of innovative print materials have been produced under SUMATA (Care, 

Share, Prepare) initiatives including posters, lampshades, danglers, and prayer flags 

featuring the SUMATA images and messages of care, share and prepare. It was 

found that they had three different types of posters promoting care, share, and 

prepare for both urban and rural couple, and mother-in-law. These print materials are 

used by Nepal Safe Motherhood Programme at mother-in-law and daughter-in-law 

meetings and adapted by local community-based organizations into own formats 

(37). However, flipcharts are expensive and cannot be mass-produced for each 

woman. It is, therefore, essential to make story-based flipcharts and handouts by 

most community-based group/peer committees. It was found that peer-to-peer 

process of communication through flipcharts were successful in creating a 

sympathetic connection between a trainee and audience (35). 

The study quickly discovered that shukhi paribar-the national TV drama facilitates 

community people to think about care of pregnant mother. Many projects have 

supported the idea that entertainment media can play a positive role in educating the 

public about significant health issues (12, 38-42). In 1984, India began broadcasting 


25

for 17 month the first soap opera titled ‘we people’. It was about promotion of family 

planning and elevation of the status of women. Research indicates that 70% of the 

viewers think that they had learned that women should have the freedom to make 

their personal decisions about life and family size (37). Nigeria, Maldives, South Africa 

and India also experienced similar success with television (12, 40, 41). However, it 

was difficult to accurately measure the influence of this programme in relation to the 

adoption of positive maternal and child health promoting practices. The impact 

appeared in our study to be associated with the support the television show brought 

to what community members learned through IPC. The influence of audience 

involvement on IPC showed an overlap of mass media and IPC reported by Sood 

(42). The present study also found that though few of the community people had 

access to watch television programmes and mothers-in-law and husbands of the 

women were not seen the television programme mostly. So community television, 

where more individuals gather around, can be one of the way to broadcast health 

related programmes. MNCH programme should consider the distribution of DVDs. 

Though radio and television are not widely available in our communities, folksong is 

also an effective mass media. Community people have eagerness for entertainment 

education. This kind of low cost and low tech communication systems may be 

effective for promotion of any social and behaviour change. Folk song as reported 

was a good way to quickly disseminate messages to the community. Memorization 

was easy as people can watch, hear and interpret the story at the same time. If the 

folk song is properly organized in a systematic manner any intervention has 

opportunities to quickly share messages. 

It was also reported in several studies that using traditional media as a BCC method 

may be effective (11, 12, 43). In Tanjania, traditional singing and dancing 

performance called mamanju is held as part of a three-day festival on the theme of 

skilled care. Incorporating music, singing and traditional dancing, in Burkina Faso, the 

performances dramatized different scenarios to promote use of facility-based skilled 

care. This medium can work more fruitfully if it is used more strategically. The 

performances should be staged in conjunction with the community events, such as 

holiday, village market day (hat bar), traditional day, special open days at health 

facilities, community-level meetings, etc. Besides the local drama troupes, TBAs 

could play an important role in disseminating the messages. TBAs in the remote rural 

district of Pallisa in eastern Uganda play a significant role through some simple songs 

where they are able to teach mothers about ANC, birth preparedness, newborn care, 

also cite the major local killers of women in childbirth such as, anemia, cephalo-pelvic 

disproportion, maleria and facilitate early identification and referral. It was seen that in 

these villages without doctors and hospitals, TBAs and community members 

themselves are solving the most serious health problems through the teaching power 

of songs and stories (44). 

Our findings reveal that in Nilphamari these media were used rarely and messages 

could not reach to the community properly due to unsuitable time and place of 

organization. But research confirmed that entertainment educations are highly 

acceptable in communicating maternal and child health information and influencing 


community to behaviour change. As we found they have had emotional engagement 

with the materials (stories, lyrics, languages, plays, artists) of street theatre. Women 

could identify and evaluate the situation in terms of their own lives and perceived 

realities. Research identified that when characters express their feelings, the audience 

responds emotionally (42, 45). Though the community people had limited education, 

communication materials were easily understood by them. It was accepted due to its 

traditional popularity and easy way of communication. In India, street theatre was 

effective for HIV/AIDS programme although had limited formal education and also the 

audience due to its traditional popularity and cost effectiveness (42). For maximum 

audience coverage and rigorous dissemination this media performance should be 

arranged regularly with especial focus on the specific issues. 

Combining interpersonal, mass media and community-based communication 

channels like local song, street theatre and puppet show can help maximize the 

effect of a BCC programme. But the programme should identify the right way to mix 

channels considering time, place, gender, story, and availability of mass 

communication channels. Because, individuals vary in levels of motivation and are at 

different points in the process of change they can benefit from different interventions 

(40). One method is not effectively sustainable without support of other methods. It 

is, therefore, important to segment the audience and apply a suite of communication 

methods that reinforce one another. 

Many countries undertook interventions applying the mixed method strategy for 

behaviour change. In Egypt ‘The Mabruk’ initiative offers a comprehensive package 

of messages using a mix of different channels and strategies (46). In Taiwan the field 

workers transfer knowledge and adoption of family planning practice to newlyweds 

through posters and community meetings. With the addition of mass media 

intervention, the programme was recognized as one of the first family planning 

successes (47). One of the poorest countries of Asia, Timor-Leste has also 

developed mix communication strategy for child health development including IPC, 

advocacy, community mobilization, E-E and mass media. The Soul City experience in 

South Africa used several forms of media (television, radio and comic strip) each 

carrying a different storyline (40). Using the E-E approach, the SUMATA initiatives are 

also developed including radio spots and dramas, print materials, a television drama 

and community-based street theatre performances (38). Thus, this combined 

process of health education can play a fundamental role in continuing education. 

Then a programme can achieve long-term sustainability of health promotion efforts. 

In conclusion, overall we found that the MNCH messages were acceptable; for the 

most part comprehensible and were reported to have begun to effect change in the 

behaviours of all types of respondents, including, the health workers themselves. 

Some of the materials need to be revisied to improve comprehensibility. Although 

there is evidence that a programme with a BCC component can produce effective 

results but it was not clear that how much value the BCC component contributes. 

Besides these limitations, findings suggest that within the BRAC MNCH 

communication strategy, there should be more application of differentiated messages 

for segmented audiences and ongoing use of multi-media communication. Ongoing 


27

monitoring should identify how best to combine IPC, traditional and mass media in 

different field situations. 

Implications of findings for programme: 

This study recommends some specific actions to improve MNCH-related 

communication. These are as follows: 

• Improve training on message content and communication skills of SSs, SKs and 

MNCH Committee members, particularly on the preventive and promotive 

aspects of MNCH and specifically on the newer messages (safe birth planning, 

danger signs of pregnancy, delivery, newborn care and danger signs). 

• Increase number of SK visits during pregnancy and post-natal period. 

• Revise illustration in flip charts, posters and stickers in accordance with the study 

findings. 

• During home visits, SKs should emphasize and explain in detail using local 

terminology, the pictures that difficult to understand (bleeding during pregnancy, 

delivery and post-partum, prolong labour, retained placenta, and maternal 

headache). CHWs can tell practical stories at the time of showing posters or 

flipcharts. 

• Participatory group meeting headed by senior officers (PO/BM/RM) can be useful 

to reinforce messages communicated by junior SSs and SKs. 

• Improve communication with key decision-makers such as the elderly and male 

members of the household not only the mother alone. Design and pre-test 

specific messages for men and mothers-in-law. For example, include the role of 

husbands and mother-in-law in messages. 

• Align delivery of messages to annual patterns of pregnancy and birth (Annex 4). 

• The growing popularity of entertainment education, programme should 

concentrate on developing the characters of drama which the community 

members can relate with them. And the characters have ability to elicit emotional 

reaction which would be positive towards the performing the new behaviour. 

Street theatres and local songs should be arranged in market place for children 

and elderly people at times suitable for them. 

• Programme may start to employ some small format of community media such as 

loudspeakers or megaphones-stationary (those in mosques and connected to 

vehicles)’, organize participatory drama; test SMS messaging, quiz etc. to SSs, 

SKs and interested community peoples and MNCH committee members. 

• Hence many women and mothers-in-law were not able to enjoy street theatre 

and folk song due to their household work a video drama about change focused 

on gender, women’s status, household work sharing, husbands, mother-in-laws 

and other family member’s responsibility, delivery preparedness etc. and that can 

be arrange in a pregnant women’s house. 


References 

1. NIPORT, ORC Macro, Johns Hopkins University, and ICDDR,B. Bangladesh maternal 

health services and maternal mortality survey 2001. Dhaka and Claverton: NIPORT, ORC 

Macro, Johns Hopkins University and ICDDR, B, 2003. 

2. NIPORT, Mitra and associates, and Macro International. Bangladesh demographic and 

health survey 2007. Dhaka and Claverton: NIPORT, Mitra Associate and Macro 

International, 2009. 

3. Bhuiya A and Streatfield K. Feeding home-remedy practices and consultation with 

healthcare providers during childhood illness in rural Bangladesh. J Diarrhoeal Dis 

Res1995;13(2):106-12. 

4. Goodburn EA and Gazi R. Maternal morbidity relating to delivery and the puerperium: 

beliefs and practices in rural Bangladesh. (unpublished) Dhaka: BRAC, 1993. 

5. Adebiyi A, Ganesan PA, Prasad RNV. Papaya (carica papaya) consumption is unsafe in 

pregnancy: fact or fable scientific evaluation of a common belief in some parts of asia 

using a rat model. Br J Nutri 2002;88:199–23. 

6. Darmstadt GL, Syed U, Patel Z, Kabir N. Review of domiciliary newborn-care practices in 

Bangladesh. J Health Popul Nutr 2006;24(4):380-93. 

7. Gurung G. Practices on immediate care of newborn in the communities of Kailali district. 

Nepal Med College J 2008;10(1):41-4. 

8. Winch PJ, Alam MA, Akther A, Afroz D, Ali NA, Allis AA, Baqui H, Darmstadt G, El Arifeen 

S, Habibur RSM. Local understandings of vulnerability and protection during the neonatal 

period in Sylhet district, Bangladesh: a qualitative study. Lancet 2005;366(9484):478-85. 

9. Mohan P, Lyengar SD, Agarwal K, Martines JC, Sen K. Care seeking practices in rural 

Rajasthan: barriers and facilitating factors. J Perinatol 2008;28(suppl 2):S31-7. 

10. Jalil F. Perinatal health in Pakistan: a review of the current situation. Acta Paediatrica 

2004;93(10):1273-9. 

11. Piotrow PT and Rimon JG. New directions in family planning communication: 12 

predictions for the 1990s. Asia-Pacific Popul J 1988;3(4):17-32. 

12. Hornik RC. Public health communication: evidence for behavior change. 

http://books.google.com/booksid=0SaSVp3BMzYC&dq=public+health+communication 

&printsec=frontcover&source=in&hl=en&ei=L9RLTOPQHpf80wTXiOWECw&sa=X&oi=bo 

ok_result&ct=result&resnum=12&ved=0CEQQ6AEwCw#v=onepage&q&f=false 

(accessed 17.02.2011). 

13. Pulmgreen P, Donohew L, Lorch EP, Hoyel RH, Stephenson MT. Television campaigns 

and adolescent marijuana use: tests of sensation seeking targeting. Am J Public Health 

2001;91(2):292-6. 

14. Farelley MC, Devis KC, Haviland ML, Messei P, Healton CG. Evidence of a doseresponse, 

relationship between “truth” antismoking ads and youth smoking prevalence. 

Am J Public Health 2005;95(3):425-31. 

15. Niederdeppe J, Farreley MC, Haviland ML. Confirming truth. more evidence of a 

successful tobacco counters marketing campaign in Florida. Am J Public Health 

2004;94:255-7. 


29

16. Sood S, Chandra U, Mishra P, Neupane S. Measuring the effects of behavior change 

interventions in Nepal with population based survey results. Johns Hopkins Bloomberg 

School and Public Health. Center for Communication programme, 2004. 

http://www.jhpiego.org/resources/pubs/mnh/mnhSurveyRpt_Nepal.pdf(accessed 

16.02.2011). 

17. Vaughan PW, Regis A, Catherine F. Effects of an entertainment-education radio-soap 

opera on family planning and HIV prevention in St.Lucia. Int Fam Plann Perspectives 

2000;26(4):148-57. 

18. Lantican CM: Behavioral change communication and advocacy and information and 

communications technology as tools for population and development and poverty 

reduction; selected papers of the fifth Asian and Pacific Population Conference. 

http://www.unescap.org/esid/psis/population/popseries/apss158/part2_4.pdf(accessed 

22.02.2011) 

19. Afsana K, Rashid SF. Discoursing birthing care: experiences from Bangladesh. Dhaka: 

The University Press Limited.2000;128p 

20. Banu M, Nahar S, Nasreen HE. Assessing the manoshi referral system. addressing 

delays in seeking emergency obstetric care in Dhaka slums. Dhaka: BRAC, 2010.20p 

(Manoshi Working Paper No.10). 

21. Salam SS, Khan MA, Salahuddin S, Choudhury N, Nicholls P, Nasreen HE. Maternal, 

neonatal and child health in selected northern districts of Bangladesh. findings from 

baseline survey 2008. Dhaka: BRAC,2008. 

22. Guin LA. Triangulation: establishing the validity of qualitative studies.FCS6014, Institute of 

Food and Agricultural Sciences, University of Florida, 2002. http://www.raymanbacchus.net/uploads/documents/Triangulation.pdf(accessed 

22.02.2011). 

23. Oliver DG, Serovich JM, Mason TL. Constraints and opportunities with interview 

transcription: towards reflection in qualitative research. Soc Forces. 2005;84(2):1273-89. 

24. Shrivastava A, Thomson AB. Framework analysis: a qualitative methodology for applied 

policy research. JOAAG 2009;4(2):72-9. 

25. Rabiee F. Focus group interview and data analysis. Proceedings of the Nutrition Society. 

2004;63:655-60. 

26. Graneheim UH and Lundman B. Qualitative content analysis in nursing research: 

concepts, procedures and measures to achieve trustworthiness; Nurse Edu Today 

2004;24:105-12. 

27. Burnard P. A method of analysing interview transcripts in qualitative research. Nurse Edu 

Today 1991;11:461-6. 

28. Community based interventions that improve newborn health outcomes: a review of 

evidence in south asia. Evidence review series-5 2008. 

http://www.intrahealth.org/~intrahea/files/media/maternal-neonatal-and-childrenshealthfamily-planning/ER_Brief_NBC%205.pdf 

(accessed 25.7.10). 

29. Mosquera M, Obregon R, Lopez R. Behavior change communication strategy for child 

health 2008. http://www.basics.org/documents/12-Timor-Leste-BCC-Strategy-for-Child- 

Health_Draft.pdf (accessed 22.02.2011). 

30. Leventhal H. Changing attitudes and habits to reduce risk factors in chronic disease. Am 

J Cardiol 1973;31:571-80. 

31. Cassell MM, Jackson C, Cheuvront. Health communication on the internet: an effective 

channel for health behavior change J Health Communi: Int Pers 1988;3(1):71-9. 


32. Tanjanias elderly coming out from the darkness. 

http://www.rapidfundingenvelop.org/pdf/SuccessStories/0507_KINSHAI.pdf (accessed 

18.8.2010). 

33. Kozara KM. Reproductive health and behavior change communications: situational 

analysis/existing interventions in Bangladesh. James P. Grant School of Public Health 

Dhaka, 2008. 12p. (Monograph Series No.8). 

34. Afsar HA, Qureshi AF, Younus M, Gulb A, Mahmood A. Factors affecting unsuccessful 

referral by the lady health workers in Karachi, Pakistan. J Pak Med Assoc 

2003;53(11):521-8. 

35. Soloman AW, Akudbillah J, Abugri P, Hagan M, Foster A, Bailey RL et al. Pilot study of 

the use of community health workers to distribute Azithromycine for trachoma control in 

Ghana. Bull WHO 2001;79(8-14). 

36. Flip Charts: Trachoma health education materials library. 

http://www.cartercenter.org/health/trachoma_education/flipcharts.html(accessed 

22.11.2010). 

37. The Maternal & Neonatal Health Program: Nepal. 

http://zambia.jhuccp.org/asia/nepal/maternal.shtml(accessed 27.10.2010). 

38. Daly P, Taylor M, Tinker A. Integrating essential newborn care into countries policies and 

programs. Policy perspectives on newborn Health. 2003. 

http://www.prb.org/pdf/integratessentcare_eng.pdf (accessed 17.02.2011). 

39. The Henry J Kaiser Family Foundation (2004). Entertainment education and health in the 

United States. 

http://www.kff.org/entmedia/loader.cfmurl=/commonspot/security/getfile.cfm&PageID= 

34381(accessed 8.7.2010). 

40. UNFPA (2002). Communication/behavior change tools; Program Briefs No-1 

Entertainment-Education. http://ceae.colorado.edu/meedc/pdf/Behavior%20communication%20change%20tools.pdf 

(accessed 23.05.2010). 

41. INFO Reports (2008): Entertainment-education for better health. 

http://info.k4health.org/inforeports/E-E/E-E.pdf (accessed 21.06.2010). 

42. Sood S. Audience involvement and entertainment-education. Communi 

Theory;2002;12(2):153-72. 

43. Knippenberg R, Lawn JE, Darmstadt GL, Begkoyian G, Fogstad H, Walelign N et al. 

Systematic scaling up of neonatal care in countries. Lancet 2005;365(9464):1087-98. 

44. Silver D. Songs and storytelling: bringing health messages to life in Uganda; education for 

health: change in learning and practice. Edu Health. 2001;14(1):51-60. 

45. Kincaid DL. Drama, emotion and cultural convergence. Communi Theory 

2002;12(2):136-52. 

46. Communication initiative network. http://www.comminit.com/en/node/276306/38 

(accessed 7.19.2010). 

47. Freedman R and Takeshita JY. Family planning in Taiwan: an experiment in social 

change. Princton: New Jersey, Princeton University Press 1960. 


31

Annexes 

Annex 1. Process of data analyzing using framework analysis technique 1 

Familiarization 

Immersed an overview of the collected data through listening 

the audio tapes, reading the transcripts and thinking about 

issues and made a note. 

Identifying a thematic framework 

Filtered and classified the data according to key issues, 

concepts and themes. 

Indexing 

Identified the portion or sections of the data that correspond to a 

particular theme. 

Charting 

Data was lifted from its original textual context and placed in 

charts that consist of the headings and subheadings. For clarity 

each cases was kept in the same order in each chart. 

Mapping and interpretation 

Analyzed key characteristics as laid out in the charts. 


Annex 2. Name of Flipchart: Care of pregnant and lactating mother 

Chart name Chart No Exact messages in the flipchart 

Nutrition during 

pregnancy 

1 Eat extra food in each meal, drink 8 glass of water 

every day, take 1 iron tablet every day, take iodized 

salt 

Safety during 

2 Do not do heavy work 

pregnancy 

Rest during 

3 Everyday take rest at lay down on the bed 

pregnancy 

Delivery 

4 In case of emergency keep contact with van driver to 

preparedness 

Antenatal check 

up 

Danger sign 

(convulsion) 

Danger sign 

(excessive fever) 

Danger signs of 

pregnant mother 

Danger sign 

(convulsion) 

Danger signs of 

lactating mother 

Nutrition of 

lactating mother 

Danger sign 

(excessive 

bleeding) 

go to the hospital and save money. 

6 Do antenatal check up for 4 times at the health centre 

and take advice from SK. Take TT vaccine during 5th 

- 

8th 

month of your pregnancy 

10 In case of convulsion during pregnancy take woman to 

the hospital and make a phone call to BRAC provider. 

11 In case of excessive fever during pregnancy take 

woman to the hospital and make a phone call to 

BRAC provider. 

12 In case of any danger during pregnancy take woman 

to the hospital and make a phone call to BRAC 

provider. 

17 In case of convulsion of lactating woman take to her to 

the hospital and make a phone call to BRAC provider. 

18 In case of any danger of lactating woman take to her 

to the hospital and make a phone call to BRAC 

provider. 

19 Eat extra food in each meal, drink lots of water every 

day, and especially drink 1 glass of water before and 

after each breast feeding. Take 1 vitamin-A capsule 

within 14 days of delivery. 

21 In case of excessive bleeding within 42 days of 

delivery take woman to the hospital and make a phone 

call to BRAC provider. 


33

Annex 3. Misinterpretation of the messages 

Name of Flipchart: Care for pregnant and lactating mother 

Chart name 

Chart 

no 

Actual messages in the 

flipchart 

Interpretation and perception of 

messages 

Nutrition 

during 

pregnancy 

Birth 

preparedness 

Delivery 

assistance 

Cleanliness 

during 

pregnancy 

Danger sign 

of pregnancy 

(bleeding) 

Danger sign 

of pregnancy 

(Headache, 

blurred vision, 

oedema) 

Danger sign 

of delivery 

(prolong 

labour) 

Danger sign 

of delivery 

(bleeding) 

1 Eat extra food in each meal, Women should take ‘BRAC SALT’ 

drink 8 glass of water and take during pregnancy 

one iron tablet every day, take 

iodized salt 

4 Keep contact with van driver in 

case of urgency and save 

money 

5 During delivery BRAC trained 

TBA and Shebika should 

present 

7 Let take bath regularly and 

clean your breast. 

When a pregnant mother have 

obstructed and prolonged labour, then 

arrange the van and have to break the 

mud bank. 

- Shebika is examining the woman’s 

body to see whether she is alright or 

not. It is the time of delivery. Who is 

she (another women with green color 

saree) Whether mother or mother in 

law cannot understand. 

- A mother in law is seeing her 

daughter in law 

Participants could not understand what 

is being done to the breast. Some think 

it is a navel 

8 In case of bleeding during 

pregnancy lets’ take to woman 

to the hospital and make a 

phone call to BRAC provider. 

- It is not understandable whether the 

woman is pregnant or not 

- this is the picture of abortion. When 

she (pregnant women) is 3-4 month 

of pregnant it is happened. 

9 In case of headache, blurred - A pregnant woman is thinking what 

vision, oedema during she will do 

pregnancy lets’ take to woman - She is in same problem. Thus she is 

to the hospital and make a thinking. 

phone call to BRAC provider. - Her husband is making a phone call 

to the family planning office. 

13 In case of labour pain more 

than 12 hours during delivery 

lets’ take to her to the hospital 

and make a phone call to 


14 In case of excessive bleeding 

during delivery lets’ take the 

woman to the hospital and 

make a phone call to BRAC 

provider. 

- Maybe she (pregnant women) has 

completed her pregnancy period (in 

Bengali mash purse) and Shebika is 

examining her. 

- Participants’ could not understand 

the symbols representing 12 hours. 

- It is not clear whether the woman is 

going to deliver the baby or not. 

- The woman has bleeding during 

delivery. Now Shebika Apa feed her a 

tablet (misoprostol) 

(Annex 3. cont……) 


(cont…….. Annex 3) 

Danger sign 

of delivery 

(retained 

placenta) 

Danger sign 

of delivery 

(convulsion) 

Care of 

lactating 

mother 

Danger sign of 

post partum 

(Headache, 

blurred vision, 

oedema) 


post partum 

(convulsion) 


post partum 

(excessive 

fever) 

16 If placenta is not delivered 

within 30 minutes after child’s 

birth lets’ take to her to the 

hospital and make a phone call 

to BRAC provider. 

17 In case of convulsion during 

delivery lets’ take to her to the 

hospital and make a phone call 

to BRAC provider. 

20 Use clean pad (cloth), use lot of 

water after defecation and keep dry 

delivery place 

22 In case of headache, blurred vision, 

oedema during post partum lets’ 

take to her to the hospital and 

make a phone call to BRAC 

provider. 

23 In case of convulsion during post 

partum lets’ take to her to the 

hospital and make a phone call to 


24 In case of excessive fever during 

post partum lets’ take to her to the 

hospital and make a phone call to 


A mother should feed colostrums to her 

newborn baby as early after birth. 

It is not understandable whether the 

women is going to deliver the baby or 

not 

- She said (about it) but cannot remember 

- she is cleaning her hand after defecation 

- cannot understand what it is (the picture 

of sanitary napkin) 

- An woman is thinking what she will do 

- A newborn baby should be in the pictures. 




35

Annex 4. BCC messaging timetable 

Seasonal BCC related to MNCH in Bangladesh 

Month Event FP Mat health Mat health 2 NBC (If baby is 

ulta palta 

delivery at 

hospital) 

January 

February 

March 

April 

May 

June 

July 

August 

September 

Cold 

season 

approaches 

Monsoon 

starts 

Use FP 

October 

births 

start use 

of FP 

Discuss 

FP with 

partner 

Procure 

and use 

FP 

commodi 

ties 

February 

births 

start use 

of FP 

Unwanted 

pregnancy 

First ANC - 

birth plans 

introduction 

4th ANC 

Check that 

birth plans and 

savings are 

ready 

Use a skilled 

birth attendant/ 

early referral for 

danger signs 

Bleeding in Postnatal 

pregnancy is check 

a danger sign 

Birth plans - 

savings 

2nd ANC - 

diet and 

danger signs 

Messages for 

men and 

elders 

3rd ANC - 

Select birth 

attendant, 

danger signs 

Want a 

pregnancy 

improve diet 

esp folic acid 

Unwanted 

pregnancy 

First ANC - 

birth plans 

introduction 

Finalize birth Bleeding in 

plans - pregnancy is a 

memories danger sign 

telephone no. 

4th ANC 

Check that 

birth plans 

and savings 

are ready 

Birth plans - 

savings 

Keep newborns 

warm 

Maternal diet/ 

play with and 

talk to baby 

EPI and Breast 

feeding info 

Actively play 

with and talk to 

baby 

Maternal diet 

Breast feeding 

info 

If baby is 

ultapalta 

delivery at 

hospital 

Child health 

reduce 

smoke in 

house 

Hand 

washing and 

cleanliness 

esp crawling 

babies 

Treat 

diarrhoes 

quickly 

Treat 

diarrhoea 

quickly 

Hand 

washing and 

cleanliness 

esp crawling 

babies 

Treat 

diarrhoea 

quickly 

(Annex 4. cont……) 


(cont…….. Annex 4) 

October 

November 

Cold 

season 

approaches 

Discuss 

FP with 

partner 

Use a skilled 

birth 

attendant/ 

early referral 

for danger 

signs 

Postnatal 

check 

2nd ANC - diet 

and danger 

signs 

Messages for EPI and Breast 

men and elders feeding info 

December 

Procure 

and use 

FP 

commodi 

ties 

Want a 

pregnancy 

improve diet 

esp folic acid 

3rd ANC - 

Select birth 

attendant, 

danger signs 

Keep newborns 

warm inc breast 

feeding info 

reduce 

smoke in 

house 

** This programme is based on the normal peaks of births 9 months after the cold season and beginning 

of the monsoon. There is also a smaller peak 9 months after Eid-Ul-Azha festival, 

** Diarrhoea also often increases at the time of the Eid festival because of people travelling and food 

purchased from outside the home, 

** For child and maternal health pay special attention to the 'lean months' for nutrition communication. 

These months vary from place to place. 


37

Acceptability, Comprehensibility and Reported Influence - BRAC ...

Create successful ePaper yourself

Delete template?

Save as template?