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Diffusion Processes and Fertility Transition: Selected Perspectives (2001)

Chapter: 7 Mass Media and Fertility Change

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Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
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7
Mass Media and Fertility Change

ROBERT HORNIK AND EMILE MCANANY

Does the spread of access to mass media in a society affect the rate of decline in fertility? This essay organizes the thicket of issues bundled in that simple question and then reviews the relevant evidence, which will provide some tentative answers. We close with some comments about what we believe to be the most promising ways to think about this issue.

There is evidence of a very substantial association between access to mass media and the level of fertility in a country. That is true at the most aggregated level, when national levels of per capita television access are used to predict fertility rates. There is a strong association of the natural log of fertility with televisions per 1,000 population for 144 countries for which data are available (Figure 7–1). Excluding four oil-rich outlier countries, a regression equation fitting a linear and quadratic term shows that televisions per capita accounted for 74 percent of the variance in fertility in 1997. This is a substantially better prediction of fertility than one gets from measures of gross national product per capita (indicated by an index of purchasing power parity) or indices of female education.1

Robert Hornik is Wilbur Schramm professor of communication and health policy in the Annenberg School for Communication at the University of Pennsylvania. Emile McAnany is the Walter E.Schmidt, S.J.professor of communication and chair of the communication department at Santa Clara University. The authors extend a special note of gratitude to R. Kirkland Ahern, Jennifer Horner, and Jo Stryker for research assistance, as well as Joseph Cappella for insightful suggestions in the preparation of this paper.

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
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FIGURE 7–1 Fertility by television (N=144), normal log of fertility rate, televisions per 1000 population.

The association of media access and fertility is also found at the subnational level; for example, Potter and his colleagues (1997) show the significant association between television ownership and fertility at the municipality level in Brazil. It is true also at the individual level; for example, Westoff and Bankole (1997) show the association between various types of media access and contraceptive behaviors and childbearing intentions in seven African countries. In that study, married women who are exposed to television are two to six times more likely to be current users of contraception than the nonexposed comparison group.

However, although these associations are consistent with a claim of media effects on fertility, they are far from definitive. They are not definitive, of course, because causal inferences from cross-sectional bivariate correlations are always tentative. Even though these associations generally are reduced but still significant when likely alternative explanations for them (such as education, urban residence, or occupation) are statistically controlled, inferences remain unsure. But they are also not definitive because, even if we were willing to make causal inferences from them, they do not tell us how the observed associations came about.

There is quite a broad set of explanations that might suggest mechanisms through which access to mass media in a society might affect fertil-

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
×

ity, even if we were willing to make a causal inference about that relation. We develop five major alternative (but not mutually exclusive) hypotheses. The first is about effects of the medium itself, the way it is used, separately from its content. The next three focus on the effects of ideas, each highlighting a different possible effect of the ordinary content of radio or television. The last considers effects of deliberate programs aimed at fertility control. It will turn out that tests of this last area of effect, evaluations of family planning communication programs, are the most common on the ground, but we suspect that the middle three hypotheses may deserve the most attention.

FIVE HYPOTHESES ABOUT MEDIA EFFECTS ON FERTILITY

Economic and Time Competition Effects

First, most hypotheses about media effects focus on their content, the effects of exposure to ideas in the media. However, the central fact of exposure to media is the act of exposure—the time spent with the medium. Given the fixed boundaries of the 24-hour day, time spent with mass media may mean time lost from other activities.

This effect may be particularly important when there are sharp increases in television ownership in individual homes. Individual ownership and the resulting heavy use of television may preclude or make some other activities more difficult, such as socializing with others at a central meeting place. If enough people are engaged with television in their homes, then the availability of such places for socializing in the community may be lost. This is an argument made strongly by Putnam (1995) in his oft-quoted paper “Bowling Alone,” which attributes the decimation of Americans’ social involvement to the spread of television.

How might this relate to fertility? We can only speculate. In some societies courting behavior precedes marriage. If the amount of socializing young people do is reduced by watching television at home and age at marriage is responsive to the amount of socializing potential mates do with marriage waiting until a certain amount of socializing has occurred, then television might produce delays in age at marriage with resultant reductions in fertility. Or, if nonmarital sex and resulting pregnancy are a function of the amount of time people spend socializing, and television means people spend more time at home and have less opportunity for nonmarital sex, there may be less nonmarital fertility.

Television may also compete with marital sex. If sex is, in part, a response to the lack of other things to do, and television watching takes up time that would otherwise be spent in sexual activity, fertility reductions might result. Or, contrarily, if television keeps spouses at home, and

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
×

they spend more time in each other’s company, the opportunities for sex may be increased. Anecdotal reports of increased births about nine months after power blackouts in the United States are consistent with this suggestion. Availability of power and access to television may suppress fertility. Clearly the credibility of these noncontent-based mechanisms depends on the statement of plausible paths of effect and evidence to corroborate them.

A second noncontent-related path of effect relates to the cost of purchasing a television. In poorer countries such a purchase is a significant expense relative to annual income. In Brazil, for example, there is evidence that television sets are often the first major consumer purchase, even in households with quite low incomes. If fertility reflects a deliberate allocation of scarce resources to children versus other forms of expense, then the decision to purchase and maintain a television may directly compete with childbearing, and reduce fertility. The more usual version of this competing use of resources hypothesis, which focuses on the materialist content of television and its influence on individual interests in consumption, is discussed below.

These time and cost models are less commonly proposed than ideational models, perhaps for good reason. We turn to them now.

Mass Media Effects on Elites

Public policy in a country may favor or constrain fertility control. There is good evidence that deliberate family planning efforts have accelerated the decline in fertility (Freedman, 1997). There is also a fair consensus that other forms of public investment, in areas such as health care, female education, and social security, have important effects on fertility decisions. The question to be raised here is what leads elites to allocate resources to such programs? Is it possible that the ideas of elites on these issues are in some part the reflection of the world they see pictured on their television screens?

Over a number of years beginning in the 1960s, American television programming dominated other countries’ entertainment (Varis, 1984.) In recent years, however, a number of larger countries have managed to produce more of their own prime time fare, which generally is more popular. Even so, such national programming reflects cosmopolitan points of view from the national capital or other large urban centers, and may still reflect the production norms of foreign program sources. Elites may have more direct contact with foreign cultures, regardless of television use, than do nonelites and especially rural audiences, but television and other media may reinforce and add to these direct influences on elites within a country. Thus values such as female equality, small families,

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
×

open discussion of sexuality and contraception, and the acceptance of medical and other technology as a solution to problems all may be typical of imported or cosmopolitan national content and affect how elites view the world and what policy decisions they make.

Mass Media Effects on Population Values Indirectly Relevant to Fertility Decisions

Like the elites described above, general populations, if they watch television, watch content that typically comes from outside national boundaries, or they watch programs produced by writers and directors who are influenced by an international standard or a national cosmopolitan view. Although there are exceptions, the values of audiences who are not yet committed to reduced fertility may differ from those implicit in television content. That content, full of advertising of bright goods, may glorify consumption: when viewers must choose between consumption and childbearing, they may move toward consumption. Also, that content may tell stories which legitimate values associated with reduced fertility: a soap opera tells the story of a woman who delays marriage so she can achieve in a career. The value supporting achievement over early marriage influences viewers, which turns into lessened fertility. Locally produced dramas show that well-educated women are respected or that their education has a high economic return—parents accept the value of girls’ education; increases in girls’ education result in reduced fertility. (See very similar arguments in Faria and Potter, 1999; Westoff and Bankole, 1997; Kottak, 1990.) Fadul and colleagues (1996) show in a thematic analysis of popular telenovelas how, over a twenty-five-year period in Brazil, women’s roles have changed from housewives, teachers, and nurses to other professional roles outside the home and even to being portrayed as CEOs of major corporations. The authors also point to the consistently smaller family size on these soap operas than the current norms in Brazil, and how soap operas provided an early introduction to controversial ideas such as divorce, abortion, and premarital sex to a large Brazilian audience.

News broadcasts may highlight reductions in child mortality, so that couples may take those reductions confidently into account when they decide how many children to bear. Coale (cited in Mason, 1997) argued for the importance of acceptance of the idea that it is possible to limit family size as a precondition to the fertility transition. Small families on television may carry that message to viewers. Television programs may say what it means to be modern, and that to be modern is good. These value diffusion effects may occur regardless of whether there is any explicit mention of the value of reduced fertility.

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
×

Unintended Direct Mass Media Effects on Fertility Decisions

Media content may not only carry messages about values, which are indirectly related to fertility; they may also carry content that bears directly on the subject. These messages may be included in news programming, in dramatic or other content, for their news or dramatic value, without any conscious intention to influence behavior. Soap operas may have scenes with couples deciding to limit family size or delaying having children or scenes with unmarried couples using birth control to avoid pregnancy. News programs may provide information about available methods of fertility control, or about services available in local clinics, or about new governmental policies in support of reduced fertility.

Mass Media Effects on Fertility Through Deliberate Information, Education, and Communication Programs

Family planning programs in many countries have tried to use mass media-based programs to influence contraceptive decisions and behavior—sometimes trying to increase awareness of the need for fertility control, sometimes providing information to increase utilization of available services, sometimes marketing specific products. Those programs may use a variety of approaches: didactic programs, advertising approaches, entertainment education approaches. They may use a variety of educational strategies: providing straightforward information; modeling desirable behaviors (e.g., showing “typical” people going into clinics for services, using condoms, or discussing family planning with partners); or emphasizing social norms. These programs are not always different in purpose than ordinary population education efforts, with one exception: in each case, program developers use mass media as the primary channel, assuming that media will improve cost-effectiveness and fidelity. They may believe that mass media are potentially less effective per person reached than alternative strategies (through outreach workers or through clinic-based staff), knowing that a field agent has the great advantage of being able to respond to the needs of individuals. But they expect that the heightened control over the messages delivered, and particularly the “reach and frequency” achieved through wide exposure to mass media, should counterbalance that advantage.

MAJOR ISSUES TO CONSIDER WHEN THINKING ABOUT MEDIA EFFECTS

These are all paths of influence for media effects. Regardless of the path, however, it would be a mistake to think about media influence as a

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
×

simple direct learning phenomenon: that people learn about an idea or a behavior from mass media and they immediately put it into practice. Little mass communication theory relies on such an assumption. Evaluation of the evidence about media effects has to take into account the process through which the effects might occur. Before turning to the presentation of evidence about each hypothesis, we review some central issues in mass communication effects theory, relevant to developing expectations for what the evidence might show.

The Issue of the Social Process Around Media Effects

Media may be influential because of their direct effects on what people know and do, but they are also likely to be effective because they affect the social process around individual decision making. Media content may serve as a stimulus for discussion in which multiple individuals exposed to the same message develop a shared response; exposure to media content may create permission for open discussion of taboo topics in social networks; people considering adopting a new behavior inconsistent with the way things are done locally may gain from media exposure a sense of belonging to a broader social network; one individual exposed to media content may pass on what he or she learns to others inside his or her social network.

Fadul et al. (1996) documented how controversial topics were introduced into Brazilian society over time through soap operas. Kothari (1997) explored the controversy surrounding Islamic practices regarding women that were introduced in popular soap operas in Pakistan by important women writers. A soap opera in Mexico (San Jose Mercury, 3 January 1998, 4A) stirred controversy by directly attacking in its story line the macho double standard about marital fidelity. In all cases the public nature and popularity of national television drama opens up opportunities to discuss sensitive social issues, including those regarding sexuality, divorce, abortion, and vasectomy.

This social view of the effects process has an important implication for the search for evidence. It says that the effects of mass media diffuse beyond those who are directly exposed to the content. Then comparisons between those individuals who are or are not exposed to media may tend to underestimate effects. Thus if person A is exposed to televised messages and person B isn’t, but person A shares the content of the messages with person B, then a measure of exposure will show a difference between them but such exposure will not be associated with effect, even if there are effects. This idea of a diffused effect, likely to be lost if one focuses on individual differences, also can operate at a higher level of aggregation. If a certain proportion (about 30 percent) of a village is exposed to televi-

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
×

sion, then the entire village may be substantially exposed because the messages are shared throughout the social network. A comparison of villages with 30 percent versus 60 percent access may not show the true effects of exposure, because the effects of exposure may be diffused in both places. We are often appropriately concerned about the ecological fallacy when we risk making erroneous inferences about individuals from aggregated data. But also we need to be careful on the other side. We can miss an effect if the evidence is based on individual comparisons of exposed and not exposed individuals, but the appropriate unit of effect is not the individual but the social network with whom the individuals affiliate.

Media May Be Effective Because They Change the Frame People Use to Think About an Issue

Media may be influential because people learn specific messages, but they are also influential because they influence the frame through which people process information (compare Iyengar and Kinder, 1987). This phenomenon is sometimes called agenda setting (compare McCombs et al., 1997). Here is an example regarding a woman’s decision to obtain a modern method of contraception. Assume that two beliefs influence her decision: her (lack of) belief that her living children will survive to adulthood, and her belief that repeated pregnancies will make her less attractive to her husband. Media content may provide information about one or another of these beliefs, but it also may provide messages that influence which of the beliefs should matter more in her calculus of the contraceptive decision. If television tells her she ought to weigh her potential attractiveness to her husband more highly, then she might adopt contraception, without changing the level of either belief. These possible framing effects of exposure to media content may complement effects on the levels of beliefs or attitudes. Research that focuses only on level changes but ignores complementary framing effects may underestimate effects.

The Issue of Active Audiences Versus Universal Effects (Strong Audiences Versus Strong Media)

Since the beginnings of mass media research, a consistent controversy has been the extent to which effects are universal, widely shared among audience members, or contrarily, highly conditional on characteristics of individual audience members and their social networks. One view focuses on the common effects, stressing the widely shared experience of media viewing, and while recognizing that individuals will vary in response, they are mostly interested in the main effects (compare Gerbner et

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
×

al., 1994; Schiller, 1976). These theorists are interested in how society at large is affected by media, and assume that those effects will be large. Others insist that audiences make use of media largely to solve their own problems and are highly active in the process, reading the content, making sense of it, from within their particular belief system and social context (compare Katz and Liebes, 1990). These scholars tend to expect more limited effects of media as media influence is constrained by the characteristics of audiences. This theoretical dispute has important implications when we begin the search for evidence for effects of mass media on fertility.

If the universal effects hypothesis is substantially true, then main effects are the appropriate place to focus our analyses, whether those were effects on knowledge or attitudes or behavior. We would look for noticeable average effects across the entire population. If, in contrast, effects are highly conditional on the beliefs and contexts of individuals, then main effects may be small, and only interaction terms will show effects. In that case a focus on the average correlation in a population, or the average effects of a media-based purposive program, may be misleading; if they are small they may be obscuring larger effects for particular subgroups for which the message was most relevant. An example: a media program that provides information about clinic services may be quite effective for the subset of people who are currently seeking contraception and are unaware of available services. An evaluation that asks for the average change in the population may fail to include enough of those people to show worthwhile effects. Early AIDS education evaluations foundered when they looked for increased condom use among all sexually active adults. But when they focused on people who reported “casual” sexual encounters, they found sharp increases in condom use (compare Dubois-Arber et al., 1997).

The Issue of Effects on Awareness Versus Effects on Behavior

An additional controversy bears on the issue of where to look for effects. The established diffusion literature stresses a claim that media effects are largely on awareness, on getting people to think about a new behavior. In contrast, that literature is skeptical about whether media have much influence on decisions to adopt behaviors (Rogers, 1995), expecting interpersonal sources to be more influential at decision-making stages. The diffusionist view is analogous to a more recently popular version of the same argument, called stages of change theory. That theory expects people at different stages of a change process (labeled precontemplation, contemplation, ready for action, action, and maintenance— which are similar to the awareness, behavior, and other categories used

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
×

by diffusion theorists) to be affected by different types of messages (Prochaska and DiClemente, 1983) rather than different channels.

A contrary position is more inclined to credit media with direct influence on behavior change, pointing to the examples of advertising effects and some other evidence (compare Hornik, 1989). That hypothesis expects direct learning effects, but also credits media with effects because they initiate person-to-person discussion and diffusion, which produce change, and because they crystallize latent demand—telling people how to act to realize what it is they have chosen to do.

The Issues of the Nature of the Relationships Between Media Exposure and Fertility Outcomes

This issue of what media can affect also relates to two final issues—the time lag for effects and the shape of the relationship. Some effects will occur rapidly with a limited exposure to a message. For example, women ready to adopt a modern contraceptive may respond quickly to information about eased access to a clinic. On the other hand, some behaviors are more deeply ingrained in the belief system and social context of individuals. Individuals might be affected by media content but require a broad change in the public communication environment, with mass media and other channels of communication providing new messages supportive of changed behavior, but then one would not expect instant response. Rather, the time lag of effects can be in years or even decades. For example, there has been an extraordinary decline in cigarette smoking in the United States, so the current level is half or less what it was at the height of smoking prevalence. But that change occurred at a slow pace, one or two percent per year, often not detectable in the short term with typical samples we can study. Programs that operate for a year or two, and evaluations that are only able to detect substantial and rapid change, may not be informative for change depending on communication effects on world views.

Gradual change over longer periods also suggests that consistent reinforcement of the change messages is necessary. Even though advertising campaigns, for example, can create important short-term changes in buyers’ behavior, the longer term strategies of companies such as Coca-Cola or Nike is to reinforce short-term gains with follow-up ads. If the mass media are generally promodern, as many have argued since Lerner (1958) first introduced the idea of modernization and media’s role in the process, then their reinforcing value may be considerable in promoting not only consumerist desires but also modern and even Western views about fertility ideals and practices.

A related concern is about the shape of the curve associating media exposure to effects, both for individuals and for larger aggregates. At the

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
×

individual level, will the effects of media exposure be the same when an individual moves from no exposure to one hour of daily exposure as they are when he or she moves from three hours to four hours of exposure? Or, will the effects on a village be the same when the tenth percentile of households gets televisions as when the fiftieth percentile gets television? Some effects might be larger at the high levels of exposure (e.g., the effects on decline in social interaction); others may show little additional effect after a low level of exposure is achieved (effect on knowledge about the existence of contraceptive methods).

This issue explores three overlapping concerns: the absolute quantity of exposure, the distribution over time of the exposure, and the time lag before the exposure produces effects. Any assessment of the effects of mass media needs to ask whether the evidence used as the basis for inference is consistent with hypothesized expectations for how each of these operate.

Thus far we have laid out the various paths through which mass media might influence fertility, and pointed to a series of conceptual controversies in mass media research that bear on the search for evidence. These discussions followed a brief presentation of the global evidence for an association between media spread and fertility. We now turn to a more extended treatment of the evidence. It contains two major sections: evidence for overall effects of media spread on fertility, and evidence for effects of specific programs that have used mass media to influence fertility. The first of these is relevant to all of the first four hypotheses. Each would predict an overall association between media access and fertility. The second section tests the final path of direct effects of purposive programs.

EVIDENCE ABOUT OVERALL EFFECTS

Studies Showing Associations at the Aggregate Level

We have noted the very substantial correlation (.86) between television access and fertility rates across 140 countries for which data were available (excluding 4 oil-rich outliers). The relation is still strong (.76) when the analysis is restricted to lower income countries (the countries classified as below the median on the purchasing power parity index used by the World Bank).

There are two typical threats to a causal inference from this type of association. One is a concern with causal order. Is it possible that the association reflects not the effects of television on fertility but the effects of fertility on television ownership? After all, we did previously argue that television and children compete for scarce family resources. Isn’t it

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
×

possible that in countries where there are families with fewer children, there are more people who can afford televisions? There is no useful way to distinguish these hypotheses from the cross-sectional associations, but some evidence from studies of individuals over time, presented below, may ease this concern.

A more conventional threat to causal inference would be that the association is the product of the influence of other confounding variables. However, the television relationships with fertility are as strong or stronger than those between purchasing power parity and fertility and are still significant when purchasing power parity is statistically controlled.

Nonetheless, there are rival hypotheses to the idea that these associations establish that media indeed have the hypothesized effects: one is that television ownership is a very good measure of average economic position of people in a country, and correlates with fertility because it is a measure of income. It may correlate better than do measures of wealth, such as purchasing power parity per capita, because it is a better measure of average income than that measure which is distorted as a measure of average income by income inequities. Or it may be that television ownership is a very good indicator of a broad range of social and institutional development variables, and one or more of them is the true causes(s) of fertility level. Nonetheless these results are consistent with an aggregate effect of media access on fertility, and the sheer size of the correlation is worth attention.

The second type of aggregated evidence comes from the Potter et al. study cited in this volume and from an earlier paper. Potter et al. (1997) do a quite elegant analysis of fertility rates in two Brazilian regions, showing that unmet demand for televisions in municipalities in one year predicts fertility rates ten or eleven years later, controlling for prior fertility and other likely determinants. They attribute these effects to Brazil-specific television content (the extraordinary telenovelas that dominate the airwaves), but we see no reason to assume that the effects are unique. They estimate that each 1-percent drop in television access is associated with a .10 increase in the total fertility rate in one region and a .16 increase in the other.

In both of these cases, even if one considers the evidence relevant to a claim of causal influence, one must be careful to avoid claims about individual-level effects, that individual exposure produces individual reductions in fertility. Insofar as they are credible, they are consistent with a claim of aggregate-level effects; nations or municipalities in which televisions are more widely owned are nations or municipalities in which there is lower fertility. Because some of the hypotheses about media effects on fertility operate at levels of aggregation higher than the individual, this is

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
×

suitable and relevant evidence. The evidence may also be consistent with individual-level effects, but those effects are addressed directly by individual-level analyses.

Studies Showing Associations at the Individual Level

There is a long history of studies that have shown relationships between individual media exposure and “modern” attitudes, including those that bear on fertility. Lerner (1958), among the earliest scholars interested in effects of mass media on development, found in his six-country study of the Middle East that people who were more exposed to radio and film were more likely to express prodevelopment attitudes of various sorts. Inkeles and Smith (1974), in what was probably the biggest project involving survey-based investigation of determinants of modernity, found that television, radio, and newspaper use were good predictors of “modern” attitudes, even when other likely predictors of both media use and attitudes were controlled. Inkeles and Smith’s measures of modernity included attitudes toward limiting family size.

Westoff and Bankole (1997) have updated those studies using cross-sectional African Demographic and Health Surveys (DHS); previously we noted that they found quite substantial associations of media use with a wide range of reproductive attitudes and behaviors. They examined associations of television, radio, and newspaper exposure with (a) knowledge of any modern method, (b) intention to use a method, (c) current use of any method, and (d) desire to stop childbearing, among other outcomes, while controlling likely covariates. Their data came from samples of 2,200–5,300 women in six Sub-Saharan countries (Burkina Faso, Ghana, Kenya, Madagascar, Namibia, and Zambia) as well as from Morocco. Although the magnitude of the associations varies with the country and with the outcome, they are virtually all consistent with a positive effect of media exposure on outcome. Odds ratios for one representative measure of media access, exposure to two of the three media, are reproduced in Table 7–1.2

The authors are extremely careful in interpreting these cross-sectional data, recognizing that the associations simply cannot eliminate the possibility that some other characteristic of the women, not controlled here, made them both more likely to expose themselves to mass media and more likely to use a contraceptive method. Nonetheless these data are also consistent with a media effects hypothesis.

An additional analysis enhances their argument. The authors have data from a three-year cohort study in Morocco in which the same women were reinterviewed. They show that both among women who were not using contraception in 1992 and separately among those who were, media

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
×

TABLE 7–1 Adjusted Odds Ratios of Media Use with Reproductive Attitudes/Practices, Controlled for Other Characteristics

Country

Has Knowledge of Modern Method

Currently Using a Method

Intention to Use a Method

Expresses a Desire to Stop Childbearing

Burkina Faso

6.23

1.98

2.50

.96

Ghana

4.30

1.50

1.33

1.02

Kenya

NR

1.71

1.82

1.29

Madagascar

2.18

2.40

1.64

1.35

Namibia

1.63

1.25

2.73

1.15

Zambia

2.40

1.30

1.51

1.46

NOTES: Odds ratios comparing those with exposure to exactly two versus no mass media, controlling for age, education, urban residence, number of living children, number of husband’s other wives, husband’s occupation, electricity at home, refrigerator at home, car, motorcycle or bicycle, religion, and exposure to family planning on radio. NR=97 percent of Kenyan women knew a modern method, so data not reported.

SOURCE: Adapted from Westoff and Bankole (1997).

use in 1992 predicted current use in 1995, while controlling for all of the covariates listed in Table 7–1. In both cases, women who were heavy users of media in 1992 were more than 2.5 times as likely to be using a method in 1995 than were women who did not use any media. They also show that media use in 1992 predicted a desire to stop childbearing in 1995, when only those women who wanted more children in 1992 were included; heavy media users were about twice as likely as nonusers to express a desire to stop childbearing. These longitudinal analyses add to the claims of effects, but the authors do not claim definitive support. It remains possible that women who were heavy media users in 1992 were already on a different reproductive trajectory (what Cook and Campbell, 1979, call a “selection by maturation” threat to inference) that was independent of but correlated with their media use.

It is customary and legitimate to express wariness about making causal inferences from correlational data of this sort, even with the extra longitudinal information from the Moroccan data. But it is good to recognize that these data also might well underestimate the effects. If the effects occur at a level of aggregation higher than the individual, the individual associations will be too small. If the effects occur for some people but not others (e.g., for those who lack interpersonal sources of antinatalist information), the associations will be too small. If the effects occur only in some contexts (e.g., where there is easy access to contraceptive supplies), the associations will be too small. Causal inferences from these data are unsure, both because they are at risk of overestimating effects and because they are at risk of underestimating effects.

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
×

EVIDENCE ABOUT INTERVENTION PROGRAM EFFECTS

There are two types of evidence available here: the first are evaluations of discrete projects, and the second are associations between self-reported exposure to family planning messages and reproductive behavior. We begin with the evaluation studies.

Most efforts at IEC (information, education, communication) in population programs are deeply integrated into multipronged programs, involving changes in government policies, increased access to contraceptive methods, and improvements in other aspects of service delivery (Ross and Mauldin, 1996). In most of those programs, it is impossible to isolate the effects of all of the IEC aspects of such programs, never mind the specific contributions of a mass media subcomponent of a broader IEC strategy. Although this complicates our search for relevant evidence, it is sensible policy. Although some might argue that a change in ideas about family limitation produced by mass media content would be enough and that couples would find some way of limiting family size even absent access to contraceptives, that is a long-term view. When the focus is on achieving short-term effects, for example, it is unlikely that one would find effects of IEC on contraceptive behavior absent sufficient access to contraceptive supplies.

A particularly important group of programs that often makes heavy use of media, but that does not allow isolation of media effects, is the variety of programs that fall under the term “social marketing.” Several major operations, including the Social Marketing of Contraceptives (SOMARC) program sponsored by the United States Agency for International Development (USAID) and Population Services International (PSI) as well as particular national programs, have created sophisticated contraceptive social marketing programs. They couple new contraceptive brand development with appropriate pricing and packaging, private distribution networks, and major promotion campaigns, including mass media-based advertising. These programs have published regular reports (e.g., Ferreros, 1990; Harvey, 1991) that describe major successes in numbers of contraceptives sold in some countries. Although the nature of their evidence precludes any specific claims of success due to the mass media component in isolation, the results are relevant to our review; they represent a class of projects that make serious use of mass media and are successful, in some cases, but about which we cannot make specific media effects claims.

There is some 1970s-era evidence referenced by Rogers et al. (1978) that points to the aggregate association between the level of IEC in a country program and its national level of contraceptive use. Nonetheless, for the great majority of programs that incorporate media into their popu-

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
×

lation programs, we have not seen published reports that permit us to isolate media effects. Also, small programs and programs without international funding are much less likely to make it into the literature. The lack of evidence from those programs is not evidence that such components do not work; indeed, the fact that IEC components are so often incorporated is evidence that policy makers on the ground value them. It just means that the media-specific evidence we do have has to be treated as a highly biased sample of the population of IEC and mass media-based programs. It is biased because it underrepresents programs for which there are no reports or for which the media component is not studied in isolation.

There are some evaluations of programs that do attempt to isolate media-specific effects. With one exception, they claim that media campaigns were associated with contraceptive adoption. This is no surprise; programs that find no effects are much less likely to make it into the literature. In a 1976 Rogers and Agarwala-Rogers study (summarized in Rogers et al., 1978), the authors describe evaluations of media campaigns in Colombia and Isfahan in Iran. Both evaluations involve interrupted time series and estimate changes in the number of adopters visiting family planning clinics. The Colombia results describe the reversal of a two-year decline in clinic adopters during the first nine months of a radio campaign, with effects fading during the final months. Isfahan shows a particularly strong increase in clinic demand in that region relative to the rest of Iran (30 percent greater), reflecting a three month “all-out media campaign” in that region, although there was some possibility that “other changes in the family planning program…may have contributed to increases” (Rogers et al., 1978:37). In any case the Isfahan advantage faded after the media campaign was over.

Hornik et al. (1987) evaluated a national media campaign in Peru designed to increase demand at government clinics for contraceptive services. It was the first such campaign in the country in which television spots were used to encourage modern contraceptive use. The campaign was associated with a substantial increase in such demand, but the increases could be accounted for by the preexisting secular trend in demand for family planning services, and an overall tendency for people to increase their use of government clinics for all purposes. The evaluators concluded that they could not claim effects.

An evaluation of a controlled four-community study meant to increase demand for vasectomy in Guatemala (Bertrand et al., 1987) provides mixed results. Compared to the control community, the community that was subject to a one-year radio intervention showed some increases in awareness and knowledge but not in behavior in a sample survey. However, clinic demand did increase quite rapidly in the radio

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
×

community, with nearly three times the number of vasectomies occurring in the radio community than would have been expected on the basis of precampaign behavior. Consistent with the results of the Colombia and Isfahan projects, the monthly demand for vasectomies appeared to have returned to close to baseline after the radio campaign ended.

Strikingly, these results are consistent with some of the additional evaluations reported below: they show no behavioral effects when studied on a population level, but have evidence consistent with effects when clinic demand is examined. This is not surprising. If, at baseline, clinics are serving a small proportion of the population, and all effects are realized in increased clinic demand, then a very small population increase will appear as a very large increase in clinic demand. For example, the radio town in Guatemala had 38,000 people and was producing demand for two vasectomies a month before the campaign. The campaign appears to have tripled that demand, to around six vasectomies a month. But as a proportion of all adult males in the community, which is what would be reflected in a good sample survey, that increase would not be detectable.

Kincaid et al. (1996) describe the results of a series of media campaigns in Brazil designed to encourage vasectomy demand. They present a time series of number of vasectomies performed over a twelve-year period at one large Sao Paulo clinic, and from that note two important tendencies. Each media campaign was associated with a sharp rise (around 80 percent for a 1989 campaign) in demand for vasectomies during a six-month period, and the end of each media campaign was associated with a subsequent return to prior tendencies, including a sharp downward trend in demand through 1992.

The 1989 Brazilian campaign was one of a large number of programs that USAID has sponsored through its work with the Johns Hopkins University Population Communication Services Program. The Johns Hopkins program has been the major channel through which the USAID has provided support to countries that wish to include IEC in their population programs. Johns Hopkins has been a major advocate for an approach often called Entertainment-Education, which is a broad title for a number of distinct programs that incorporate population messages in entertainment formats, including the use of music videos, serial dramas, feature films, and advertising spots.

Although most of Johns Hopkins’ work is provision of technical advice to government and private agencies, they have published evaluations of some of their programs. Piotrow and colleagues (1990) report the results of an evaluation of an entertainment education program in three states in Nigeria. They show that their interventions, which involved the incorporation of narrative vignettes in ongoing televised variety pro-

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
×

grams, all were associated with a substantial rise in demand for services at family planning clinics, and frequent reports among clinic visitors that the television programs had stimulated the visits.

Piotrow et al. (1992) also report the results of their “Male Motivation Project” in Zimbabwe. This program involved the production and broadcast of a 52-episode serial drama meant to affect men’s willingness to make new reproductive choices with their partners. In contrast to the evidence from Nigeria, they focus their evaluation on before and after national survey data rather than only clinic records. They provide some evidence for improvements in beliefs and attitudes associated with the period of their campaign; however, the evidence for behavior change is much less secure. A very small change in self-rep or ted behavior is not shown to be statistically significant and, in any case, relies on two imperfectly matched samples whose noncomparability could easily account for small observed differences in behavior.

Valente et al. (1994) provide an additional evaluation of a Johns Hopkins-advised radio drama, in The Gambia. The report relies on before and after surveys of 400 men and women in three villages in one region of the country. The surveys were taken about nine months apart and report a large gain in contraceptive practice, from 19 percent to 30 percent “using a modern method,” including a jump from 9 percent to 22 percent among people with no education. And it appears that the reported increase in use rates is underestimated, since the authors report that nearly all of the increase in use was for pill use among women, who make up only half the sample. They also show some evidence that individuals who report listening to the programs held better knowledge, attitudes, and practices than did nonlisteners.

However, these results seem almost too good to be true: this would have to be an extraordinary program, indeed, to produce a doubling of use rates in a nine-month period. A suspicion that there was some problem in administration of the instrument is enhanced when one looks at scores on a 12-item “attitude towards family planning” scale. Precampaign attitudes had a mean of 4.9, while postprogram attitudes were a near perfect 11.2, including a score of 10.6 for those who were classified as not having radios and not hearing the program. It appears that these apparently strong results may be unreliable.

Another published evaluation of a serial drama campaign was undertaken in Zambia, but was not, in fact, a family planning campaign. Rather it was an AIDS campaign, but with an ultimate objective of affecting rates of condom use. The evaluation (Yoder et al., 1996) concludes that although there were substantial changes in condom use, and in other process variables (in beliefs and attitudes and talking about AIDS with family members) during the period of the campaign, they were not associated

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
×

with exposure to the campaign. There was lots of public information and discussion about HIV/AIDS in Zambia during the period of the campaign, and presumably the observed changes were associated with those inputs, but they could not be attributed to specific listening to this serial drama.

A three-month family planning multimedia campaign in Mali used television plays and spots and radio songs (Kane et al., 1998) to encourage adoption of family planning. A pre-and postevaluation design showed a high level of recall of exposure to the campaign, some striking changes in attitudes including intention to use “a modern method” in the future, but only statistically nonsignificant trends toward increased use of any modern method.

Rogers et al. (1999) report about a radio serial drama in Tanzania that targeted both family planning and HIV/AIDS prevention objectives. The evaluators were plagued by large differences in precampaign practices between their treatment and comparison areas, making difficult the interpretation of advantages in rates of change to the treatment area. To deal with this unfortunate problem, the authors undertook correlational analysis at the ward (a small geographical unit) level, examining the associations between the average level of program exposure in a ward and rates of change on process and outcome variables. Many analyses are reported, and some of those related to beliefs and attitudes show positive slopes (e.g., changes in rates approving of the use of family planning, and proportion mentioning a higher ideal age for marriage for women). If we focus on behavioral outcomes relevant to family planning, there is a significant association between ward-level exposure and change in women’s “always or sometimes use of family planning.” The authors also report evidence from time series data of new adopters at 34 family planning clinics divided between the treatment and comparison areas. They show a long period, precampaign, of similar levels and trends in demand, and a quite sharp differentiation between the treatment and comparison area clinics six months into the broadcast of the serial drama, with the treatment area clinics serving 45 adopters per month and the comparison area clinics serving around 30 per month.

Storey et al. (1999) evaluated a radio communication project in Nepal involving both entertainment education through a soap opera, and additional radio and print programs aimed at consumers and health service personnel. They followed a cohort of currently married women for roughly 2–1/2 years, and found that exposure to the radio programs was associated with new adoption and with continuation of use. They also showed that much of the effects of exposure on behavior was mediated by changes in attitudes and perceived normative support, the explicit targets of the campaign. In a separate analysis of clinic service data from some sentinel

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
×

clinics, they established sharp increases in demand for services accompanying the initiation of broadcasts, a decline during a nonbroadcast period, and a renewed demand associated with the reintroduction of broadcasts.

These studies represent the major published studies of discrete programs that used mass media in a way that permitted some exploration of their effects. The central results are summarized in Table 7–2. The most optimistic results from the credible studies say that there are effects of mass media programs, but they seem constrained in two ways: first, they are effective at increasing demand on clinics, but only in one or two cases seem to show much detectable effect on population-level behavior. Second, when data are available over a longer period, it seems as though program effects last as long as the programs are operating at a high level, but the effects seem not to stick; behavior returns to prior trends soon after the broadcasts stop. The lack of evidence of long-term effects may reflect the too short lives of these programs and the resulting premature collection of behavior data; funding agencies want evidence of effects on a schedule that may be inconsistent with the time it takes to realize behavioral change that can be detected on the population level.

At the beginning of this presentation of results of discrete programs, we noted that they represent a highly biased sample of all of the IEC, media-using, purposive programs. There are some additional results that do have relevance to the more ordinary programs. In their useful analyses of African DHS, Westoff and his colleagues establish a substantial association between self-reports of exposure to family planning messages on the mass media and reproductive beliefs, attitudes, and behaviors.

TABLE 7–2 Summary of Mass Media Intervention Projects

Country/Project

Effect on Clinic Demand

Effect on Population Behavior

Comments

Colombia

Yes

Fading after project end

Iran/Isfahan

Yes

Fading after project end

Peru

No

 

Guatemala

Yes

No

 

Brazil

Yes

Return to preproject level

Nigeria

Yes

 

Zimbabwe

No?

Data quality issues

The Gambia

Yes?

Data quality issues

Zambia

No

 

Tanzania

Yes

Yes?

Research design makes inference hard

Mali

No?

Nonsignificant trend

Nepal

Yes

Yes

 

NOTES: —means effect not examined in published study.

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
×

The results reported previously referred to general media exposure; the results reported here refer specifically to recall of exposure to family planning messages on the mass media.

Westoff and Rodriguez (1995) show, using the 1989 Kenyan DHS data, that exposure to family planning messages on radio, print, and television were associated with current use of a method and use of a modern method, intentions to use in the future, and mean number of ideal children among other outcomes, while controlling for a wide range of covariates.

Bankole et al. (1996) show that reports of exposure to media messages in 1990 in Nigeria predicted current use of a modern method in 1993, among a small sample of women for whom data were available at both time periods. Among women who had never used a method by 1990, 28 percent of those who heard messages by 1990 claimed current use of a modern method in 1993, while only 9 percent who did not claim exposure to media messages by 1990 were modern method users in 1993.

Westoff and Bankole (1997) also use the DHS data already described above to show that self-reports of exposure to family planning messages on radio were positively associated with several outcomes in the five countries for which data were available about such exposure. These include significant associations with knowledge of modern methods and intention to use a method in all five countries studied and with current use of any fertility control method in three out of five countries studied. They control for general exposure to television, radio, and newspapers and to the other covariates listed in Table 7–1. In the same report of results, they also provide supplemental longitudinal analysis for Morocco. In Morocco, 1992 exposure to radio messages was also associated with 1995 use of a method, and with 1995 desire to stop childbearing.

In all of these studies there is a substantial association; as before, the question is whether these data permit a causal inference. Concerns about causal direction are partly dealt with through the longitudinal results from Nigeria and Morocco. Concerns about other variables causing both reported exposure to messages and the outcomes are partly dealt with by the analyses controlling for covariates. But as the authors cautiously indicate, they are unable to rule out a counterexplanation that suggests that people who are interested in family planning (or in the case of the longitudinal studies, about to become interested) are more likely to recall exposure to relevant messages.

Evidence from Qualitative Studies

There is another area of study of mass media that focuses on the microprocesses of reception and incorporation of messages into the daily lives of audiences. Most of the studies in this tradition have been con-

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
×

cerned with defining how the reception process takes place and how audiences make sense of the ideas that come to them in the media (Katz and Liebes, 1990; Moores, 1993). There has been little attempt until now to link this body of evidence with evidence of change in receivers’ attitudes or behaviors, partly because the focus was exclusively on reception processes and partly because changes were viewed as longer term and sometimes indirectly related to the ideas contained in the programs.

The link between reception and outcome is critical and one that Freedman (1997) has recently highlighted for understanding changes in fertility preferences due to family planning programs. He suggests that qualitative studies can add to the evidence about how ideational processes take place. He points out that the little evidence that we do have suggests the importance of discussion of demographic issues in social networks. He concludes:

Interaction in social networks is likely to be an important basis for diffusion and legitimization of ideas about smaller families and birth control. But where do these ideas come from? Establishing their origins and pathways in the growing national and international networks, in the direct and indirect influence of local programs, and in the changing life situations of the population is a primary challenge, (p. 9)

The argument of models three and four above is partly based on the assumption that large numbers of people are exposed daily to information about issues relating to norms and values of family relations, women’s roles, and sexuality coming from metropolitan or international mass media sources that generate reactions and discussions among audiences over long periods of time. Serial dramas like the Latin American telenovelas or equivalent genres in Asia, Africa, and the Arab countries often raise demographically relevant issues (Fadul et al., 1996; McAnany and La Pastina, 1994). Moreover, there is consistent evidence that audiences strongly identify with these stories and discuss issues of norms and values in family, neighborhood, and social groups (Brown, 1994, for English-speaking countries; McAnany and La Pastina, 1994, for Latin America; Mankekar, 1993, for India; Diase, 1996, for Egypt; and Kothari, 1997, for Pakistan).

In an ongoing study of Brazilian television and demography (Potter et al., 1997; Faria and Potter, 1999; Rios-Neto et al., 1998; McAnany, 1997), a series of qualitative studies of audience reception and incorporation have been carried out to delineate how demographically relevant ideas enter social networks and circulate beyond the family. The preliminary evidence (Hamburger, 1998; La Pastina, 1997) suggests several pathways and processes: (1) new ideas about nontraditional roles for women and taboo ideas, such as divorce, abortion, and vasectomy, reach the public sphere over time through television narratives that reach all levels of a

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
×

national audience; (2) audiences engage with these narratives, discuss the issues raised in them, and compare and apply them to their own lives; (3) other media such as newspapers, magazines, and radio, not only reinforce and popularize the stories but discuss issues and debates raised by government, religious, and social groups; (4) mothers and fathers sometimes intervene in television viewing by their children to discuss issues about sexuality, authority, and social roles; most parents express the conviction that their children are influenced by the models, norms, and values presented in the stories. All of the evidence suggests a pathway for entry of new ideas concerning modern value issues confronting national audiences. Some behavioral outcomes are immediate, such as the buying of recorded music appearing in the series or adopting new fashions and styles of characters, but most are longer term and less direct, such as attitudes about women’s work roles, the value of virginity before marriage, or the legitimization of divorce for women in loveless marriages. Historical records of the first treatment of such sensitive issues as divorce or abortion in a public medium such as national television (Fadul et al. 1996) provide some basis for tracking the debate surrounding such issues. The long-term nature of such changes, however, makes it difficult but not impossible to establish the link between changes in fertility practice and the spread of television (thus the integration of various sources of evidence within a single project like the one in Brazil is a critical step).

There is one more conclusion to the audience reception literature: there are a wide variety of reactions to messages received. The macro studies reviewed earlier suggest that media exposure is somehow related to a series of similar practices resulting in lowered fertility. One is left with the impression that it is a single, simple process of influence. What ethnographic audience studies reveal is that audiences represent a wide variety of positions on value and normative issues. The commonality of audiences is that they receive on a daily basis the stories and situations that they will discuss and debate with family and neighbors. Moreover, this process is repeated again and again over months and years, with varying degrees of intensity, depending on the issue that a particular story may raise.

The process outlined here is not, for the most part, an ideational campaign from government or other social agency. It is often random and even chaotic. The media, especially radio and increasingly television for developing countries, carry many messages in their programs, but in many countries the serial narratives making up the prime listening and viewing hours deal consistently with family matters that legitimate or at least open for debate problems facing their societies regarding women and their roles, families, premarital sex, and other modernizing pressures. Scriptwriters with an intent of raising debate (compare Kothari,

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
×

1997, on women’s issues in Pakistani soaps) often consciously introduce these issues, but there may not be any immediately observable change. Looked at in the long term, however, and linked with studies of media exposure and changes in fertility beliefs and practices, the process of ideational change takes on a clearer path.

DISCUSSION

Thus far we have painted a complex picture of evidence around the hypothesis that the spread of mass media is associated with reductions in fertility. The correlational evidence, both cross-sectional and longitudinal, but not associated with discrete programs, is consistent with such an effect. The evidence from discrete programs is much less convincing about broad effects, although it provides some evidence for (short-lived) increases in demand for clinic services. The evidence that falls between the two types, reporting on the association of exposure to family planning messages but not tied to a specific program, is more optimistic.

However, we recognize there are problems with these data. The correlational studies do not permit us to reject the rival hypothesis that selection, the effects of unmeasured exogenous variables, accounts for the observed association. The discrete program evaluations have suffered from mischance in data collection, or too short a time frame for the intervention programs and for the estimation of effects, or too complex an environment to attribute effects cleanly. In some sense, the very attempt to make them open to study as discrete interventions may have worked against producing or measuring their success. The problem of openness to study relates directly to the issue of a proposed model of effect. How is it that mass media are to have their effects?

The review of specific evidence just completed corresponds to two particular models of media effects. The first model often underpins the evaluations of discrete programs. They assume that a focused input can produce specific effects in the short term. This may be a reasonable model when the effects involve shifting people from intending to engage in a behavior to actually engaging in the behavior. A good example from the evidence presented here would be a program designed to stimulate those people who are already intending to use modern methods to actually visit the clinic to obtain a contraceptive. The evidence from several programs of increases in clinic demand, without corresponding evidence of a population change in contraceptive use, is consistent with this model. It would suggest that the success of short-term programs might rely on a substantial population of people who are ready to act and just need a final push. Although in these family planning examples this group was apparently small, limiting the size of population effects, that does not have to be the

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
×

case. In another area, encouraging immunization of young children, there is evidence that the ready-to-act population is much larger and media campaigns can stimulate rapid changes in immunization rates. In the Philippines, the proportion of urban children fully immunized by their first birthday increased from 32 percent to 52 percent as a result of a one-year media campaign. It apparently worked mostly by teaching parents who were having their children vaccinated, but on a delayed schedule, that they needed to bring their children in before their first birthdays (Zimicki et al., 1994).

However, there is also a second model of media effect, particularly relevant when behavior is not so close to realization. People may be aware of the new behavior but do not yet intend to do it, and then the model of effect may be different. Media may still have profound effects but the process may be slower and have a different character. Then the process of influence may take substantial time, and require reinforcement through repetition and transmission through multiple channels. This complex process of effects is described in studies of how people respond to prime time soap operas (compare McAnany and La Pastina, 1994; Brown, 1994). A program exposes television owners to messages directly; it generates conversation among those who watch it and with others not exposed; newspapers may regularly report about ongoing story lines, especially those stories that cause controversy. Soap operas, and other programs, address similar issues. This constant lapping against the shore, rather than a single large wave, may produce slow, long-term changes in values underlying fertility intentions.

There is some recent work analyzing health communication programs in the more developed world that has bearing here. There have been a series of discrete intervention programs directed toward smoking and other heart disease-related behaviors. These have included the Stanford Heart Disease Prevention Program, the Minnesota Heart Health Program, and the Community Intervention Trial for Smoking Cessation (COMMIT) trial (Farquhar et al., 1990; COMMIT, 1995; Luepker et al., 1994). Each has compared treatment and control groups to measure the effects of media (and other IEC efforts) on behavioral outcomes. Each has had to conclude that the evidence is inconsistent with an effect, or at best that the evidence is ambiguous. These discrete programs may contrast with a series of uncontrolled efforts at public education that are associated with massive changes in behavior. To point to just two: the Swiss AIDS program was associated with an increase from 8 percent to 56 percent of young people always using condoms for casual sex (Dubois-Arber et al., 1997); the National High Blood Pressure Education Program (NHBPEP) was associated with a 57-percent drop in stroke rate in a 12-year period (Roccella and Lenfant, 1992). (See Hornik, 1997, for a fuller discussion of these cases and others.)

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
×

One explanation for the difference between the small success of the discrete programs and major successes of the uncontrolled programs may be that the evaluations were of radically different quality. But a more important distinction may come from an understanding about how communication programs have big effects.

First, there is relatively little evidence for big differences in exposure to messages over time between the treatment and control areas in the discrete studies, while for the messy programs (like Swiss AIDS and NHBPEP), the levels of exposure achieved are much higher. This may be less of a problem in many developing country contexts in which the media environment is less competitive. Indeed, in many of the evaluations summarized here, authors are able to point to quite substantial levels of basic exposure to messages.

People may also change behavior when many aspects of their environments communicate new messages in a repeated and reinforcing way over time. They may change when there is substantial diffusion of those messages through social networks in the ways previously described. That is the way that programs that are considered strong family planning programs operate. Elsewhere one of us has speculated about the way that someone might initiate new practices related to high blood pressure:

How might the NHBPEP have worked? One can imagine how the process of change occurs: a person sees some public service announcements and a local TV health reporter’s feature telling her about the symptomless disease of hypertension; she checks her blood pressure in a newly accessible shopping mall machine, those results suggest a problem; she tells her spouse who has also seen the ads and encourages her to have it checked; she goes to a physician who confirms the presence of hypertension, encourages her to change her diet and then return for monitoring. Meanwhile the physician has become more sensitive to the issue because of a recent Journal of American Medical Association article, and some recommendations from a specialist society, and a conversation with drug detailer, as well as informal conversations with colleagues and exposure to television discussion of the issue. The patient talks with friends at work or family members about her experience; they also increase their concern and go to have their own pressure checked. She returns for another checkup and her pressure is still elevated although she has reduced her use of cooking salt; the physician decides to treat her with medication. The patient is ready to comply because all the sources around her, personal, professional and mediated, are telling her that she should (Hornik, 1997:49–50).

We would suspect that the story, while different in the details for a developing country, would not be radically different in essence for adoption of family planning behavior.

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
×

This may be why many of the discrete evaluations are unable to find population-level effects that stick. They are evidence about media effects on fertility within the first model. If the question at issue here is how media affect fertility in the broadest sense, although these projects get the lion’s share of research, they may represent only quite a small share of the influence. They examine a small proportion of all the media content developed to affect fertility because for most programs media effects cannot be isolated from other program effects. Of greater moment, they are an even smaller proportion of all the media materials that may affect fertility, if we speculate that most fertility effects are due to hypotheses two, three, and four stated at the start—the ideational effects of ordinary media content. In that case, if what we are interested in is the long-term large effects of multifaceted programs, and of natural exposure to media content, the discrete evaluations are much less interesting than are the correlational studies. The correlational studies, both cross-sectional and longitudinal, address the model of effect that is most likely to have produced big fertility effects. And the correlational studies, for all their methodological tentativeness, support the claim that the spread of mass media affects fertility.

The evidence base is certainly open to challenge, but here are conclusions and speculations based on what is available:

  • There is good evidence that short-term campaigns can affect clinic demand, which may relate to shortening the time lag between intention and behavior for those who are ready to act. The evaluations of those campaigns have been less successful in establishing that they produce detectable population-level changes in behavior.

  • Access to mass media is substantially related to fertility (or fertility-related behavior), at three levels of aggregation—individual, municipal, and national—even when other likely causes of the relation are controlled. There is some evidence that mass media access predicts subsequent changes in fertility-related behavior.

  • This second type of evidence is the strongest support for the argument that the spread of media affects fertility on a scale that is important. However, even if that claim was accepted, the mechanism of effect is undetermined. We have suggested at least four paths for such influence: medium noncontent effects, influence on elites, influence on basic values of general audiences, and influence on fertility-specific knowledge of general audiences.

  • Nonetheless, we would speculate that if the spread of mass media has effects on fertility, it reflects a complex social process rather than a medium effect or a discrete learning process: multiple channels, providing reinforcing messages, over time, producing inter-

Suggested Citation:"7 Mass Media and Fertility Change." National Research Council. 2001. Diffusion Processes and Fertility Transition: Selected Perspectives. Washington, DC: The National Academies Press. doi: 10.17226/10228.
×

personal discussion and a slow change in values, and working at a level of social aggregation higher than the individual.

  • Most of our discussion has focused on two types of effects: those related to discrete mass media interventions, and those related to general media access and exposure to ordinary media content. But there is a third type of possible effect: the effects of continuing messages delivered through the IEC efforts of general profamily planning programs. The explicit evidence relevant to these programs is that self-reported attention to media family planning messages, not in the context of a discrete intervention, is related to fertility-related behavior in the African sites studied by Westoff and Bankole. Most programs incorporate such efforts, but they are of unknown heft and quality, and of unknown effect. These programs cannot separate IEC or mass media messages from the rest of their activities, but they operate over the long term and with constant reinforcement of messages. In some ways they may behave more like the general media content, long-term effects model than they do the discrete, short-term effects model. More attention to these operational programs may produce evidence of long-term effects not seen with the short-term evaluations of discrete programs, just as the messy NHBPEP showed effects that the better evaluated but less comprehensive Stanford and COMMIT programs did not.

NOTES

1.  

Analysis based on 1997 data from World Development Indicators (World Bank, 1999); the predicted variance including the omitted countries is still a very substantial 66.1 percent.

2.  

The self-reported exposure to family planning messages on radio is also controlled in these analyses. Because that measure is likely to be highly correlated with radio exposure, it probably artifactually reduces the observed associations with overall media use.

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This volume is part of an effort to review what is known about the determinants of fertility transition in developing countries and to identify lessons that might lead to policies aimed at lowering fertility. It addresses the roles of diffusion processes, ideational change, social networks, and mass communications in changing behavior and values, especially as related to childbearing. A new body of empirical research is currently emerging from studies of social networks in Asia (Thailand, Taiwan, Korea), Latin America (Costa Rica), and Sub-Saharan Africa (Kenya, Malawi, Ghana). Given the potential significance of social interactions to the design of effective family planning programs in high-fertility settings, efforts to synthesize this emerging body of literature are clearly important.

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