Forman Journal of Social Sciences (2021) Vol. 1, Issue 1-2 (December)
DOI: 10.32368/FJSS.20210101

Mothers-in-law as Key Influencers: Study on a Radio Drama Intervention to

improve Maternal and Child Health in Pakistan

Syed Ali Hussain

1. Syed Ali Hussain, Ph.D.
Assistant Professor
Walter Cronkite School of Journalism and Mass Communication
Arizona State University
Email: sahussa8@asu.edu
ORCiD: https://orcid.org/0000-0002-2704-4551

ABSTRACT

Mothers-in-law play an integral role in promoting maternal and child health practices in

rural Pakistan. This study discusses the design, implementation, and evaluation of a 25-

episode radio drama featuring the mother-in-law as the primary influencer for maternal

and child health practices. The radio drama was designed after an extensive pre-drama

audience research comprising of 10 focus groups, and 14 in-depth interviews in Bagh

and Mansehra. Post-drama evaluation comprised two focus groups in the target areas.

The endline evaluation found that viewership of the drama improved communication

between people of all age groups and social roles without offending their dignity,

intelligence, and sense of tradition. Additionally, the findings showed that the audience

demonstrated improvement in knowledge about danger signs for mother and child, as

well as positive attitudes to seeking timely service from a trained healthcare provider.

The study makes a contribution to existing health communication campaigns by

introducing a culture-centric approach, through radio dramas, to influence mothers-in-

law and consequently impact maternal and child health practices.

Keywords: mother-in-law, radio drama, entertainment education, maternal health,

child health, Pakistan

Forman Journal of Social Sciences (2021) Vol. 1, Issue 1-2 (December)
DOI: 10.32368/FJSS.20210101

INTRODUCTION

The maternal and child health (MCH) situation in Pakistan has shown little progress

since the past decade. For instance, the maternal mortality rate has declined from 186

deaths per 100,000 live births in year 2019 compared with 276 deaths in year 2007

(Pakistan Report, 2020). This corresponds to an average annual rate of reduction of

3.1%. However, to achieve the 2030 sustainable development goal (SDGs) target of 70

per 100,000 live births, Pakistan needs a decline rate of 8.3% i.e., more than double the

current efforts. The situation is similar for newborn mortality rate. Even though the

newborn mortality rate has declined from 41 to 31 per 100,000 live births in the past

decade, still significant efforts are required in improving the quality of neonatal

interventions such as quality of care for mother and the newborn, and for sick newborn

care.

An important step towards improving MCH has been through the doorstep

community outreach services of the Lady Health Worker (LHW) program launched by

the government. Even though the LHW programme has made significant strides in

improving MCH, the statistics show a decline in the number of women who were

visited by the LHW for family planning services between years 2012-13 (29%) to 2017-

18 (19%). The women of age 30-34 years were most likely (24%) to have been visited

by a LHW and discuss family planning, with low service provision for the other age

brackets for reproductive years (15-49 years). Overall, the LHW programme also

requires significant improvement to achieve the SDGs by reducing gaps in financing

and technical supervision.

The MCH predicament in Pakistan is compounded by women resorting for home

births and relying on unskilled birth attendants or Dais. Even though, Pakistan’s health

infrastructure is expansive, only 15% of childbirths take place at public health centers

(Bhutta et al., 2013). Main reasons for home-births comprise structural and socio-

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cultural issues such as lack of family permission, distant facilities, costly services, and

inadequate quality-of-care (Shah et al., 2010). Another reason for preference of home-

based deliveries is because institutional deliveries are considered Western practices

(Moyer & Mustafa, 2013). Such a situation requires investment in media-based

behaviour change interventions to influence public attitudes and behaviors towards

health-facility based professional care, which is the focus of the current study.

Aim of study

This study presents the design, implementation, and evaluation of a radio program for

MCH promotion in Pakistan. The radio drama was produced as part of a behavior

change communication campaign for roughly 1.8 million residents in Bagh and

Mansehra districts of northern Pakistan. The intervention contributes a novel way to

engage with elders, especially mothers-in-law, to improve understanding about MCH,

which are often too sensitive and challenging to openly discuss in rural households,

especially in Pakistan. The study proceeds with providing a brief background about the

radio program project that was developed and implemented by the Primary Healthcare

Revitalization, Integration, and Decentralization in Earthquake-affected Areas (PRIDE)

project. The project was implemented in the Bagh and Mansehra districts of KPK.

Three steps pertaining to the project are described in this study:

1. The qualitative results of the audience research, which was conducted to gain

feedback for content development for the radio program;

2. Content and character development for the radio drama design workshop; and

3. Assessment of the impact of the radio drama upon the listeners.

Ethics and permissions

The author has received permission from PRIDE project to use and interpret the data

collected by them. Ethics approval has also been taken from Michigan State University,

USA.

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BACKGROUND

Nearly two million people were living in the mountainous regions (Munir et al., 2007)

of Mansehra and Bagh districts in northern Pakistan when a 7.4 Richter scale

earthquake struck in November 2005. The devastating earthquake, led to the

implementation of the Primary Healthcare Revitalization, Integration, and

Decentralization in Earthquake-affected Areas (PRIDE) project in the Bagh and

Mansehra districts of KPK. PRIDE was a four-year project launched by the United

States Agency for International Development (USAID) in August 2006.

The project was implemented by a consortium led by the International Rescue

Committee (IRC) with Management Sciences for Health (MSH), and Johns Hopkins

Program for International Education in Gynecology and Obstetrics (JHPIEGO) as

partners. PRIDE project’s objectives included: (i) strengthening the management

capacities of district health authorities, (ii) improving access to quality primary

healthcare services, (iii) increasing participation of communities in health service

management, and (iv) enhancing household’s level of knowledge and their care-seeking

behaviors.

After the earthquake, PRIDE project’s efforts have led to an improved

infrastructure to the extent that the health facilities significantly improved from the pre-

earthquake period. Still, the uptake of primary health care services was low because

access to healthcare was a function of socio-cultural factors that go beyond the

availability of and access to health services (Chan & Griffiths, 2009). The underlying

factors for low uptake of services needed a mass media communication campaign which

aimed to positively transform audiences’ beliefs, social norms, and motivations.

In lieu if this, PRIDE project initiated a behavior change communication

campaign that comprised an interdisciplinary team including communication

consultants, advertising agency staff, district health officials, community mobilization

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staff, health services staff, health systems staff, and monitoring and evaluation officers.

The author of this study, served as the behavior change communication manager,

working closely with the project director, to ensure the smooth execution of the

campaign and also for communication with stakeholders for the entire duration of the

project.

The behavior change communication campaign, consisted of a half-hour radio

program that aired once a week, for a total of 25 weeks, on local FM radio channels in

district Bagh and Mansehra from February 2010 to May 2010 during evening prime

time hours. The radio program was named: Rishton ki Wadian A'na kay Pahar (“Battle

between love and pride”; hereafter Rishton) and the genre was fictional narrative. The

objectives of the Rishton radio program were multifaceted, and focused on: (i)

promoting institutional delivery to enhance a dialogue about MCH in households, (ii)

empowering LHWs, (iii) reducing health risks for mothers and children, (iv) promoting

the efficacy of household members to seek healthcare information, and (v) improving

retention of health messages.

Based on this radio program data was then gathered by PRIDE to understand the

audience and community response. The data collected included: (i) a baseline survey

(2006), (ii) audience research to gain feedback for content development of the radio

program (2008), and (iii) a post-intervention qualitative evaluation (2010). The data was

gathered by interviewing couples (women and their spouse), their mothers-in-law,

health officials, and community leaders. The following section presents the details of

audience research and how it led to the creation of Rishton program for radio.

STEP ONE: AUDIENCE RESEARCH

The first step of the communication campaign was to conduct an in-depth assessment of

the target audience. The aim was to identify the main influencer for MCH practices and

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then develop a radio program based on the findings. This included a qualitative

audience research led by an internationally renowned private research firm in December

2008. The study comprised of 10 focus groups, and 14 in-depth interviews in Bagh and

Mansehra.

Participants and Procedure

The selection criterion for the women participants included: (i) women of reproductive

age, (18-35 years), (ii) women having minimum of one child but no more than two

children, and (iii) women currently residing in rural and urban Bagh and Mansehra. As

mentioned earlier, the husbands and mothers-in-laws of the women participants were

also sampled. For the focus groups, a minimum of 10 people were invited, and on

average, eight participated. The focus groups and interviews followed a semi-structured

questionnaire format. An experienced moderator accompanied by a note-taker

facilitated each interaction. The participants were informed about the nature of the

research, and consent was taken before the interaction began. Each interaction lasted

approximately 2-3 hours (Table 1).

In addition, in-depth interviews were organized with medical staff of local

BHUs and Nazims (religious leaders) of each district. Each respondent was explained

the purpose of the research and a prior consent was taken. The focus groups and in-

depth interviews were audio recorded and later transcribed. The audience research

including focus groups and in-depth interviews was completed in eight days starting

from 17

September and terminating on 27

September 2010, and a total of 18 people

from the field team were assigned to this project. The following section presents the

main findings of the audience research specifically in the context of insights that

resulted in formulating the creative strategy of the Rishton program.

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Table 1:
Sampling for Audience Research

Bagh

Manshera

FGDs

Interviews

FGDs

Interviews

(n=5)

(n=7)

(n=5)

(n=7)

Women

Husbands

Mothers-in-law

Religious Leaders

Medical Staff

Findings from Audience Research

It is important to clarify the meaning of Rishton ki Wadian A'na kay Pahar (“Battle

between love and pride”). The phrase, emerging from the audience research, basically

depicts a complex mix of barriers that people face in accessing MCH services. The

identification of these barriers led us to the realization that people of Bagh and

Mansehra are experiencing a range of inner conflicts or doubts. This insight served as

the central creative strategy of the radio drama and was later embedded in the script

writing and character development process. The next section presents these conflicts

and doubts experienced by our audience and then elaborate on the process through

which the Rishton program addressed and resolved these conflicts.

Conflict I: Home-Based or Health Facility-Based Delivery.

Generally speaking, all entertainment programs are based on some form of a conflict.

Such as, conflict between people, conflict between opinions, conflict of interest, and

often conflict with one’s own self. Conflict fuels debate and may lead to change in

attitudes and behavior. The people of Bagh and Mansehra had their own set of conflicts.

For example, a key conflict associated with mothers-in-law was that though they are

considered a respected member of the household, they generally lacked knowledge

about modern MCH methods. They appeared resistant to change because of their

attachment to age old traditions. This made them the protectors of tradition within the

family and often made them consider modern health centers unnecessary. It is the

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influence of mothers-in-law that encourage women to seek help from untrained

midwives or Dais, local medics or Hakeems, herbalist, faith healers or other informal

health providers. The overall result is a conflict between traditional knowledge bearers

(mothers-in-law) and modern health practitioners such as LHWs and other trained

healthcare practitioners.

The audience research also discovered access and availability of a trained birth

attendant as a key conflict. The results show that it became particularly challenging for

a pregnant woman to reach a health facility as the time of child birth approached.

Several reasons contributed to it, such as a difficult and mountainous terrain, which was

further exacerbated by inadequate transportation services. As a result, people had no

option but to walk to the nearest highway and then wait several hours for public

transportation to reach a hospital, all of which was often also beyond their limited

financial means.

The possibility of reaching a hospital is even lower at night time. Women were

hesitant to leave their houses in this state of being pregnant. Government hospitals

provided free services but did not provide the required care. For instance, doctors are

not available after evening. The hospitals did not have labs, fully functional ultrasound

facilities, and other basic services. Furthermore, poor and uncooperative attitude of the

health center staff deterred people to seek services from these facilities.

Another important reason for low utilization of health services was the non-

availability of female staff in the maternal care services. Due to religious and cultural

reasons, women preferred to be seen by a female doctor. Additionally, male members of

the household, such as the husband, father-in-law, or brother-in-law, only permitted

women to visit health facilities if female staff was present. If the husband or male

members of household are not at home, then women cannot visit the heath facility, and

must wait for male family members to return or resort to self-treatment. Women also

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didn’t have financial independence or income to call transport or consult a doctor in the

absence of the male members. As a result, many women ended up delaying treatment or

not receiving timely services.

The audience research found LHWs as a helpful resource; someone the

community members could turn to, for pregnancy related matters. However, there was a

perception that LHWs need more education and training to handle complex maternal

health problems. Also, they were considered less experienced, due to their younger age,

as opposed to a midwife or Dai who was many years older and more respected in the

community. For these reasons, women in rural areas of Bagh and Mansehra mostly

consulted a Dai for pregnancy and child birth related matters.

All of these factors further contributed in their intention to call a midwife or Dai,

which in many cases was the only available option. Dais are available round the clock,

costs less, have strong family ties, and are trusted members of the community. Based on

these reasons, many families in Bagh and Mansehra relied on Dais for the MCH advice.

There were incidents when a patient was rushed to the hospital in an emergency because

the Dai could not handle the complications resulting in the death of mother or child.

Such incidents were accepted as divine will.

Conflict II: Who makes the Decision on Mother and Child Health?

Another main conflict that emerged from audience research pertained to the decision-

making authority about MCH. Generally, most matters were discussed and opined with

the elders in the family who are obeyed as a sign of respect. The woman often does not

have the authority to make decisions that affects her and her child’s life. Husbands have

the authority to take care of their family’s health generally, but are not exclusive

decision-makers related to maternal health issues.

Mother-in-law was identified as the most influential person in terms of decision

making when it comes to pregnancy and childcare. She was considered experienced and

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respected because she has given birth to and raised children herself and is the elder of

the household. The husband is the second person in line to make these decisions. It was

found that mothers-in-law preferred home-based birth by Dais because she was easily

accessible, charge minimal amounts, and is usually a family relative or a close friend. In

this situation, most women were not allowed to make alternative decisions because of

the preference of mothers-in-laws.

Overall, the results show that maternal and child health-related decision-making

was a highly social process. Even if women opt to benefit from improved health

services provided by the PRIDE project, they were restricted in their ability to seek

timely and quality care for themselves and their children due to the social and economic

barriers. Additionally, the leading influencers, such as mother-in-law, did not value new

health services. Overall, mothers-in-law play a crucial role in determining access to

health services especially when it comes to MCH and therefore required the most

persuasion. Therefore, the project selected mothers-in-law as an important influencer

for the behavior change communication intervention aimed at increasing awareness and

improving attitudes and practice about pregnancy and childcare.

STEP TWO: RADIO DRAMA DESIGN WORKSHOP

The Storyline

The storyline and script of Rishton were produced during a three-day radio drama

design workshop that was implemented as per the guidelines provided by the Johns

Hopkins University Center for Communication Programs (DeFossard, 1998). The

objective of the workshop was to reach agreement on the technical and creative aspects

of the drama. The workshop participants included staff members from Bagh (N=5),

Mansehra (N=5), head office in Islamabad (N=2), advertising agency (N=2), and the

health communication consultant (N=1); representing an interdisciplinary mix of

professionals from health services, health systems, community mobilization, and

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creative design.

The team met for three days in PRIDE’s head office in Islamabad. The

brainstorming sessions and exercises resulted in setting up the main structure of Rishton

that included key topics and messages for all episodes. The health messages and

behavior change communication objectives for each episode is summarized in Table 2

and presented in detail in Appendix A.

Table 2:

List of episodes and messages for the Rishton radio program

List of Episodes

Maternal and Child Health Messages

Episode 1-4:

Character intro and story build-up with few MCH messages

Episode 5-10:

Ante-natal care

Episode 11-13:

Labor and birth

Episode 14-17:

Immediately after birth mother and neonatal healthcare

Episode 18-25:

Post-natal care, Neo-natal care, and child health

Drama Characters and their Contribution to Resolving the Inner Conflicts

The findings from the audience research and message design workshop informed the

creation of the main drama characters and their contribution to the behavior change

process. The main characters comprised of the mother-in-law, husband, woman, father-

in-law, LHW, untrained traditional birth attendant or Dai and a comic character among

several others. The drama characters were carefully designed to relate to both men and

women of all age groups in the target community. A detailed psychographic profile of

each character is presented in Appendix B. The next section briefly elaborates the role

of the mother-in-law and a few other characters in context with the creative theme of

inner conflicts.

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Figure 1: Radio Drama Promotional Poster

The central character of the mother-in-law was developed to be similar to a

typical mother-in-law in the target community. The mother-in-law character was named

as Amma Jee, a term often used for mothers in Pakistan. She was lovable, though self-

righteous and argumentative. She depicted a person that the audience could relate to and

yet a character who is enigmatic and charismatic. The aim was to gain audience

attention in addition to creating a sense of self-reflection and empathy. The character

was designed to showcase dilemmas between traditional values, messages, and practices

in a non-threatening manner (Figure 1). The Rishton radio drama built a story around

Amma Jee’s life, her inner struggles, and the resolution of conflicts between her

immediate and extended family, and healthcare providers. These providers included a

hardworking though discouraged LHW and an untrained traditional birth attendant or

Dai who later had a change of heart about hospital-based childbirth and modern

healthcare practices.

The creation of Amma Jee’s character facilitated communication with people of

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all age groups and social roles. The idea of Amma Jee’s inner conflict, depicted through

the creative use of an alter ego, allowed the audience to identify and resolve their own

doubts and dilemmas. For example, a typical mother-in-law could have an alter ego of

being the family protector and guardian of family values. Having an alter ego is

generally a positive phenomenon because it allows people to express in such a way that

they would not feel comfortable expressing with their own self. The Rishton drama

highlighted and crystallized these inner conflicts in the minds of people and aimed to

help them make appropriate and timely decisions for MCH. Appendix C provides an

example of the conversation between Amma Jee, the Dai and the LHW worker as an

example of the content of one of the drama episodes.

In addition to the mother-in-law character, the radio drama addressed a wide

range of inner conflicts that existed in a typical household to communicate and reinforce

the health messages. For instance, mothers realize the benefits of antenatal care, facility-

based delivery, and postnatal care but did not want to go against the century-old

traditional practices and beliefs. Husbands had the authority to take care of their

family's health but did not feel responsible to act on their role. For them, the birth of a

baby was a female matter, beyond their domain. Even if they wanted to be involved in

the health matters of their wife and child, traditions and gender norms prohibited them.

These inner conflicts were not always apparent and often operated at a sub-conscious

level. The goal of Rishton was to highlight these inner conflicts, and bring them up for

dialogue to help them make decisions in favor of better health for their families.

Objective of radio drama communication

The main objective of Rishton was to increase knowledge at the community and

household level about sensitive MCH issues. Additionally, the drama wanted to address

the inner conflicts related to important health decisions and influence attitudes and

behaviors of key decision makers. The goal was to achieve this in a manner which was

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nonthreatening, believable and informative for all members of the household and

community notables. To summarize, the radio program intervention aimed to answer the

following questions:

1. How did the listeners respond to the transformation of mother-in-law and Dai from

traditional to modern maternal and child health-related practices?

2. How did the listeners respond to the role of characters such as LHW, and husband in

influencing their attitude about MCH practices?

3. Was the radio drama believable and how did it influence community-level as well as

household level dialogue among family members about MCH?

STEP THREE: ASSESSMENT OF THE RADIO DRAMA

Participants and Procedure

Though an independent quantitative assessment of the PRIDE project was conducted in

2010 (Zaman et al., 2013), this study aims to report the modest results of the qualitative

assessment of the Rishton radio drama that was conducted by the behaviour change

communication team after the drama ended in May 2010. Two focus group discussions

were conducted in Bagh and Mansehra. The participants (n = 25) comprised both male

and female listeners. The participants were selected from a radio quiz competition that

was conducted at the end of each episode. The quiz competition received an

overwhelming response from listeners who participated by sending SMS text messages,

emails, and handwritten letters. From this group, a list of twenty-five listeners were

randomly selected and invited to participate in the focus groups. The session

proceedings were recorded on paper and then transcribed by the author. The

demographic information of participants was not collected. Informed consent was

received from the participants. Table 3 summarizes the main characters and their roles.

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Table 3:
Main drama characters, their names and roles

Positive Characters

Neutral Characters

Negative Characters

Amma Jee

(Mother-

in-law)

Tahira

(Daughter-

in-law)

Muneer

(Husband)

Parveen

(Daughter

of Dai)

Rozeena

(Dai)

Azra Khala

Dilshad

(Radio Host)

(LHW)

Findings from the Post-Intervention Assessment

Transformation of mother-in-law and Dai from traditional to modern beliefs

As mentioned earlier, the central character of Rishton was Amma Jee. Therefore,

listeners’ feedback on the role of mothers-in-law from a behavior change perspective

was particularly important. As expected, the study participants indicated the recognition

of a gradual shift in Amma Jee’s thoughts, attitude, and beliefs towards trained health

staff as opposed to contacting a Dai for the health of daughter-in-law and for the child

health. For example, a female listener from Mansehra said:

Through this drama information was spread very nicely. The drama especially

communicated with the elders about the importance of going to a health centre.

Other listeners also commented on the transformation of the characters Amma Jee and

Dai:

Both Amma jee and Dai had orthodox and traditional beliefs which was not right at all. But,

Amma Jee used to understand quickly; whereas the Dai was more stubborn in her views

(Female, Bagh).

…Personally, I liked the Amma Jee character because she loves her family and children

and when she was told about the health concerns in a nice way she was convinced (Male,

Mansehra).

… This drama has potential to change the consciousness of a lot of mothers-in-law like

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Amma Jee (Female, Mansehra).

Listeners acknowledged that the neglect of MCH is widespread in their community and

tangible efforts must be done to address the issue. For example, a male listener from

Mansehra acknowledged:

In our rural areas the mothers-in-law do not take care of their daughters-in-law. They

burden them with a lot of household work. From this drama we learned more about what is

important and how they should be treated.

During the script development and drama execution process, it was very important to

keep the drama close to reality. This was achieved through the in-depth audience

research and was acknowledged by listeners:

The role of mother-in-law and Dai were very close to the reality. The whole drama was

based on real-life scenarios just like it happens in our village. People did not know many

issues discussed in the drama and because of this ignorance we have suffered a lot. We

used to talk about the drama after each episode. It was indeed full of important lessons. I

think the key message of this drama has been to persuade people to visit the health facility

for mother and child health issues instead of relying on home-based remedies (Female,

Bagh).

The results also show signs of involvement, and engagement from listeners. A female

listener from Mansehra talks about how the drama kept all members of the family

deeply engaged with the story:

Our whole family used to wait for this drama. Before its start, we used to finish the

housework and turn on the radio. Everybody enjoyed listening to it. After the drama we

used to continue discussing the story and the characters. From this drama we have learned

more lessons than what we ever knew about mother and child health (Female, Bagh).

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Participants shared improvements in their knowledge and efficacy to act on the health

messages:

I learned from the drama that pregnant women should have at least 4 antenatal visits,

receive vaccination, and should choose health facility-based delivery (Female, Bagh)

… I learned the importance of health facility-based delivery, exclusive breastfeeding and

about family planning (Female, Bagh).

… I think this drama was 90% successful. We should plan for the maternal and child health

matters so as to avoid any trouble at the time of child birth. This drama was helpful because

many people still don't believe in seeking services from health facilities and trained

providers (Male, Mansehra).

Role of lady health worker, and husband in influencing maternal and child health

In addition to the mother-in-law, several other drama characters contributed to the

behavior change process. Foremost among them was a hardworking LHW who makes

door-to-door visits to educate people about health services. The drama showed a

constant battle between LHW and Dai as they argue with each other about the

importance of trained health staff versus traditional practices for antenatal checkup,

health facility-based delivery, and child health. For example, a female listener from

Bagh talked about the problems associated with birth preparedness and how the lady

health worker addressed these issues:

My favorite character is Dilshaad [LHW]. In this area, people used to have a low opinion

about LHWs; people said they did not do enough work. In the drama, however, Dilshaad is

a caring and hard-working LHW. She is a good person. My sister-in-law is training to be a

LHW and I think she will be just like Dilshaad. Our village is in a very rural, remote area.

It takes a very long time to reach the nearest hospital, as the roads are so bad. Taxis are

expensive and hard to come by. They charge about PKR 3,000 (USD 30) to go to the

nearest hospital. Often women have to be carried on a bed and sometimes they suffer

severely before even reaching the hospital. I like this radio program because it's the first

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source of information I have ever heard about women to prepare for birth by saving money

(Female, Bagh).

… The guidance given by LHW was the soul of the drama (Female, Bagh).

A female listener further alluded to the conflict between traditional versus modern

practices in the context of drama characters:

… I disliked how the Dai misled Amma Jee. The Dai didn't want Tahira's (daughter-in-law)

delivery to happen at the health facility. Instead, she insisted for home-based birth. But

every time Muneer (husband) interfered and sorted out the misperceptions. I think the

drama was very close to reality because, in many families, child birth happens at home,

resulting in either the woman or the child losing their life. In many cases both end up with

serious health concerns after home-based deliveries or even death.

These sentiments were shared by male listeners which is important because when it

comes to reproductive health, often women do not have access to information or agency

to control health matters. Men are important decision-makers for providing finances and

arranging transport to reach health facility for medical checkups and delivery. A male

listener from Bagh expressed his views:

LHW played a marvelous role. She continued to guide the community and increase

awareness on mother and child health, despite the fact that she was ignored and hurt by

many. She explained the health matters in a very nice and affectionate manner. She also

used to follow up with people on the progress and help them out.

The listeners looked up to the LHW as a role model who possessed both knowledge and

moral character to help the community:

I loved the character of Dilshad (LHW). Even though Dai falsely accused her of theft but

she did not complain. Instead, she helped the Dai’s daughter during her pregnancy. She

also did not remind the Dai of the false blame that was put on her earlier. This shows the

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high character of Dilshad (Female, Bagh).

Another important character of the Rishton was husband (Muneer). The findings

showed that male listeners closely associated with this character and were able to

rethink about the traditional beliefs and stereotypes through this lens. For example, a

male listener from Bagh expressed his opinion about the importance of male

involvement in MCH issues:

My favorite character is Muneer (husband). He is the main hero. He is very caring towards

his wife, and he gave importance to her opinions. In my opinion, the main message of the

drama is that ‘life is precious.’

Another male listener from Bagh talked about the health consequences they have faced

due to lack of knowledge about MCH issues:

This drama was close to reality because in our villages Dais are rigid and firm in their

traditional beliefs. They follow their ego that often results in poor health outcomes for the

mothers (Male, Bagh).

… This drama successfully spread information in society about a topic that is difficult to

talk about in a direct way. So that the listener could understand solutions. The story was a

home-based story; same as it happens in reality (Male, Bagh).

Promoting dialogue among community and household members

MCH was a sensitive issue to discuss at household and community level in Bagh and

Mansehra. Thus, it was important for the drama to generate positive dialogue among the

listeners. To achieve this, a comic character; Suleman Rahi, was introduced based on a

famous film character in Pakistan. The humor added by the Suleman Rahi kept the

listeners engaged and reduced information overload. A female listener from Bagh said:

I liked the comic character of Suleman Rahi because he makes everybody laugh even under

tense situations.

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Several participants talked about their engagement with the Rishton drama and how

it enabled them to start a dialogue with elders in their family:

The drama also helped me understand how to persuade our elders and how to communicate

with them (Female, Bagh).

… I think talking about reproductive health is a sensitive and complicated matter which

was nicely dealt with through radio drama (Male, Mansehra).

A male listener from Mansehra talked about the importance of using the radio medium

and how it helped him start a conversation with family members:

The radio drama was beneficial because a lot of girls and women, both literate and not

literate, could listen to it from their homes. I think every character of this drama was full of

lessons and advice. The drama helped me understand how to persuade our elders and how

to communicate with them.

… Although it was mostly audio, but from the drama I could imagine that all of this is

happening in my own family (Female, Bagh).

…We really liked the name of the drama because it used very nice and appropriate words

(Female, Bagh).

… The broadcast of drama on radio medium was very helpful. Because then a lot of girls

and women could listen to it from the privacy of their homes (Female, Bagh).

…It is the first time we have heard a drama like this on radio (Female, Mansehra).

…I think this drama should be broadcasted on TV as well (Male, Mansehra)

DISCUSSION

The purpose of this study was to present the design, implementation and evaluation of a

radio drama to promote the role of mothers-in-law for MCH in rural Pakistan. The

intervention, a radio drama, was developed based on an in-depth audience research that

directed all creative aspects of drama production, including message design,

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scriptwriting, and post-production. The central theme of the Rishton drama was the

insight that people live with inner conflicts that influence their decision making about

MCH. The Rishton drama introduced unique challenges at every stage of the MCH

continuum. For example, during the pregnancy and delivery phase the challenges were

cost of delivery, lack of doctor and services, distance from health facility, and whether

to select Dai or a trained healthcare provider for the birth of child. After the birth of

baby, the episodes introduced new challenges such as knowledge about postpartum

care, neonatal care and child vaccination and family planning.

To address these conflicts, a lovable, though self-righteous but argumentative

mother-in-law character, Amma Jee, was created that showcased dilemmas of traditional

values. The radio content messages promoted practices in a non•threatening, non-

dogmatic manner. The use of this character allowed the campaign to communicate with

people of all age groups and both genders without offending their dignity, intelligence

or sense of tradition. The idea of Amma Jee’s inner conflict, depicted through the

creative use of an alter ego enabled us to communicate with target audience, and

identify and resolve their doubts and dilemmas about maternal and child related health.

There is an established history of producing entertainment-education programs

to promote MCH and family planning. Few notable examples from Pakistan include TV

drama Aahat, Nijat, BOL, Sammi, Mujey Jeenay Dou, and Angoori. These dramas

prominently showed the character of mother-in-law as key influencers for positive

cultural change. The current study contributes in two ways. First, the drama portrayed

the mother-in-law as the main character who went through a change of heart about

health facility-based deliveries. Second, it was the first time an audio drama was

developed and successfully broadcasted in North Pakistan.

A key factor in the success of Rishton intervention was its relevance to the local

culture. We find support for this approach from other scholarship on international health

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communication. For example, Dutta and Basnyat (2008) examined entertainment-

education radio dramas from a cultural point-of-view and provided a theoretical

framework for participatory communication projects. The authors argued that such an

approach enabled listeners to be an active participant in the meaning-making process of

messages broadcasted from the drama. These meanings are socially constructed as the

media interventions open opportunities for dialogue about the lived experiences of the

listeners. Rishton also promoted dialogue between household members, as well as

community members. The dialogue helped to prepare families for pregnancies as soon

as they are aware of conception and to identify an appropriate health facility, save

money, and arrange transport for the time when they needed to go for the delivery. The

study also highlighted the important role of LHWs in educating the mothers and

mothers-in-law about pregnancy and related complications and encouraging them to

prepare for delivery at a health facility. However, the recent research shows that the

LHW program is facing several constraints such as resource gaps in financing and

technical supervision (Pakistan Report, 2020).

Our study results are also supported by international research that emphasized

the effectiveness of including mothers-in-law for MCH decision-making. Studies from

Pakistan and Bangladesh show that the inclusion of mother-in-law into health

promotion significantly increases the uptake of health services (Mumtaz, & Salway,

2007; Chowdhury et al., 2003; Shaikh et al., 2008). Similarly, in Nepal, the mother-in-

law holds a prominent position when it comes to maternal and child health-related

decisions (Masvie, 2006). Mother-in-law also appeared as a significant influencer in

Botswana and Zambia for HIV-related health information seeking to prevent mother to

child transmission of the disease (Nyblade, & Field, 2000).

In Senegal, mother-in-law involvement led to improved nutrition for the mother

and child (Aubel et al., 2004). Further, the mother-in-law’s interventions positively

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influenced breastfeeding practices as evidenced by health programs in Malawi (Kerr et

al., 2008) and Tanzania (Leshabari et al., 2006). Researchers have also studied the role

of the mother-in-law in the context of family communication, with a positive social and

health effect for daughter-in-law (Rittenour, 2012). Similarly, in Pakistan, mother-in-

law is considered experienced because she has raised children herself and is a respected

elder of the household (Lee et al., 1995).

Overall, the results show positive trends in increasing knowledge and improving

attitude and behaviour towards recommended MCH practices. The evaluation found

evidence of one-on-one interactions between family members about issues which are

generally difficult and sensitive to discuss openly. Results also show evidence for

community-level engagement such as recognizing the role of LHWs and the value of

trained healthcare providers. To sum up, Rishton was effective in building social and

psychological capital in the community and in improving knowledge about MCH.

Limitations of study

The study followed a non-probabilistic sampling method and the sample could be

skewed towards participants who are enthusiastic about the Rishton program, thereby

lacking generalizability. Similarly, the results are specific to Bagh and Mansehra

communities, and may not hold true for other regions with different cultural beliefs and

practices. This limitation can be addressed through modifications in drama script

according to region and cultural differences. The qualitative evaluation of the radio

drama is limited because of a small number of participants. A more systematic and

longitudinal evaluation was needed to assess the long-term impact of Rishton to

determine which messages were most effective in influencing attitude and behavioral

intentions to seek health information and services.

It is also hard to infer from data if the radio drama influenced any policy-level

change. While acknowledging these limitations, the study serves as a pilot for future

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programs to promote the involvement of community elders, specifically mothers-in-law,

for health communication in Pakistan. Existing health communication projects in

Pakistan could benefit from this resource by implementing Rishton again in a new

geographic region.

CONCLUSION AND IMPLICATIONS

Did the PRIDE project have a long-term impact? That is a difficult question to answer

because the project officially ended in 2010 thus measurement of impact in the long-run

was not possible. Also, due to the nature of field-based research and implementation of

the drama, it is hard to separate the impact of Rishton from other health education

services provided by the PRIDE project. Still, this study makes a modest contribution to

inform researchers and practitioners as a starting point to replicate the process of

creating an entertainment-education drama for other audiences and locations.

The MCH-related constraints are not unique to Pakistan and are generally

observed across South Asia and in other regions such as Latin America and Africa. To

that end, this study offers a significant step forward for international scholars and

practitioners to explore the role of mothers-in-law from the lens of utilizing

entertainment-education to reach masses especially in remote and rural communities. It

is hoped that this work will inform researchers and practitioners dealing with social and

structural challenges and offer family members alternative solutions to be ready and

prepared for MCH needs. This approach can also be used to persuade and increase

involvement from stakeholders such as religious leaders and community notables. These

factors make this study uniquely relevant to a broad group of international and

interdisciplinary scholars and practitioners in MCH practice. This study is relevant to an

interdisciplinary audience and serves as a pilot to replicate radio-based interventions for

MCH in a developing country context with emphasis on mothers-in-law as the primary

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influencer.

For future researchers in this area, stakeholders, and policy-makers, it is integral

that efforts are made to re-launch the radio drama on social media sites such as

Facebook or YouTube, because new media and communication technologies provide a

whole range of opportunities to reach diverse population, such as women, children,

husbands, mothers-in-law, and other stakeholders in ways which was not possible

before. Additionally, the cost and effort of introducing the Rishton radio drama on

Facebook, Instagram and YouTube is estimated to be lesser as compared with

advertising on traditional AM/FM radio channels. Moreover, the monitoring evaluation

mechanism provided by Facebook Insights and other ways of measuring audience

interactions and engagement on social media – likes, comments, shares – will provide

more in-depth information about audiences’ reaction to the messages and possible

outcomes.

Conflict of Interest Statement
There is no conflict of interest to declare. It is important to report however that the
author served as the behavior change communication manager of the project for the
entire duration from 2008 to 2010; and managed the creative design, implementation,
and evaluation of the intervention.

Funding
This study has not received funding.

Ethics and permissions
The author has acquired written approval from PRIDE, as well as the funding
organization for the PRIDE project, to use their data to prepare this manuscript. Ethics
approval has also been taken from Michigan State University, USA.

Data sharing and availability statement
Data is available from the corresponding author based on request.

Author Contributions Statement
The author developed this manuscript alone.

Acknowledgements
I would like to acknowledge Howard and Delafield International for designing and
implementing the creative strategy. I would also like to acknowledge Spectrum

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DOI: 10.32368/FJSS.20210101

Communications advertising agency for an outstanding job in producing the radio
drama and other communication deliverables of the project. Additionally, I would like
to acknowledge consortium partners headed by the International Rescue Committee
(IRC), with major partners including Management Sciences for Health (MSH) and
JHPIEGO, an affiliate of Johns Hopkins University.

Author Bio
Dr. Hussain has a Masters (Fulbright scholarship 2013) and PhD (2018) in Health
Communication from Michigan State University. During his PhD, Hussain worked on
research projects funded by Global Development Lab USAID, National Science
Foundation, and Robert Wood Johnson Foundation. After completing his PhD, Hussain
worked as Assistant Professor at Arizona State University Walter Cronkite School of
Journalism and Mass Communication (2018-20). Hussain’s research is about maternal
and child health communication, entertainment-education, behaviour change
communication, and intercultural communication. Hussain has published in the Journal
of Health Communication, Communication Research Reports, Intercultural

Communication, Journal of Medical Internet Research, and BMC Public Health among
others.

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DOI: 10.32368/FJSS.20210101

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