It is often noted that some individuals become aware of a mass media program's messages through discussions with other individuals. However, the extent to which indirect exposure occurs, and its influence on behavior, are somewhat unclear. This study examines the role of indirect exposure in extending the reach of a family planning mass media campaign in Nepal. Sociometric data, gathered from nearly all women between the ages of 15 and 49 years living in six villages in Dang District, Nepal (N = 667), assessed indirect exposure to the radio program. Indirect exposure was extensive; half of all respondents were indirectly exposed to the program's messages and the overall reach of the program increased from 50% to 75% when indirect exposure was considered. Members of community groups had higher levels of direct exposure to the radio program and more extensive and diverse social networks, allowing them to serve as a conduit for these messages into the wider community. While direct exposure to the radio program appeared to influence family planning knowledge, indirect exposure was more strongly associated with contraceptive use. These findings suggest that program evaluations that ignore indirect exposure underestimate the impact of a mass media program on behavior.

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BackgroundSBCC campaigns are designed to act on cognitive, social and emotional factors at the individual or community level. The combination of these factors, referred to as ‘ideation’, play a role in determining behaviour by reinforcing and confirming decisions about a particular health topic. This study introduces ideation theory and mediation analysis as a way to evaluate the impact of a malaria SBCC campaign in Tanzania, to determine whether exposure to a communication programme influenced universal coverage through mediating ideational variables.MethodsA household survey in three districts where community change agents (CCAs) were active was conducted to collect information on ITN use, number of ITNs in the household, and perceptions about ITN use and ownership. Variables relating to attitudes and beliefs were combined to make ‘net ideation’. Using an ideational framework, a mediation analysis was conducted to see the impact exposure to a CCA only, mass media and community (M & C) messaging only, or exposure to both, had on household universal coverage, through the mediating variable net ideation.ResultsAll three levels of exposure (CCA, M & C messaging, or exposure to both) were significantly associated with increased net ideation (CCA: 0.283, 95% CI: 0.136-0.429, p-value: <0.001; M & C: 0.128, 95% CI: 0.032-0.334, p-value: 0.018; both: 0.376, 95% CI: 0.170-0.580, p-value: <0.001). Net ideation also significantly increased the odds of having universal coverage (CCAOR: 1.265, 95% CI: 1.118-1.433, p-value: <0.001; M & COR: 1.264, 95% CI: 1.117-1.432, p-value: <0.001, bothOR: 1.260, 95% CI: 1.114-1.428, p-value: <0.001). There were no significant direct effects between any exposure and universal coverage when controlling for net ideation.ConclusionsThe results of this study indicate that mediation analysis is an applicable new tool to assess SBCC campaigns. Ideation as a mediator of the effects of communication exposure on household universal coverage has implications for designing SBCC to support both mass and continuous distribution efforts, since both heavily rely on consumer participation to obtain and maintain ITNs. Such systems can be strengthened by SBCC programming, generating demand through improving social norms about net ownership and use, perceived benefits of nets, and other behavioural constructs.