Women’s mass media exposure and maternal health awareness in Ota, Nigeria

Abstract Maternal health has been an issue of priority to nations across the globe for years now. This study sought to: identify the sources of maternal health awareness; examine means of obtaining maternal health information; determine the frequency of mass media exposure; and analyse the influence of mass media exposure on maternal health awareness among the female residents. The Agenda-setting theory and the descriptive (survey) research design, using the questionnaire as the research instrument, were utilized in this study. For this study, the purposive and haphazard sampling techniques were used. The internet (49%) was the topmost source of maternal health awareness; adverts/campaigns (30.6%) were the most common means of obtaining maternal health information; once in a month [27.6%] was the exposure frequency of most participants to the mass media while the least exposure frequency was once in two weeks [5.1%]. It was discovered that mass media exposure had a significant influence on maternal health awareness. Given a number of factors noted to challenge people’s access to communication interventions in Nigeria, the study recommends that the goal of increasing the level of maternal health awareness needs to be matched with action thereby influencing the adoption of intervention measures aimed at reducing the rate of maternal mortality to the barest minimum.

Abstract: Maternal health has been an issue of priority to nations across the globe for years now. This study sought to: identify the sources of maternal health awareness; examine means of obtaining maternal health information; determine the frequency of mass media exposure; and analyse the influence of mass media exposure on maternal health awareness among the female residents. The Agendasetting theory and the descriptive (survey) research design, using the questionnaire as the research instrument, were utilized in this study. For this study, the purposive and haphazard sampling techniques were used. The internet (49%) was the topmost source of maternal health awareness; adverts/campaigns (30.6%) were the most common means of obtaining maternal health information; once in a month [27.6%] was the exposure frequency of most participants to the mass media while the least exposure frequency was once in two weeks [5.1%]. It was discovered that mass media exposure had a significant influence on maternal health awareness.

ABOUT THE AUTHORS
Miss Angie Igbinoba majors in health communication and her research comprise sexual and reproductive health; maternal and child healthcare; public health; development studies; media management; and science and risk communications. Prof. Ebenezer Soola is an erudite statesman in the academia whose research spans across media, development and business communications.
Dr. Oladokun Omojola is a seasoned print media journalist and journalism educator whose research encompasses media studies, advertising and political communication.
Dr. Jonathan Odukoya -the National Coordinator of the Educational Research Network for West and Central Africa [ERNWACA] in Nigeria -specializes in psychological, educational and social science research.
Prof. Olujide Adekeye is a seasoned Counselling and Psychology educator whose research revolves around health issues (maternal health, HIV/AIDS, and substance use).
Dr. Odunayo Salau is a social science intellectual whose research revolves around organizational behaviour, structure and design; trade unionism; labour-management relations; entrepreneurship; and related subject areas.

PUBLIC INTEREST STATEMENT
Decreasing maternal mortality ratio (MMR) by three quarters between 1990 to 2015 and ensuring healthy lives and promoting well-being for all at all ages is encapsulated in the third sustainable development goal (SDG). As much as the exposure of a given audience to the mass media relates to its awareness of messages in the same (i.e. mass media), undertaking a study that sought to prove the relationship between women's exposure to the mass media and their awareness of topical matters in the mass media became imperative. Previous studies, statistically, portrayed outcomes of mass media influence on other forms of health issues. This study, which portrays the outcomes of mass media exposure and maternal health awareness, is a significant statistical guide to health intervention expertssuch as mass communicators, medical practitioners, clinical psychologists, government community extension workers and othersto enhance safe motherhood project plans and strategies aimed at minimizing the rate of maternal mortality.
Given a number of factors noted to challenge people's access to communication interventions in Nigeria, the study recommends that the goal of increasing the level of maternal health awareness needs to be matched with action thereby influencing the adoption of intervention measures aimed at reducing the rate of maternal mortality to the barest minimum.

Introduction
The challenge of reducing maternal mortality has been a global public health concern for decades and continues to feature in most global developmental agenda one of which is goal 3 of the Sustainable Development Goal (SDG-3) (World Health Organization, 2015). In spite of the several initiatives and efforts devoted to curbing maternal mortality, only relatively little improvement has been achieved (WHO, 2019). The millennium development goal (MDG) of decreasing the maternal mortality ratio (MMR) by three quarters between 1990 and 2015 is encapsulated in the third SDG of ensuring healthy lives and promoting well-being for all at all ages. In recent times, there have also been initiatives involving the utilization of mass media campaigns to achieve wide coverage towards attainment of improved well-being (Odorume, 2015). Communication is a vital component of healthcare delivery. It has long been invaluable in health promotion which, in the last few decades of the 20 th century, became a critical part of public healthcare delivery programmes (Bhattacharyya, 2020;Calvert, 2011;Fatema and Lariscy, 2020;Mahmouda & Omarb, 2018;De Wet et al., 2014).
Public health concern on maternal mortality and morbidity has not dwindled and is becoming increasingly parameter for measuring societal performance (Amoo, Ajayi, Olarewaju, Olawande & Olawole-Isaac, 2020). Maternal mortality reflects the capacity of health systems, specifically it is a test of effectiveness of measures to address the pregnancy complications and challenges of childbirth. It could also be a measure of nutrition adequacy and reproductive rights of women especially during pregnancy (Amoo, Ajayi, Olarewaju, Olawande & Olawole-Isaac, 2020;El-Kak et al., 2020). In a bid to tackle varying maternal health concerns, Nigerian government and other nations across the globe had resorted to the utilization of communication campaigns to reach out to the public with the aim of influencing their engagement in desired health practices. Specifically, several governments have resorted to the use of communication campaigns through the mass media to reach out to the people, with the main purpose of influencing them into carrying out desired healthy practices (Amoo et al 2020;Bhattacharyya, 2020;Lariscy, 2020).
Mass media exposures can promote awareness of an issue, enhance knowledge and beliefs, and reinforce existing attitudes (Calvert, 2011;Khan & Ali, 2017). The mass media is the key component of a global strategy for sustainable health issues (Ogunjuyigbe & Adepoju, 2014). The mass media play vital roles in every society as they shape culture, influence politics, affect people's attitude, play important roles by raising concerns in health especially as it relates to women, children as well as in the contemporary business world (Amoo, Ajayi, Olarewaju, Olawande & Olawole-Isaac, 2020). According to the Baseline Survey that guided this paper, 35% of mothers failed to continue breastfeeding their babies for the recommended two years. Nearly 60% of caregivers were introducing solids or semi-solid foods before six months of age. Many believed that one either breastfed or fed solid food, leading to late introduction of complementary foods and abrupt weaning (cessation of breastfeeding). The baseline survey findings, therefore, reflect a relationship between a lack of knowledge (misconceptions) and malnutrition, which necessitated a communication intervention.
However, earlier models of health communication messages originated from individual health care experts, such as doctors and nurses who are authoritative disseminators of health messages; what (Kreps et al., 1998, p. 123) describes as formal health education. Today health messages can be accessed not just from health experts, but also from the mass media, organisations and other informal sources, such as everyday communication contacts with family, friends, and co-workers, who provide informal opportunities to discuss health issues (Jahan et al., 2017;Kreps et al., 1998).
The neglected health of expectant and nursing mothers was never a focus for policymaking until two researchers at Columbia University in New York-Alan Rosenfield and Deborah Maine-published a seminal paper entitled "Maternal health-a neglected tragedy: Where is the M in MCH (Maternal and Child Health)?" in 1985. Thomas (Thomas, 2013, p. 1) describes Alan and Deborah's paper as a call "on multi-lateral agencies, particularly the World Bank, to prioritize maternity care, considerably reduce maternal morbidity and mortality and perinatal mortality, and encourage contraceptive practice." This study aimed at knowing the mass media sources of maternal health awareness, the format of mass media messages on maternal health awareness, and the frequency of mass media exposure among female residents in Ota; it also aimed at finding out the influence of mass media exposure on maternal health awareness of female residents in Ota.

Literature review and theoretical framework
Sub-Saharan Africa, by the 2000 United Nation (UN)'s millennium declaration at the fifty-fifth session of the UN's general assembly, had the highest maternal mortality rate globally. Nigeria, the most populous country in Africa, has the highest maternal mortality ratios in the world (Bankole et al., 2009;Ogu & Orazulike, 2017). Nigeria, in virtually all development planning, has failed in performance (Amoo, 2018). Weak policy frameworks that pertain to maternal health should be strengthened via the joint effort(s) of the state and its development partners in monitoring as well as accounting for the progressive realization of reducing maternal deaths, using a human rights-based approach (DFID, 2005;Mpembeni et al., 2019;Smith-Estelle et al., 2015). Safe motherhood, by definition, encompasses series of initiatives, practices, protocols and service delivery guidelines designed to ensure that women receive high-quality gynaecological, family planning, prenatal, delivery and postpartum care, to achieve optimal health for the mother, foetus and infant during pregnancy, childbirth and postpartum. Unsafe motherhood consists of maternal mortality or morbidity due to preventable pregnancy and childbirth-related causes (United States Agency for International Development (USAID), 2013). Ignorance is one of its unnatural causes; unnatural causes of death in the words of De Wet, Dean and Odimegwu (De Wet et al., 2014, p. 587) "are largely preventable through the promotion of safe lifestyle and behavioural practices." According to Khan and Ali (2017), the role journalism plays in promoting maternal health awareness when there is exposure to the mass media is essential.
Journalism, which is the nucleus of the mass media in every society, concerns itself with the account and spread of incidences in any specified locale. It is a concept viewed by Agee, Ault and Emery (1982) in Rabiu (Rabiu, 2008, p. 27) as "the occupation which allow news to be interpreted and reported. News is information people urgently need in getting their bearings in a rapidly changing world." Calvert (2011) affirms the association of exposure to quality media content with positive educational outcomes. Responsible journalism is one in which information from the mass media does not contain any form of inaccuracy, distortion, confusion and error of fact (Igbinoba, 2009;Orhewere & Kur, 2004). Augmenting the aforementioned is Naveena (2015) who establishes how important the mass media are to their publics-small and large-as it relates to their role(s) in disseminating health messages. Schramm & Roberts (1971), as cited by Rabiu (Rabiu, 2008, p. 27), posit that "journalism sensitises people to available opportunities and forewarns them of possible dangers ahead." The mass media influence maternal health (Adeusi et al., 2014), sexuality and reproductive behaviour (Ogunjuyigbe & Adepoju, 2014); they are also capable of influencing maternal health awareness. The technical devices, known as the mass media transmit messages to sensitize people generally comprise the radio, television, film, book, video, newspaper, magazine and internet (Rabiu, 2008;Zamawe et al., 2015). In this study, the listed media constitute the sources of information to determine the maternal health awareness among female residents of Ota.
The study by Ghosh (2006) shows that a significant relationship exists between women's mass media exposure and maternal health awareness. Mass media exposure, as Ghosh (Ghosh, 2006, p. 282), opines "makes women aware of the need for basic maternal and child healthcare and enables them to receive information regarding essential healthcare and recent developments in health issues." The knowledge that is applicable and relevant is powerful and life-transforming (Odukoya et al., 2018). The knowledge of maternal health is, therefore, crucial to the safety of pregnant women and nursing mothers. The mass media are popular means of general health awareness and have the potential to disseminate adequate maternal health information. Building awareness among women through the mass media to provide information about health issues holds significant importance (Jahan et al., 2017). The mass media, as opined by Igbinoba et al. (2019), aid individuals in making sense of their world as they propagate maternal health awareness through their messages.
Based on the information dissemination and education functions of the mass media, exposure becomes critical if one need not be left behind in a world of constant development. The mass media are not all-powerful in knowledge generation, acquisition or dissemination, though designed to meet various information needs. Maternal health awareness, in this instance, has some level of dependence on mass media exposure. Sedlander and Rimal (2019) consider access to the world and other interactions through the media as an important factor for conducting interventions; the provision of greater access to the media is the best first intervention step. They stress the crucial position that is being occupied by the mass media in situations that require one form of intervention or the other. Tackling the high maternal mortality rate in Africa and the world at large requires a combination of interventions, one of which is the promotion of maternal health awareness via the mass media.
In corroborating the essence of mass media exposure, Fitzpatricka et al. (2019) note that media content and quality matter. As essential as quality media and content may be, inadequate exposure to them poses a big limitation to interventions regarding maternal health awareness. The study by Kamau et al. (2019), however, portrayed adequate exposure of pregnant women to the mass media as those adjudged to have the highest level of maternal health knowledge from brochures-which are under the print division of the mass media-were the majority. Increasing maternal health awareness among pregnant women improves their maternal health compliance, whereas their limited knowledge or lack of information on maternal health remains a set-back that adversely affects societal health and development.
Understanding the role of health communication in the development process is imperative to this study. The theoretical support for this study is anchored on Agenda-Setting concept, which has its origin rooted in the 1922 publication of Walter Lippmann on public opinion. According to the proponents of the agenda-setting theory, mass media possess greater influence to instill on the audience what they have heard, watched, or read and what they should think on the news or information received (Lee & McLeod, 2020;McCombs & Reynolds, 2002;Wanta & Hu, 1994). By emphasis, the theory specifically argues that the presentation of salient issues by the news media creates public awareness that is capable of influencing the viewers. It states that the media concentration on a few issues and subjects leads the public to perceive those issues as more important than other issues. As Zain (2014) observes, Walter Lippmann's publication was an expression of concern on the mass media's influence in setting certain images on the mind of the public as well as an indication on how the mass media can influence the opinions of the public through a particular agenda they set. Consequently, the mass media are empowered to influence the mindset of women, particularly the pregnant and nursing mothers-on the prevention of maternal mortality or the adoption of safe motherhood practices when maternal health awareness is the agenda, in the course of exposure to mass media messages.
Development scholars have asked the question of what causes people to change, and the situation of things as well as how much change occurs (DiClemente & Velasquez, 2002). Weinstein (2010) observes that since change occurs at different times and in different places under different circumstances, there is no independent theory that comes up to explain all changes that occur. However, one factor observed in all the theories that occur is that there must be communication and the exchange of information (Nassanga, 2009) and this partly explains why some of the earliest theories of development communication, such as modernization theory, had an overblown view of the impact of the mass media and communication on development. Models like the diffusion of innovation, the mass media were seen to have the potential of "blowing the winds of modernization" to isolated traditional communities, replacing their structure of life, values, and behaviour with ones seen in modern western society (Lerner, 1958;Singh, 2018;Thussu, 2000). The mass media is the magic multipliers of development benefits in the third world.

Data and methods
The study adopted the descriptive (survey) research design. The descriptive (survey) method was adopted for this study because of its large representativeness. The survey method allows for wider coverage of respondents. Data were collected from women in their reproductive years (15--49 years) who were resident in Ota, Ado-Odo Ota Local Government Area (LGA) in Ogun State. Ogun State is one of the 36 states in Nigeria located in the South-western region, with a total land area of 16,980.55 sq.km [29]. It consists of three (3) senatorial districts, nine (9) federal constituencies and twenty (20) Local Government Areas.
The researchers employed haphazard sampling in the selection of three landmark areas-Canaan Land, Iyesi and Oju-Ore-from Ota, as they had no access to the entire list of landmark areas to afford simple random sampling; they also utilized the haphazard sampling technique for questionnaire administration among the 100 females resident in the three landmark areas that 8participated in the study due to their consent and availability. The questionnaire formed the primary source of data collection. It consisted of 29 questions which included open and closeended items drafted in simple sentences such as how often do you access maternal health enlightenment via the mass media?; in which form have you mostly obtained maternal health information from the mass medium of your choice?; and which of the following mass media do you use most for maternal health awareness? Trained research assistants translated questions in the research instrument from the English language to the Yoruba language for non-English speaking respondents to actively take part in the survey.

Analysis procedures
The questionnaire was reliable, with a Cronbach's alpha value of 0.826. Data collected were carefully edited to ensure completeness, consistency and accuracy. Analyses involved the use of binary logistics and descriptive statistics-frequency, percentage and bar chart-to achieve the objectives of the study. However, the linear regression technique was used to ascertain whether women's exposure to the mass media has a significant influence on their maternal health awareness.

Ethical consideration
Before administering the research instrument, the participants were exposed to the purpose of the study. Participants had the freedom to withdraw from the study since their participation was voluntary. Also, there was no incentive given for participation. Those who were willing to participate signed a consent form. Confidentiality was maintained by requesting the participants not to write their names on the questionnaire forms.

Demographics
Only women of child-bearing age (15-49 years) were interviewed. Majority of the respondents are educated and have awareness of mass communication. Those that have access to traditional mass media are: 7% (radio), 16% (television). However, in term of social media, only 48% used internet, while 18% have used other social media such as GSM and cable (Table 1). In terms of education, all the women interviewed can communicate in Nigerian Pidgin English, however, only 7.1% have no formal education. While 21.4% have attained higher level of education, 71.5% had secondary education and below (Table 1).
A 3-D chart, as illustrated in Figure 1, was used to describe the survey participants' sources of maternal health awareness; mass media maternal health information formats; and frequency of mass media exposure.
In Figure 1, the internet (48 respondents) and television (16 respondents) were the two mass media sources that respondents were mainly exposed to. Maternal health information was primarily accessed in the form of campaign/advert (30 respondents [30.6%]) as well as news (28

Exposure to the mass media and maternal health awareness
The only hypothesis formulated tested the significant influence of exposure to mass media and maternal health awareness in the study location. The dependent variable is maternal health awareness while the independent variable is the access to mass media as idenitifed such as radio, television, internet, GSM and Cable, and so on. The result is presented in Table 2   Table 3c shows result of the regression analysis for the combined influence of mass media exposure on safe motherhood awareness among female residents in Ota, Ogun State, Nigeria. Table 3a shows that mass media exposure produced a coefficient of multiple correlation R = 0.940 and a coefficient of determination R 2 = 0.883, which is significant at 0.05 level. The coefficient of determination [R 2 = 0.883] signifies that 88.3% of the changes in maternal health awareness could be explained by a combination of internet, television, newspaper, radio, among others. The overall significance of the model as presented by the ANOVA in Table 3b (F = 723.516, p < 0.00) show that the model is sufficient and adequate for the contribution of mass media exposure to maternal health awareness among female residents in Ota, Ogun State.

Discussion
The study has provided empirical information on the exposure of women to the mass media and shed light on the significant relationship it has with maternal health awareness. The use of agenda-setting and the synthesize of the existing literature on both traditional and modern media portray the work as relevant to the contemporary media world and public health information. The overall summation of the study portray mass media as potent ways of instilling concern information and enhancing the understanding of the women towards maternal health information as conjectured by agenda-setting theory (Lee & McLeod, 2020;McCombs & Reynolds, 2002;Wanta & Hu, 1994).
The study highlighted that mass media would play a significant role in raising awareness about critical maternal health issues among the affected women, government and other stakeholders Figure 1. Combined chart on media source, format and exposure frequency. (Odesanya et al., 2015). This is critical to the achievement of SDGs-3 of promoting healthy lives and wellbeing for all at all ages and especially the agenda to reduce the global maternal mortality and preventable deaths of newborns (Amoo, Ajayi et al, 2020. Specifically, the results from this study indicated that since most participants were exposed to the internet, and the variables are positively related, efforts to enhance maternal health  awareness by various agents of sustainable development either mass communication professionals, medical practitioners, government health extension workers or other stakeholders, could then statistically rely on the utilization of the internet as a principal medium of communicating maternal health messages in the study location in particular and by extension, Nigeria as a whole. This finding is in tandem with the assertion from Singh (2018) that as society gets more computerized, significant changes in behavioural manifestations appear in the individual experiences regarding knowledge gain. In other words, more exposure to technology such as the internet, in this case, affects the knowledge of maternal health that is gained by its users-who include those that participated in the study-thereby causing significant changes in their maternal health behaviour, which implies that exposure to the internet not only enhances maternal health awareness in women but produces significant maternal health behaviours as well, thus, facilitating the attainment of the third sustainable development goal.
It would be a worthwhile investment for health communicators to reach pregnant women and nursing mothers, especially those in Ota, via news and advertising campaigns since majority of the respondents' access mass media messages in those formats. Advertising campaigns, as noted in Zamawe et al. (2015), are capable of generating maternal health knowledge in those exposed to the mass media and their spouses as well. Information on maternal health awareness was received via the internet, television and GSM, and on a once-a-month basis via advert and news. The respondents showed a preference for the internet, which is an indication that using the internet as a channel for disseminating safe motherhood messages would not only appeal to but be accessible to more women in Ota.
Irrespective of whether a nation is developed or developing, it is pertinent to note that the mass media are significant factors of influence on topical issues of development such as safe motherhood and maternal mortality eradication so long as women of childbearing ages get exposed to their messages (Amoo et al 2020;Bhattacharyya, 2020;El-Kak et al., 2020;Lariscy, 2020). Although the frequency of media exposure for most participants indicated in this study was low, maternal health awareness was significantly associated with mass media exposure but not the magnitude of exposure. Zamawe et al. (2015) corroborated the study by revealing that high or regular media exposure had no significant association. In the previous cases, the magnitude of one's exposure to the mass media was not as important to the subject matter as being exposed to the mass media.
Maternal mortality is rated high in Nigeria, and this has been a major cause of public health concern at both national and international levels (Okonofua et al., 2017). Research is a requirement to provide a database that informs policy decision (Adejuwon et al., 2015). This study, therefore, has provided data that could be useful to policymakers in the country for addressing maternal mortality via implementing policies that drive the promotion of maternal health awareness and mass media exposure.
Several communication studies have identified ignorance, asides other factors (namely social, demographic, literacy levels, language, and paucity of trained professionals, etc.), as the impediment to healthy living as well as health communication efforts (Asut et al., 2018;Forman, 2004;Thuy et al., 2004). This study, however, establishes that the mass media are potential sources of health communication and thus there is the expectation that information emanating from the mass media is intelligible to all recipients thus ensuring the success of maternal health interventions.

Conclusion and recommendations
The study concludes that media professionals, who are part of the government's development partners, need not employ just one or two dominant formats in the dissemination of maternal health messages; rather, balanced utilization of various mass media message formats should be encouraged to meet the diversified health needs of women. There are some factors noted to challenge people's access to communication interventions in the country; the study recommends that the goal of increasing the level of maternal health awareness needs to be matched with action thereby influencing the adoption of intervention measures aimed at reducing the rate of maternal mortality to the barest minimum. We recommend that all development stakeholders adopt health communication strategies which combine the traditional media of mass communication-radio, television, newspaper, etc.-and the social media-Facebook, WhatsApp, YouTube, etc.-for the actualization of the third SDG which targets healthy living and well-being for all ages.