Association of Mass Media with Women’s Health Risk Behavior and Service Utilization in Nepal

Background and Objective: Mass media can be a powerful tool for promoting maternal health and improving health outcomes, but it is important to carefully consider the design and implementation of media campaigns to ensure their effectiveness. This study investigates the link between media exposure and maternal healthcare seeking in Nepal, providing insights to improve women’s health and well-being. Materials and Methods: Data were collected from 14,085 women aged 15-49 across urban and rural areas of Nepal's seven provinces. Descriptive, bivariate and logistic regression analyses were conducted, considering individual, household and community-level variables to assess the association between mass media exposure and reproductive health outcomes among women in Nepal. Results: The findings showed, that in comparison with women with no media exposure, women with media exposure were more prone to health service utilization. Logistic regression models revealed significant associations between media exposure and non-smoking (OR = 1.78, p = 0.001), abstaining from alcohol (OR =1.35, p = 0.001), menstrual hygiene management (OR=1.59, p = 0.001), CPR awareness (OR = 1.26, p = 0.001), knowledge of HIV (OR = 3.17, p = 0.001) and HIV testing (OR = 2.55, p = 0.001). Conclusion: Media exposure among women in Nepal is linked to risky health behavior and increased health service utilization. This research informs targeted mass media campaigns for policymakers and healthcare practitioners, offering a potent tool to enhance maternal healthcare and overall health awareness in low-resource settings.


INTRODUCTION
According to the Nepal Demographic and Health Survey (NDHS), from 1996 to 2016, the MMR decreased from 539 to 239 maternal deaths per 100,000 live births 1 .Maternal health is a critical issue in Nepal, as the country has one of the highest maternal mortality rates in South Asia.Despite progress in recent years, the rate of maternal deaths remains high, with many women in Nepal lacking access to quality maternal healthcare services 1 .
One factor that may impact maternal health in Nepal is media exposure.The media has the ability to shape public opinion and influence healthy behaviors and in the case of maternal health, media exposure can play a role in raising awareness about the importance of maternal healthcare and the risks associated with pregnancy and childbirth 2 .Women who are expecting require accurate information about healthcare services and the mainstream media (such as television, radio and newspapers) may provide this information 2 .Along with serving as a source of information and pleasure, mass media also has a significant impact on how people, families and organizations make decisions 3 .Additionally, media exposure can also help to promote maternal health initiatives and policies and can provide a platform for women to share their experiences and advocate for their rights 4 .
The behavior of seeking reproductive healthcare can be explained by the sociocultural background, selfefficacy and belief systems of the individual 5 .Healthcare behavior modification is a difficult task, but numerous studies have been done on how to increase health literacy and encourage getting medical attention 6,7 .Knowledge exchange and raising public awareness through various community activities have also had a good impact on maternity healthcare 5,8 .In order to help communities, shape their health ideas and perceptions and rectify activities with unscientific foundations, health communication through a variety of conventional and electronic media serves as an effective information and awareness-building tool 7 .By learning about risk factors, preventive measures and the availability of professional services, women who have access to information about family planning via social media should be able to make better health decisions 9,10 .
There aren't any empirical studies on the relationship between exposure to such media communication and maternal healthcare seeking in Nepal, though, at the moment.Overall, understanding the relationship between media exposure and maternal health in Nepal is crucial for improving the health and well-being of women in the country.By examining the role of media in shaping women's attitudes and behaviors related to maternal health, policymakers and healthcare providers can better identify and address the challenges facing pregnant women and new mothers in Nepal.
This study was carried out utilizing data from the Multiple Indicator Cluster Survey (MICS) 2019 in order to fill this research gap.This study sought to determine whether women's media exposure had any positive effects on their use of health services.

MATERIALS AND METHODS
The data for this study were obtained from the Multiple Indicator Cluster Survey, which is a comprehensive household survey conducted nationally and internationally.The MICS is regularly carried out in numerous developing countries, Nepal included, offering valuable insights into factors influencing child health, nutrition, education, development and overall well-being across diverse global regions.The MICS dataset encompasses information about households and their residents in both urban and rural areas of Kathmandu.This area is segmented into seven provinces and 77 districts.The survey sample was chosen using a two-phase, stratified cluster sampling method.
The Nepal MICS 2019 gathered data on media exposure, computer utilization and internet usage.The survey included 14085 women aged 15-49 years and captured details about their engagement with newspapers/magazines, radio and television.Use of media was defined as women who read a newspaper at least once a week or listened to the radio at least once a week or watched television at least once a week.
The variables for the study were the individual mother characteristics and household characteristics.Mother characteristics encompass the educational attainment (classified as non-literate/illiterate or literate) and their functional capabilities.Household-level attributes consist of the household wealth index, categorized as poorest, second, middle, fourth and richest.This index is evaluated based on household amenities, resources, assets and the presence of health insurance.Furthermore, this study incorporates three community-level variables: the place of residence (categorized as rural or urban) and the provincial level (comprising seven provinces).These variables were selected based on literature and their availability in the dataset.Ethics statement: As per the Statistical Act 11 , the study protocol for the Nepal MICS survey was approved by the Central Bureau of Statistics (CBS) along with UNICEF.Since this study involved the analyses of publicly available anonymized secondary data, ethical approval from respective institutions was not required.
Statistical analysis: Data were extracted in SPSS (version 26) and convert to R program for further analysis.Data analyses in this study comprise descriptive analyses, bivariate analysis and logistic regression analyses.All the data were weighted to account for the complex sample design, such as stratified sampling and probabilities of unequal sample selection between regions.Pearson's Chi-square Test was used to determine mother's characteristics and household characteristics among mothers who use media.
The study employed logistic regression analysis to investigate the impact of various factors on the outcomes.To begin, individual determinants were introduced into the model one by one to assess their individual association with the outcome.Subsequently, complex logistic regression models were utilized to identify the most influential determinants for each outcome.Statistical significance was defined as a p-value below 0.05.The study utilized Adjusted Odds Ratios (AORs) alongside their corresponding 95% confidence intervals (95% CI) to illustrate the autonomous relationship between predictors and dependent variables.The entire statistical analysis was performed using the R program for statistical analysis.1 presented illustrates the percent distribution of women aged 18-49 by background characteristics, including age, educational status, place of residence, province, wealth index quintile, health insurance, marital status and functional difficulty.

DISCUSSION
The study findings compare women aged 18-49 years with use of media by their background characteristics such as age, educational status, health insurance, place of residence, wealth quantile, marital status and status of functional difficulties.The study suggested that social determinants such as age, place of residence, province, educational status, marital status, number of children and wealth quintile were associated with the use of mass media.For instance, urban women were more likely to `be exposed to the media compared to the rural women.Education-wise use of media shows that use of media was higher among educated than non-educated women.Similarly, the study shows an association between wealth quantile and the use of media.Wealthy women were more likely to be exposed to the media.In terms of disability, media use was higher among persons with no disability compared to the person with a disability.A study that examined media, knowledge translation and action on the social determinants of health also supports the findings from the study of Ndumbe-Eyoh and Mazzucco 12 .
Risky health behavior and health outcomes such as the use of cigarette and alcohol consumption, menstrual hygiene management, use of family planning method, place of delivery of the child and knowledge of HIV showed a positive association with the use of media.One of the implications of this study brings is the more women are exposed to mass media, they are likely to have positive health outcomes.The study shows that a high number of women, who used mass media, delivered babies at health institutions compared to those who did not use or use mass media less.This finding followed the trends indicated by previous studies in other countries.For instance, mass media exposure was found to be independent contributor to various aspects of maternal health care including awareness raising about critical maternal health issues among women and stakeholders in Bangladesh and Nigeria 4,5 .The study further found that a higher number of women who were exposed to the media used family planning methods and maintained menstruation hygiene compared to those women who were not exposed to media confirming other studies' findings showing positive influence of mass media messages with reproductive health such as family planning in the countries like Kenya, Uganda, Ghana, Bangladesh and other low and middle income countries [13][14][15][16][17] .
Other finding showed a positive association between media uses and HIV knowledge and health seeking behavior such as getting tested to confirm the status transmission in line with other studies in other parts of the world that found the use of media contributing to positive health outcomes related to HIV [18][19][20]  study also found that HIV/AIDS knowledge was higher among individuals with high education levels potentially having greater exposure to the media.
A study highlighted, a noteworthy relationship that was observed between engagement with mass media and HIV testing among young individuals in Kenya and Nigeria, but this association was not evident in Zambia 21 .The results underscore an uptick in HIV testing among youth who had been exposed to mass media communication.The study's outcomes imply that consistent and preemptive media initiatives could potentially facilitate the spread of constructive notions among young people, ultimately fostering a culture of HIV testing.
The current study has also indicated association between the use of mass media and smoking among women showing a large portion of women who are not exposed to media involved in smoking compared to those who use the media.Although, this study does not include the type of content accessed by the media, health information is integral part of media contents.Health related Public service announcements and radio drama as well as information, education and communication materials constitute sizable portion in media content in Nepal.Therefore, media interventions are likely to influence people in positive way.This fact has been finding was similar to other studies that found specific media interventions such as health campaigns huge role in reducing risky behavior such as tobacco consumption and smoking among women 22,23 .
Access to the mobile device and the internet has made it easy to access mass media content easily since mass media like radio and newspapers are available in digital format whereas television contents are also available in YouTube.Since health messages are also one of the prioritized contents by media, those women who access media may be likely to be aware of health issues.However, further research is required to know to what degree media contents impact the health outcome of women.

CONCLUSION
Our secondary data analysis shows an association between background characteristics and health outcomes of women in Nepal with the use of mass media.Exposure to the media is linked to the utilization of maternal healthcare services such as institutional delivery and regarding menstrual hygiene management, use of family planning methods and knowledge of HIV.Media's role can be pertinent in persuading the women with low-educated and encourage them to seek maternal healthcare services.
Increasing access seems critical to reach out to them by policy makers and program implementers.Overall, mass media can be a powerful tool for promoting maternal health and improving health outcomes, but it is important to carefully consider the design and implementation of media campaigns to ensure their effectiveness.Media exposure can aid a woman in accessing healthcare services in bringing positive health outcomes in low resource settings such as Nepal.

SIGNIFICANCE STATEMENT
This research highlights a noteworthy correlation between media exposure and the uptake of vital maternal healthcare services, including institutional delivery, awareness of menstrual hygiene management, utilization of family planning methods and knowledge of HIV.These outcomes underscore the pivotal role that mass media plays in influencing women's healthcare-seeking behavior, particularly among those with lower levels of education.Media interventions hold the potential to effectively persuade and motivate these women to seek essential maternal healthcare services.As policymakers and program implementers endeavor to enhance women's access to healthcare, it becomes evident that increasing media accessibility is of paramount importance.

Table 1 :
Table 3presented below shows the comparison between social determinants by use of media.The findings revealed that indicators such as age, place of residence, province, educational status, marital status, number of children, wealth quintile was statistically significant for use of media (p<0.05).Based on the residential setting, women belonging to urban area Distribution of women aged 18-49 by background characteristics This table was generated by authors based on the statistical analysis of data set of the MICS https://doi.org/10.17311/tmr.2023.102.111| Page 104

Table 2 :
Proportion of women by use of mass media

least once a week during the last three months
were more than 1.26 times aware of CPR [OR = 1.26 (95% CI: 1.3-1.4)p = 0.001] to women without using media.Women who used media had three times more knowledge on HIV compared [OR = 3.17 (95% CI: 2.85-3.53)p = 0.001] to women without using media.In regard to women testing for HIV, women who used media were 2.55 times tested for HIV [OR = 2.55 (95% CI: 2.21-2.95)p = 0.001] to women without using media.https://doi.org/10.17311/tmr.2023.102.111| Page 106

Table 3 :
Use of media by social determinants Use of media -

Table 4 :
Use of media by health indicators Use of media

Table 4 :
Continue Use of media - https://doi.org/10.17311/tmr.2023.102.111| Page 107 p<0.001 and this table was generated by authors based on the statistical analysis of data set of the MICS *