Assessing the Credibility of Best Suited Communication Channels in Rural Communities for Meeting the Unmet Need Towards Reducing Child and Adolescent Marriage: a Model From Upper Egypt

doi:10.21203/rs.3.rs-790266/v1

Background: Low levels of scholarly achievement, poverty, and geographical isolation are all known to be linked to early marriage. This study aimed at identifying the most credible and the best-suited communication channels (CCs) to reach rural communities for motivating them to reduce child and adolescent marriage.

Methods: A cross-sectional study targeted 1000 wives and their husbands were conducted in 21 rural village units of two governorates of Upper Egypt through questionnaires. Decisions concerning the choice of the best-suited communication channels were based on their Reach; Frequency; Managerial feasibility and Effectiveness.

Results: a vast majority of the surveyed wives (96.6%) were married at an age ranging from 15-24 years. The spread of social media through smartphones was limited to only one-third of wives and their husbands through mainly searching on YouTube (31.7% of wives and 27.8% of husbands). Television was the most accessible means of mass media for both wives and husbands (72.5% and 63.3% respectively). The most credible and the best-suited CCs methods for wives were talking with the health promotors and doctors with two times significantly higher (OR= 2.0) than that with the search on YouTube and three times significantly higher (OR = 3.1) than that for social media using browser engine. For husbands, the odds were 1.6 for all.

Conclusions: Despite the availability of recent social media worldwide, rural communities; with high illiteracy, limited access to the internet, and limited availability of smartphones. Interpersonal communication is considered the most effective CCs for achieving equity in reducing child marriage. It seems vital during the implementation of any strategies towards reproductive health to use not only the media broadcasts but also to rely on the channels that are most credible and suitable for the targeted communication to support meeting the unmet need.

Health Economics & Outcomes Research

Infectious Diseases

Health Policy

Child

Adolescent

Marriage

Communication

Channels

credibility

Adolescence is defined as the transition period between childhood and adulthood (between ages 10 and 22 years) although age categories vary among different cultures (1). A recent viewpoint defines the age between 10–24 years as age of adolescence (2).

One third of girls in developing countries are married before the age of 18 and one in nine are married before the age of 15 (3). Though the legal age of marriage has been set at 18 years old since 2008, child marriage is still frequently practiced in Egypt especially in rural communities because the law prohibits but does not criminalize the practice.

Marriage of a young daughter in Egypt allows parents to reduce household expenses and to gain a source of income through the dowry paid to the bride’s family. The percentage of women aged 20 to 24 years who were married before the age of 18 had declined from 19.5 % in 2000 to 16.6 % in 2005, remained steady at 16.6 % from 2005 to 2008 and increased slightly to 17.4 % in 2014 (4). According to the Egypt Census of 2017, child marriage declined with nearly 1 in every 20 girls (5%) between age 15 to 17 years and 1 in every 10 (10%) adolescent girls 15–19 years are either currently married or were married before. Meanwhile, large significant differences were observed between rural and urban residence (5) indicating that child marriage remains an important issue among rural communities.

Early marriage deprives girls of education and employment opportunities and places them at risk of early and repeated pregnancy, gender-based violence (GBV) and sexually transmitted infections (STIs) (6, 7). Moreover, child and adolescent marriage can refrain economic empowerment in Egypt. Women’s opportunity to learn and invade labor market in the future will decrease which can hinder Egyptian economic development, in addition to being a burden as they can experience more complications during pregnancy (8). Moreover, many Egyptian studies concluded that young age at marriage is a cause of education deprivation and acts as a risk factor for child malnutrition and poor development (9–12).

Women living in rural Upper Egypt have less access to high-quality obstetric care, making them about twice as likely to die from pregnancy as women in northern Egypt (13). In 2013, Egypt developed the National Strategic Plan (NSP) for Prevention of Early Marriage, aiming to reduce the prevalence of early marriage by 50% within a five- year timeframe. However, due to the political situation in Egypt, the plan was not implemented because of the sensitive nature of the problem (14, 15). Meanwhile, it is each woman’s right to enjoy healthy reproductive life and improving adolescents’ care seeking behaviors to have healthy children and happy families (16–18), irrespective to the feasibility of implementing NSP for prevention of early marriage.

The achievement of the global Sustainable Development Goals (SDGs) that are needed for the realization of the national development priorities requires that the beneficiaries and communities are informed about and engaged in the issues that most affect them. Moreover, empowering their decision-makers with knowledge to influence their decisions and improve their lives is necessary. Mass media is one of the popular and cost-effective global public health promotion tools (19) as well local one (18). Mass media (including radio, television, newspapers, magazines, leaflets, posters, and pamphlets) is proved to influence the use of health services.

In response to these findings, it was important to access our target audience and their direct influential decision makers and to dig deeper for identifying the most favorite and credible CCs that are essential for success of strategies needed for effective reproductive health promotion (RHP) for women in general and future adolescents’ mothers.

The idea of the present study raised from the belief that any change requires recognizing the voices of those who would be targeted by the development of this change. The realization of equity in health through reducing child and adolescent marriage as a national development priority requires suitable strategies to achieve social movement. For achieving this, our study aimed at assessing the suitable channels of communication that could be used in the future as cost-effective channels helping in changing the behaviors of the target population and achieving development.

Study Design

This study was a community based cross sectional systematic formative research. The study was conducted over a period of two years through formative quantitative assessment research for communication channels.

Setting

Poverty is heavily concentrated in the Upper Rural region of Egypt, where 63.5 % of individuals are poor. This study was conducted in 21 villages of two of the governorates of Upper Egypt which ranked low in socioeconomic standard and high in maternal mortality, namely, Benisuef and Fayoum governorates, which were ranked as the second and the third poorest governorates respectively (20).

Participants

Two groups were targeted through this study, the first was the direct beneficiaries of reproductive health promotion interventions. Targeted women were ever married women in childbearing period aged 15–49 years within the targeted villages in the selected governorates.

The second was the direct beneficiaries’ husbands who were the main decision makers. In the present study, most women mentioned that they followed the beliefs of their husbands for all the life decisions and even for health promotion related issues based on group discussion with the participants. Accordingly, women and their husbands were considered as the priority target groups for the study.

Variables/data sources and measurements

Quantitative data was obtained through a designed standardized questionnaire that was constructed to determine favorite channels for communication out of the traditional mass media, modern social media and interpersonal communication. The questionnaire included data about the age of wife and husband at first marriage, background information for the education level of the woman and her husband, and their employment status. Decisions concerning the choice of these media were based on reach; what proportion of the target group is exposed to the media? Frequency: how often is the target group exposed to the media? Managerial feasibility: will it be possible for the future interventions to manage the use of the three most exposed media over time? and Effectiveness; what are the most credible information sources, the best-suited communication channels methods, and means to reach the target group? The questionnaire was designed according to UNICEF guidelines 2008, 1999a & b, and World Bank 2003 (21–25), with some modifications including the addition of social media as modern channel of communication.

The main questionnaire was subjected to pilot testing after its modification on women at their childbearing period attending the rural health units in the same villages that were targeted in Benisuef and Fayoum governorates (50 women from each governorate). Data from these women were not included in the analysis. The pilot test was performed aiming at testing feasibility of the study implementation and assessing the validation of the prepared questionnaire, and its internal consistencies. Based on pilot test, some modifications were done to the questionnaire. Data collection were conducted by a research team from National Research Centre of Egypt.

Sample technique and size

Sampling: Two-stage random sampling was used; households were randomly selected from the targeted villages in the selected governorates, and then one ever married woman during her childbearing period aged 15–49 years was randomly selected from each household. Selection of the targeted participants was selected after obtaining the map of each village to cover the catchment areas of the targeted 21 villages.

Sampling was conducted to meet the division of reproductive health’s standards (DRH) at the center for disease control and prevention of point estimates within +/- 3.5 % (two-sided width = .07) of the true population prevalence, with 95% confidence and estimated response rate of 80%. Accordingly, a sample size of 810 produces a two-sided 95% confidence interval with a width equal to 0.07, when the sample proportion is 0.5 (26, 27).

The exact sample size was (810 + 20 % losses) = 972 which was rounded up to 1000. The households were selected randomly. 1000 childbearing women (aged 15–49) and 1000 of their husbands completed the survey.

Quantitative Variables and Statistical Methods

All completed questionnaire forms were entered in the computer. Statistical Package of Social Science Software program (SPSS), version 18 was used for statistical analyses. Descriptive statistics such as mean, Standard deviation, frequency and percentage were used for data summarization. The analysis was done using, t test between means, chi-square test and Z-test between proportions. P-value was considered statistically significant when P < 0.05 and considered statistically highly significant if P < 0.01 (28).

The study segmented the surveyed women and their husbands regarding their demographic characteristics. Table 1 shows that more than half of the surveyed women (63.7%) were less than 25 years old which lies in the adolescent age versus one third of their husbands (30.1 %) with a mean age of 23.9 ± 5.8 for wives versus 31.2 ± 8.4 for husbands with statistically significant difference (p < 0.001). As regards the age at the first marriage, it was noticed that almost two thirds of women (69.5 %) and one third of husbands (40.7 %) married at an age less than 19 years with statistically significant difference (p < 0.001). Moreover, most surveyed women (96.6%) were married at an age ranging from 15–24 years versus 83.4% of husbands, which lies in the adolescent age.

Table 1

Segmentation of the surveyed women and their husbands according to their demographic characteristics, Upper Egypt
Characteristics	Total Wives (No = 1000)		Total Husbands (No = 1000)
Characteristics	No	%	No	%
Current age: 15-<19 19-< 25 25-<30 30-<35 35- <40 40–49	244 393 189 98 58 18	24.4 39.3@** 18.9 9.8 5.8 1.8	25 276 111 412 131 45	2.5 27.6 11.1 41.2@* 13.1 4.5
P value of X² (Significance)	< 0.001**
Mean current age# (range)	23.89 ± 5.8 (17–40)		31.2 ± 8.4 (21–45)
Age at first marriage < 15 15-<19 19-<25 ≥ 25	37 658 271 34	3.7 65.8@ 27.1 3.4	36 371 427 166	3.6 37.1 42.7@ 16.6
P value of X2 (Significance)	< 0.001**
Mean age at first marriage#	19 ± 3.0 (16–22)		25.6 ± 4.9 (15–30)
Education @ 1. Illiterate 2. Read and write/primary 3. Preparatory 4. Secondary or equivalent (technical-vocational) 5. University or more	403 152 101 307 37	40.3@** 15.2 10.1 30.7 3.7	206 176 223 372 23	20.6 17.6 22.3 37.2@* 2.3
P value of X² (Significance) <0.001**
Wife employment@ 1. Employed 2. Unemployed	41 959	4.1 95.9*	873 127	87.3 12.7**
P value of X² (Significance) <0.001**
Type of husbands' employment: 1.Owner of a business 2.Professional work (employee, engineer, teacher) 3.Labor work (craftsman, builder) 4.Others( unemployed, student, pensioner)			110 171 592 127	11.0 17.1 59.2@** 12.7
Type of residence immediately after marriage 1. In a house alone with her husband 2. With her parents or one of them 3. With her husband's parents or one of them 4. With relatives			315 91 481 113	31.5 9.1 48.1@** 11.3
N.B. ** = highly significant statistical difference, * = significant statistical difference, # t between means, @ z test between proportions (significance between the highest proportion and others).

Forty percent of surveyed wives were illiterate versus 20.6% of their husbands followed by 30.7% and 37.2 % had secondary or equivalent education for wives and husbands respectively with statistically significant difference between their pattern of distribution (p < 0.001). The great majority of studied women (about 96%) were housewives while about 60% of their husbands had paid work as craftsmen or builders. About half of families included in the survey groups lived with the husband’s parents or one of them. On the other hand, about one third of wives had their house alone with their husbands.

TV was the most accessible mean of mass media for both husbands and wives (92.7 %) followed by reading then the radio. The least accessibility was to android mobiles (31.7% of wives and 34.3% of husbands with insignificant difference between them followed by computers and/or laptops (24.0%). When comparing the frequency of exposure of wives to their husbands, wives were significantly more exposed to both watching TV (72.5% versus 63.3%) and to reading (31.3% versus 18.4%) with statistically significant difference between them (p of z test < 0.05). Whereas exposure to the android mobiles was the same for both wives and husbands, the exposure to computers and/or laptops was limited to a small percentage (18.2% of husbands and 10.5% of wives). When comparing the exposure to traditional media versus modern social media, the exposure of wives and husbands to Television were nearly six and five times than that to the android mobiles (OR = 5.6 and 4.7 respectively) with high statistical significance. On the contrary, exposure to reading and android mobiles was nearly equal among wives (OR = 0.9) and insignificantly lower among husbands (OR = 0.6). Reading sources included newspapers and magazines. Meanwhile, for both wives and husbands, the exposure to Radio were equally significantly less than that of the android mobiles (OR = 0.3 (Table 2).

Table 2

Reach (accessibility) and Frequency of the exposure to mass media and social media Channels
Channels	Wives N = 1000 no (%)	Husbands N = 1000 no (%)
1) Accessibility to Media
1.1 Reach to Traditional Mass Media
• Availability of T.V	920 (92.7)
• Reading (Newspapers/ Magazines/ Booklets/Posters)@	565 (56.7)	774 (77.4) **
• Radio	326 (32.6)
1.2 Reach to Social Media
• Mobiles@	890 (89.7)	986 (98.6) **
• Availability of Android mobiles@	317(31.7)	343(34.3)
P value of X² (Significance)
• Computer and/ or lap top	240(24.0)
2) Frequency of Exposure to Media
2.1 Frequency of exposure to Traditional Mass Media
• T.V@	725 (72.5)	633(63.3) **
• Reading (Newspapers/ Magazines/ Booklets/Posters)@	313 (31.3)	184 (18.4) **
• Radio@	140 (14.0)	126 (12.6)
P value of X² (Significance)
2.2 Frequency of exposure to Social Media
• Functioning Mobiles@	890 (89.7)	986 (98.6) **
• Android mobiles@	317(31.7)	266 (26.6)
• Computer and/ or lap top@	105(10.5)	182 (18.2) **
P value of X² (Significance)
Odds of Exposure
• OR (95%CI) for exposure to TV vs android mobiles@	5.6(4.6–6.8) **	4.7(3.9–5.7) **
• OR (95%CI) for exposure to reading vs android mobiles@	0.9(0.8–1.1)	0.6(0.5–0.7) **
• OR (95%CI) for exposure to radio vs android mobiles@	0.3(0.2–0.4) **	0.3(0.3–0.5) **
Odds Ratio = OR, @ z test between proportions, * P Value < 0.05, **P Value < 0.001

Assessing the managerial feasibility found that 81.5% of wives and 74.2% of husbands who watched TV spent less than 3 hours /day with significant difference between wives and their husbands. Meanwhile, half of the wives and their husbands (48.5 % versus 47.0 % respectively) spent > 5 hours/day on android mobiles for the use of the social media with insignificant difference. For reading there is insignificant preferences for both wives and their husbands (Table 3). Among both husbands and wives who watched TV, satellite channels were much more preferred than local channels with significant statistical difference between them (p < 0.05) (Fig. 1). The most favorite programs through which messages could be received by wives and husbands were drama and series (48.4% and 85.6 % respectively) followed by cooking programs for wives (32.6 %) and specialized programs (talk show) (65.1%) for husbands with highly significant difference between the wives and their husbands concerning the preference of the favorite programs (< 0.001) (Fig. 2).

Table 3

Managerial feasibility of the three most exposed mass and social media among target audience, Upper Egypt (time of watching TV or using social media)
Favorite Channels Ʊ	Wives No (%)	Husbands No (%)	P value of z test
Watching TV	No = 725	No = 633
Less than 3 hours/day	591 (81.5)	470 (74.2)*	< 0.05*
3–5 hours/day	86 (11.9)	94 (14.8)	< 0.05*
> 5 hours/day	48 (6.6)	69 (11.0)	< 0.001**
P value of X² (Significance)
Exposure to Social Media on Mobiles	No = 317	No = 266
Less than 3 hours/day	130 (41.1)	87 (32.7)	< 0.001**
3–5 hours/day	33(10.4)	54 (20.3)	< 0.001**
> 5 hours/day	154 (48.5)	125 (47.0)	> 0.05
P value of X² (Significance)
Reading	No = 313	No = 184
Once a month	82 (26.2)	41 (22.3)	< 0.001**
Once a week	96 (30.7)	49 (26.6)	< 0.05*
2–3 times a week	32(10.2)	18 (9.8)	> 0.05
Almost every day	58 (18.5)	38 (20.7)	> 0.05
Once per day or more	11 (3.5)	14 (7.6)	< 0.001**
Irregular	34 (10.9)	24 (13.0)	> 0.05
P value of X² (Significance)
Ʊ calculated out of the most exposed channel, * P Value < 0.05 **P Value < 0.001

Assessment of the effectiveness for the most credible information sources and the best-suited CCs methods and means to reach the target groups was shown in Table 4. The assessment revealed that the most credible sources of information for receiving messages by most husbands and wives were interpersonal communication with health promoters (39.3% for husbands and 49.1% for wives, (p < 0.05) followed by doctors (48.7% of wives), and nurses (35.5% of husbands) with significant difference between wives and their husbands (p < 0.05). A high percentage of the target group expressed their desire to receive messages through direct talk with doctors (58% of husbands and 65.3% of wives) or with health promoter (44.2% of husbands and 57% of wives), with significant difference (p < 0.001). TV (as a traditional channel) followed by YouTube videos was the second source (38.3% & 27.8 % for husbands and 42.6% & 31.7 % for wives respectively (p > 0.05). The third most desirable channel was messaging with friends/relatives/ neighbors through “Whats app” application (27.3% of husbands and 30.7% of wives) with insignificant difference. Furthermore, for wives, talk with doctors or health promotors was two times significantly higher as the most credible and favorite channels than that with search on you tube (OR = 2.0 & OR = 2 respectively) and three times higher than that for social media using browser engine (OR = 3.1 for each). For husbands, the odds were nearly one and half for all (Table 4). The second most credible and favorite channels for both wives and husbands were TV which carry more than one and half times significantly higher incidence than that with search on you tube (OR = 1.5 & 1.6 respectively) or social media (OR = 2.4 & OR = 1.5 respectively).

Table 4

Listing of channels through which messages for reproductive health promotion were received by target audience (most credible information source versus the most favorite), Upper Egypt
Channels	Wives N = 1000 No(%)		Husbands N = 1000 No(%)
Channels	Most credible	Most favorite	Most credible	Most favorite
Social Media
• Search on YouTube@	317(31.7)	317(31.7)	278 (27.8)	268 (26.8)
• messaging with friends/relatives/ neighbors through whatsApp@	132 (13.2)	307(30.7) **	113(11.3)	273(27.3) **
• Social media through Facebook group and /or twitter@	233 (23.3)	192(19.2) *	285 (28.5)	314 (31.4)
• Search through search browser engine (e.g Google, Microsoft edge…etc) @	10(1.0)	70(7.0) **	35(3.5)	85(8.5) **
Traditional Mass Media
• T.V@	426(42.6)	74(7.4) **	383(38.3)	163(16.3) **
• Newspapers/ Magazines/ Booklets/Posters@	104(10.4)	537(53.7) **	99(9.9)	545(54.5) **
• Radio@	91(9.1)	90(9.0)	66 (6.6)	101(10.1) *
OR (95%CI) for TV vs search on You Tube	1.5(1.3–1.9) **		1.6(1.3–1.9) **
OR (95%CI) for TV vs search on social media	2.4(2.0-2.9) **		1.5(1.2–1.8) **
Interpersonal communication
• Religious leaders@	150(15.0)	246(24.6) **	181(18.1)	316(31.6) **
• Talk with partner@	257(25.7)	279(27.9)	241(24.1)	292(29.2) *
• Talk with Doctors@	487(48.7)	653(65.3) **	348(34.8)	580(58.0) **
OR (95%CI) for Talk with the doctor vs search on You Tube	2.0(1.7–2.4) **		1.3(1.1–1.6) **
OR (95%CI) for Talk with the doctor vs search using browser engine	3.1(2.5–3.7) **		1.3(1.1–1.6) **
• Talk with Nurses@	417(41.7)	498(49.8) *	355(35.5)	446(44.6) **
OR (95%CI) for Talk with the nurse vs search on You Tube	1.5(1.2–1.8) **		1.4(1.1–1.7) **
OR (95%CI) for Talk with the nurse vs search using browser engine	2.3(1.9–2.8) **		1.3(1.1–1.6) **
• Talk with Health Promoters (HPs) @	491(49.1)	570(57.0) *	393(39.3)	442(44.2) *
OR (95%CI) for Talk with the health promoter vs search on You Tube	2.0(1.7–2.4) **		1.6(1.3-2.0) **
OR (95%CI) for Talk with the health promoter vs search using browser engine	3.1(2.6–3.8) **		1.6(1.3–1.9) **
@ z test between proportions ,* P Value < 0.05, **P Value < 0.001

Reproductive health promotion messages that were most received by the target group were those about risky pregnancy (58.6 % of wives and 48.7 % of husbands) and family planning (31.6% of husbands and 51.6% of wives). Statistically significant difference was observed for all the messages received in favor of wives except the messages related to reproductive tract infection (Table 5).

Table 5

Messages for reproductive health promotion received by husbands and wives, Upper Egypt as reported by participants
Channels	Wives N = 1000 No(%)	Husbands N = 1000 No(%)	P value of z test
Pregnancy and labor and their risks including risk of abortion	586(58.6)	487(48.7)	< 0.001**
Messages about family planning and spacing	516(51.6)	316(31.6)	< 0.001**
Messages about antenatal care, and safe delivery	456(45.6)	75(7.5)	< 0.001**
Reproductive tract infection health education messages	286(28.6)	275(27.5)	> 0.05
Guidelines to safe delivery	32(3.2)	52(5.2)	< 0.05*
* P Value < 0.05 **P Value < 0.001

Important decisions in our lives are not necessarily made by the right, the best or the smartest person but rather by the person who has the power to make that decision especially in young age groups where individuals cannot give consent as in adolescence. Decision makers in any society are a key group that must be targeted and approached due to their direct influence on changing the beliefs and awareness of people living in that society. Many wives in the current study reported that they follow the beliefs of their husbands for all life decisions and even for health promotion related issues. Meanwhile, in rural communities, refusal of husbands was reported by many wives to be the most common barrier to their referral to health services (17, 18, 29). Moreover, the target audience whose behaviors need to be changed the most may not be the direct beneficiaries from the messages. Often, it is -the "influencers"- the people who influence direct beneficiaries’ behaviors- that most need to be informed and to change their concerns and practices.

Targeting the influencers will guarantee effective communication that is needed to affect the environment in which healthy behaviors are requested for adoption, promotion, and sustainability. Based on all the above findings and facts, women and their husbands were considered as the priority target groups for the current study.

The Survey of Young People in Egypt (SYPE) 2014, revealed that 21.1% of married female youth aged 25–29 years were married before the age of 18, and 33.3% of young women residing in rural Upper Egypt were also reported to be married before 18 (6). Accordingly, one of main causes were that female participants in our study let their husbands take the decisions was that many of them were in the adolescent period (63.7 %) or being first married in that period (96.6 %), which is a critical and transitional period where adolescents cannot yet make their own decisions.

In the field of health, substantial evidence shows that people are willing to change their health behavior irrespective to the health condition. It is therefore important to identify channels of communications through which health promotion (HP) messages that contribute in promotion of reproductive health should be disseminated to the specific target audience. Nowadays, health care messages including reproductive health, are increasingly being delivered through digital channels such as the internet, mobile phone messaging, social media, apps, voice/ video messaging, and telemedicine. These ways have proven to be effective in developed countries, yet in developing countries many barriers such as infrastructure, lack of equipment, and technology gap hinder their successful implementation (29–32).

In the current study, the internet was not a first choice for the participants as a source of reproductive health information as only one third of them had access to android phones. Interpersonal communication appeared to be the most credible source of information and the most favorite channel through which reproductive health promotion messages could be received by target audience. Talking with health promoter (39.3% for husbands and 49.1% for wives) and talking with doctors (48.7% of wives) came as the most important means for both wives and husbands followed by TV (42.6 % of wives and 38.3 % of husbands). This result is like that of many previous old and recent studies as well, who assessed the effectiveness of broadcasted media versus interpersonal channels in delivering health messages to the public (33–38). They reported that in low and moderate socioeconomic societies, interpersonal communication serves as primary health information sources for health- oriented individuals with strong health beliefs and commitment to healthy activities, while passive consumption channels such like television and radio serve as primary health information sources for individuals in low socioeconomic societies and who are not health-oriented. Unfortunately, neither one of these studies assessed the reach, frequency, managerial feasibility nor the effectiveness of the recent social media channels versus the traditional ones as tool for health promotion.

In the present study, on investigating the channels of communication through which reproductive health promotion messages could be disseminated, the percentages of wives who had accessibility to TV, radio and reading media were 72.5%, 14 % and 31.3 % respectively, while for the husbands the percentages were 63.3%, 12.6 %, and 18.4% respectively. This indicates more accessibility of wives and their husbands to TV as a main source for health information within Egyptian families. TV serials have been proven as a very successful means of ‘edutainment” as well.’ They usually convey a particular theme which can possibly influence viewers’ behavior (39–41).

Assessing the managerial feasibility will help in the identity of the possibilities to be targeted for any future interventions depending on the exposure over time through detecting the top three types of media and platforms to which the target audience were most exposed. The current study found Television stations as key partners in disseminating messages for promoting public health. The current study revealed that the more than three quarters of wives (81.5%) and husbands (74.2%) spent less than 3 hours per day watching televisions watching drama and series (48.4% and 85.6 % respectively). This finding was in accordance with an old study dated 1999 that was done by the National Research Council (US) and Institute of Medicine (US) Board on children, youth, and families (42), indicating that the situation still the same in rural communities despite of the nowadays widespread of the social media. Whereas only half of those reported to have android mobiles spent up to five hours per day on android mobiles. This finding indicate that future programs should rely on mass media rather than social media for the large and broad campaigns to target rural communities. An example in Egypt that is proved to be successful one with the use of mass media is a soap opera called “The Family House” which reached out to millions of Egyptians with health messages on issues such as AIDS, drugs, child spacing, home accidents, and hygiene (43, 44). Another example is a soap opera on the South African television that was run by public health activists over 70% of the population addressing, from HIV and AIDS to rape (45).

For wives, talk with doctors or health promotors was two times significantly higher as the most credible information sources and the best-suited CCs methods than that with search on you tube (OR = 2.0 & OR = 2 respectively) and three times higher than that for social media using browser engine (OR = 3.1 for each). For husbands the odds were nearly one and half for all. This was in accordance with many Egyptian studies which have achieved their goals for improving behaviors for many health-related diseases and issues with the aid of the health promotors, community leaders or health care workers; e.g reduction of maternal mortality (17, 18, 46, 47), improving environmental health (48, 49), alleviating children anemia (50), counteracting barriers against diabetes (51), and accelerating HCV elimination (52–54). These studies are mainly community-based studies in rural communities respecting the culture and believes within their communities. Other Egyptian studies that relay on the nurses and physician for facility-based studies addressing a number of health issues from improvement of cognitive function (55), children nutritional habits (56–58), improving response of HBV among children (59–60) and improving compliance with hemodialysis patients (61–62). All these health communication programs were proved to be helping aid for people make these changes especially for rural communities of Egypt by using the most credible and favorite channels.

Application of cost-effective strategies for tackling rural health problems required CCs assessment to identify the on-ground situation to meet the unmet need for not only the problem of child and adolescent marriage but for facing any health problem. Despite the availability of recent social media worldwide, what worked worldwide was not the situation for rural communities, with high illiteracy, limited access to the internet, and limited availability of smartphones. For rural communities and with the widespread of many health problems, the most credible information sources and the best-suited CCs methods for delivering reproductive health messages are interpersonal communication through health promoters followed by doctors and nurses. Television, being the most favored and most accessible mass media channel, play important roles in terms of conveying information, stimulating thought, informing, and developing ideal behavior.

Recommendations

It seems vital during the implementation of any preset strategies for reproductive health to use not only the media broadcasts to promote reproductive health but also to rely on the channels that are most credible and suitable for the targeted communication. For rural communities in special, the used media must be embedded in the settings in which people live through the health promoters in the community setting and by professionals in clinics rather than being delivered through social media. These types of efforts would improve women's and men's abilities to meet their childbearing goals and empower country directions towards fulfillment of the global sustainable development goals to ensure equality by 2030.

Strengths of the study:

The current study serves as an exemplary model for facilitating the implementation of the national strategies for RHP mainly in rural communities and support meeting the unmet need. The study did not only assess the availability and accessibility of different CCs but assess their managerial feasibility and credibility as a crucial step for limiting child and adolescents’ marriage.

With the still high adolescents’ marriage in rural communities of Egypt, this study reports on the problem situation from the holistic point of view and did not dig deeper into linking wives and husbands’ characteristics to the use of channels type as it is well known that the use of social media is highly linked with education level and young age.

Limitation of the study

The study was limited to study only the beneficiaries, without evaluating the impact of CCs use on the reduction of child and adolescent marriage.

Consent to publish

Not Applicable.

Availability of data and materials

The datasets used and/or analyzed concerning the current study are not publicly available due to the privacy of the studied women and their husbands as any topic related to reproductive health in rural communities is considered taboo. Meanwhile, all data of the current study are available from the corresponding author on reasonable request.

Competing interest

The authors declare no conflict of interest.

Funding

This study was supported financially by the Science and Technology Development Fund (STDF), Egypt, Grant No 358.

Ethics approval and consent to participate

The study complied with the International Ethical Guidelines for Biomedical Research Involving Human Subjects (63). Medical Research Ethical Committee - National Research Centre of Egypt has cleared the study protocol with ethical approval registration number 10140. Informed written consent was obtained from all participants involved in the study. Information obtained at the individual level was kept strictly confidential. A worthy note to mention that although the study was looking for the child marriage with the age of both wives and their husbands less than 18 years, yet the actual current age of the surveyed women and their husbands were in the age range (17-40 years) and (21-45 years) respectively. All participants were above the age of 16 at the time of their enrollment for the study. Accordingly, there were no need for their parents/guardians consent on their behalf.

Authors’ contributions

AMM conceived and designed the study. RMS, MHA, DME, AM, AHE, HAA, SME, GAA, MME, HMH, MAA, HMH, SS, SS, HE, SIS, IIS conducted the field work and data collection. AMM, NAI, AMA, WAF oversaw the implementation. HMH, MAA, HMH, SS, SS provided clinical examination for all adolescents during the clinical conveys during conduction of the field work. RMS, AM, DME and SIS did the statistical analyses. RMS, DME, MME shared in the interpretation of the results. RMS drafted the manuscript. AMM & LEE reviewed the manuscript. AMM & MHA submitted the manuscript. All authors reviewed the manuscript and approved the final version.

Acknowledgment

The authors express their appreciation to the funding agency, all women, and their husbands for their willing in participation and cooperation.

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Assessing the Credibility of Best Suited Communication Channels in Rural Communities for Meeting the Unmet Need Towards Reducing Child and Adolescent Marriage: a Model From Upper Egypt

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