Mapping the Reproductive Health Communication Landscape: A State-of-the-art Review

Background: Reproductive health communication encompasses family planning, maternal, neonatal and child health, and sexual and reproductive health communications for adolescents and youth as fundamental elements for intervention. The objective of this study was to summarize, examine, and identify gaps in the theoretical, methodological, empirical, and measurement literature on reproductive health communication as it relates to Ethiopia. Methods: A systematic search was conducted using electronic databases such as the Medical Literature Analysis and Retrieval System (MEDLINE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Psychological Information (PsychINFO), and Google Scholar to locate theoretic, psychometric, and empirical literature on reproductive health communication. Results: Local literature identified by the databases were mainly based on crosssectional designs, had small sample size and lacked essential psychometric protocols. Results showed that most studies replicatively focused on spousal communication centering reproductive choices and decisions. A common strategy was to use student populations as data sources limiting the generalizability of findings. Conclusion: The need for more diverse designs and areas of investigation using better instrumentation is indicated.


Introduction
Globally, reproductive health communication has taken a center stage in a broad array of topics that concern individual, family, and community well-being, subsuming important areas such as health informatics, client-provider interchanges, cross-cultural medical encounters in reproductive realms, sexuality, interagency cooperative communications among reproductive health institutions, program support services, reproductive healthcare marketing, reproductive health promotion services, and mediated national policy and practice discourses on key reproductive topics [1][2][3].
In addition, reproductive health is taken as encompassing seven domains that include physical health, psychological well-being, physical functioning, sexual health, vigor and vitality, cognitive functioning, and pain and discomfort. Further categorization includes adolescent health; child health; maternal, fetal, and perinatal health; population and health; and women's sexual and reproductive health [4,5].
While the definitional core typically includes gynecological, obstetric, contraceptive well-being and functioning, more standardized definitions address more domains.
The research challenge nevertheless is how reproductive health communication has addressed these fundamental issues requiring self-management as well as more institutionalized care.
The use of mass communication technologies has been the core of reproductive health communication, especially those called legacy media such as broadcast modalities including radio and TV as well as print-based media interventions. A meta-analytic study of the period between 2005 and 2015 covering 31 countries of Saharan African found that exposure to mass media family planning communication campaigns indeed had a modest effect [6].
Traditional media/legacy media, and more recently digital affordances, have been a significant asset in reproductive communication given their efficiency as mass communicators and their ability to affect behavior and induce change in particular reference to reproductive health and family planning programs at the national level [7,8]. Media can set the national agenda highlighting certain topics such as reproductive health as national priorities. What this means is that they induce national conversation on the subject and help to involve important stakeholders to grapple with the issues identified as particularly salient. The impact is on creating more behavior change communication at the interpersonal, familial, group, and intergroup levels [9]. This change can be further aided via spiritual communication, workplace, school, and neighborhood conversations demonstrating the triple effect of mass media communications on reproductive health.
There have been several projects in Africa and elsewhere in the developing world involving the use of mHealth for reproductive health promotion [11]. A global survey showed that while mHealth for reproductive communication is widespread, the developing world has yet to catch-up. Of the 17 projects surveyed involving mHealth for SRH, two were from Ethiopia involving Marie Stopes and Pathfinder Ethiopia on contraceptives, family planning, and HIV AIDS issues [12]. In several other studies, cellphones have been considered as ideal for addressing youth in SRH promotion because they are closer to technology than other groups in addition to being cost-effective and efficient [13].
The technology in use helps address security and confidentiality concerns in

Results
A significant focus in recent scholarship has been on measurement issues and theorizing in reproductive health communication. There is also a limited but growing field studies literature on the subject.

Measurement of reproductive health communication
Measurement is vital to gauge the quality of communication and information services in medical settings and to determine the impact of any overhaul and attendant communication design changes as part of a major strategy to improve patient experience. Measures are also important to benchmark in order to compare the future measures with. Patient trust, hospital and doctor reputation, client's word of mouth can be elevated using strategic communication that is systematically planned and evaluated. The measures that tap the patient perspective can be modified or translated as may be necessary to suit local contexts but it is important that the necessary validation is done expertly before these foreign-origin inventories and scales are deployed [18,19] in areas such as family planning [20,22]. Instrument development has covered in more specific terms: decision-making [23], Sexual Coercion in Intimate Relationships Scale [24], attitudes toward gender norms (GEM Scale) [25], Reproductive Autonomy Scale [26], Sexual Relationship Power Scale [27], Sexual Assertiveness Scale [28], Revised Conflict Tactics Scale [29], The Quality of Marriage Index (QMI) [30].

Theorizing reproductive health communication
In healthcare settings, communication may be defined as a verbal and nonverbal transaction that is a purpose-driven, targeted process with intended behavioral modification outcomes expressed in terms of the adoption of healthy behaviors and lifestyles.
In theoretical terms, communication can be complex due to the fluidity of its constituent elements as well as the dynamic character of interchanges, yet it can be planned and measured. The human agency in morbidity and mortality is well-documented and behavior which can be modified using strategies of communication is center stage as the subject of interventions using principles and theories that delineate human health behavior. Thus, theory-based communication interventions are believed to make a significant difference in wellness and illness. The use of appropriate theory in health communication planning and intervention helps several functions that include description, explanation, and prediction as well as diagnosis and measurement of potential outcomes for instance in the matter of reproductive and sexual health. A growing body of evidence indicates that theoretically informed health interventions including those aimed at reproductive health promotion are highly likely to meet goals they set out to achieve [31].
Several theories underpin reproductive health promotion and the pathways to outcomes. A common observation is that interventions are not theory-driven [32], which does hamper conceptually driven goals, inputs, processes, and measurement of evidence. For instance, a study found that safe sex messages in reproductive health leaflets did not target cognitive and behavioral issues and were in consequence of limited strategic utility in regard to condom use promotion [33]. Optimal outcomes require a careful consideration of theoretical insights and conceptually-driven health messages [34].
These may be typologized broadly as intrapersonal (Transtheoretical Model-Stages of Change, Theory of Planned Behavior, Health Belief Model, Protection Motivation Theory), interpersonal (social cognition), community level (ecological models), and other (e.g., Diffusion of Innovations Theory) [35]. Reproductive health promotion has employed a diverse set of these health communication theories but the most commonly used are limited. Several reviews of these have addressed the major conceptual underpinnings [36,38].

Field studies
The international empirical literature on reproductive health communication is varied and vast. However, the use of theory-to-guide communication interventions seems to be rather limited. There is also the tendency to depend entirely or mostly on questionnaires with the worst part being that the questionnaires used were unstandardized, unpiloted whose psychometric properties were highly questionable.
Local studies also tended to be replicative and the focus of the majority of the studies was adolescent child-parent communication with regard to reproductive and sexual issues. Findings typically mentioned the cultural factor as an impediment to more fruitful sexual communication at the household level but comparison across studies would be complicated because of the differences in instrumentation. Further reports of psychometric properties of instruments in local studies are rare. Thus, we do not know how valid or reliable the measures in use are which leads to questioning the utility of findings reported. However, there were also large-scale studies that showed media had a significant impact on reproductive services use in both urban and rural settings [39].
However, the studies failed to disaggregate impact by media type, that is, broadcast versus print media, limiting the study's utility.
Another study of spousal communication centering on reproductive decisions was reported as involving a significant percentage (60 %) of change effects in shared decision-making in Ethiopia's Amhara region [40]. The significance of the broadcast media is demonstrated in an Ethiopian study based in Addis Ababa which reports that the typical woman receives her family planning information from radio and television [41]. Another Ethiopian study employing a quasi-experimental study design reported that men in the treatment group had significantly higher levels of readiness for family communication on reproductive issues than the control group [42]. However, issues of lack of statistical sophistication and the necessary controls are disturbing. For instance, sample size and effect size considerations are not worked out with regard to issues of precision.
Considering that they were commissioned, campaign evaluation studies seemed to [11] Ippoliti, N. B. and L'Engle, K. (2017). Meet us on the phone: mobile phone programs for adolescent sexual and reproductive health in low-to-middle income countries.