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From established working groups to cross-cutting caucuses, regional forms or discussion groups - these are the vehicles through which Coalition members collaborate.

WHO How to improve the use of medicines by consumers

Publication date: 2007

i (OW�TO�IMPROVE�THE�USE�OF� MEDICINES�BY�CONSUMERS Andrew Chetley Healthlink Worldwide Anita Hardon University of Amsterdam Catherine Hodgkin Royal Tropical Institute, the Netherlands Ane Haaland Communications specialist Daphne Fresle Specialist in public health WHO/PSM/PAR/2007.2 © World Health Organization 2007 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: permissions@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of speciﬁc companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication. Illustrations editor: Ane Haaland Cover illustration by Victoria Francis Designed by minimum graphics Printed in Switzerland This document has been produced with the ﬁnancial assistance of the European Community. The views expressed herein are those of the authors and and can therefore in no way be taken to reﬂect the ofﬁcial opinion of the European Community. iii #ONTENTS Acknowledgements v Abbreviations vi Credits for graphics vii Section 1. Introduction 1 Chapter 1. How communication works 9 Section 2. Communication methods 23 Chapter 2. Face-to-face communication 34 Chapter 3. Drama and other folk media 53 Chapter 4. Developing effective print materials 67 Chapter 5. Mass media 86 Section 3. Strategies for developing an enabling environment 105 Chapter 6. Working with journalists 115 Chapter 7. Advocacy and networking 127 Chapter 8. Managerial and regulatory strategies 144 Section 4. Bringing it all together 157 Chapter 9. Planning the process 161 Chapter 10. Pretesting 174 Chapter 11. Monitoring and evaluation 192 Chapter 12. Conclusions 213 Annexes 223 Annex 1. Bibliography 225 Annex 2. Useful links 234 Annex 3. Boxes, tables and ﬁgures 243 #/.4%.43 v !#+./7,%$'%-%.43 !CKNOWLEDGEMENTS Thanks to Trudie Gerrits, University of Amsterdam, Ayyaz Kiani, TheNetwork, Pakistan, Benoit Marchand, Acción Internacional por la Salud, Nicaragua, Richard Laing and Kath Hurst of the WHO Department of Medicines Policy and Standards who commented on the various drafts of this manual and helped to improve it. Thanks also to the many participants and trainers involved in the international Promoting Rational Drug Use in the Community (PRDUC) courses that have been held in Thailand, Uganda and South Africa and the national courses held in India and Nicaragua since 2000. This manual builds on course material developed dur- ing that time and the feedback from the courses. (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 vi !BBREVIATIONS AIDS Acquired immune deﬁciency syndrome ANM Auxiliary nurse midwives ARVs Antiretrovirals BCC Behaviour change communication CBIA Cara Belajor Ibu Aktif (Mothers’ Active Learning Method), Indonesia CHS Commune health station DOT Directly observed treatment DOTS Directly observed treatment short-course DSPRUD Delhi Society for the Promotion of the Rational Use of Drugs (India) EE Entertainment-education EHCN European Health Communication Network FGD Focus group discussion HAI Health Action International HIV Human inmmunodeﬁciency virus IDD Iodine deﬁciency disorder IEC Information, education and communication IGD Interactional group discussion IMCI Integrated management of childhood illness ITN Insecticide treated bednet MOH Ministry of Health MSC Most signiﬁcant change MSF Médecins Sans Frontières MTCT Mother-to-child transmission NGO Nongovernmental organization ORS Oral rehydration solution ORT Oral rehydration therapy OTC Over-the-counter PATH Program for Appropriate Technology in Health (USA) PHT Public health technician PM&E Participatory monitoring and evaluation PRDUC Promoting rational drug use in the community PSAT Cell phone prompted self administered therapy STG Standard treatment guidelines SSRI Selective serotonin re-uptake inhibitors STIs Sexually transmitted infections TDR Special Programme for Research and Training in Tropical Diseases UNDP United Nations Development Programme VHW Village health worker WHO World Health Organization YVS Youth variety show vii #REDITS�FOR�GRAPHICS #2%$)43 Haaland A, Molyneux C (2006). Quality information in ﬁeld research. WHO/TDR. Artist: Bosco Kahindi. Drawings on pages: 3, 10, 11, 12, 16, 17, 18, 27, 29, 32, 34, 48, 61, 62, 70, 81, 82, 102, 109, 116, 124, 128, 136, 141, 142, 146, 150, 160, 167, 177, 192, 195, 210, 213, 217, 219, 221. Uganda Essential Drugs Manual.* Pages: 3, 15, 22, 25, 37, 59, 75, 92, 94, 100, 199, 215. Haaland A et al. (1999). Training community providers in better drug use for fever and cough. Community Drug Use Project, Makerere Institute of Social Research, Kampala, Uganda. Artist: Maureen Origumisiriza. Pages: 3, 16, 38, 46, 51, 84, 101, 130, 132, 133, 135, 147, 153, 156. KEMRI/Ministry of Health. Operational research project on training shopkeepers to treat childhood fevers, Kiliﬁ, Kenya (1996). Artist: Vicki Marsh. Pages: 4, 5, 10, 27, 42, 58, 80, 137, 175, 204, 206. WHO/TDR (unpublished). Visual perception studies, Kenya and Tanzania (1996). Pages: 16, 148, 221. Haaland A with Oladele Akogun and Oladimeji Oladepo (2000). Reporting with pictures. Concept paper for researchers and health policy decision makers. WHO/TDR. Artist: John A. Nwagboso. Pages: 9, 14, 18, 21, 27, 36, 39, 43, 59, 69, 71, 79, 80, 95 111, 159, 167, 181, 186, 216. Ministry of Health, Temeke Municipal Hospital, Dar-es-Salaam and LHL (Asso- ciation for Heart and Lung Disease, Norway) (2006). Booklet series on TB com- munication. Artist: Mosses Luhanga. Pages: 14, 55, 92, 110, 112, 113, 119, 127, 134, 136, 154, 162, 219. African Bureau, USAID 1993. Communicating about health: A guide for facilita- tors.* Pages: 16, 197, 206, 212, 220. Drawn for this manual. Artist: Mosses Luhanga. Pages: 16, 59, 61, 65, 107, 108, 115, 117, 118, 119, 122, 125, 132, 135, 137, 147, 149, 156, 161, 170, 105, 201, 202, 203, 205, 213, 218, 220. Punjab Lok Sujag photographs. Pages: 19, 20. Promoting rational drug use in the community course training module on mass media communication (1998). Pages: 22, 87, 88, 89, 90, 91, 92, 99, 100, 125. Food and Agriculture Organization (1996): Artists as experts.* A participatory methodology to produce traditional and popular media. Pages: 53, 54, 55, 63, 217. Werner D, Bower B. (1982): Helping health workers learn.* Hesperian Founda- tion. Artists: David Werner, Pablo Chavez, Regina Faul-Jansen, Marie Ducruy. Pages: 57, 58, 63 67, 72, 73, 74, 75, 76, 77, 78, 79, 83, 94, 107, 118, 129, 133, 144, 164, 166, 168, 194, 196, 203, 205, 208. * Materials and illustrations in these manuals can be used free of charge for non-commercial purposes, when sources are acknowledged. (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 viii Haaland A, UNICEF Burma (1982). Pretesting communication materials.* Artists: U Tin Win, U Aye Ko, Narendra Basnet, Ane Haaland. Pages: 60, 96, 164, 175, 176, 178, 179, 180, 181, 182, 183, 184, 185, 187, 221. MEDEX Primary health care series (1985). Introduction to training. Clean water and clean community.* Prevention and care of diarrhoea.* Artist: June Mehra. Pages: 68, 206. WHO/TDR (1995). Towards the healthy women counselling guide. Artist: June Mehra. Page: 71. UNICEF and NDS, Nepal (1976). Communicating with pictures in Nepal.* Artists: Ane Haaland, Diana Fussell. Pages: 78, 79. WHO/TDR (1996): Health workers for change. A manual to improve quality of care. Artist: June Mehra. Pages: 82, 93, 96, 98, 130, 140, 145, 146, 152, 164, 207, 213, 215, 219. MOH, Temeke Municipal Hospital, Dar-es-Salaam and LHL (Association for Heart and Lung Disease, Norway) (2006). Booklet series on TB communication. Artist: Maureen Origumisiriza. Page 92. WHO/TDR and UNDCP (1997). Women affected by substance abuse. Health work- ers can make a difference. Artist: June Mehra. Pages: 92, 94, 214. Uganda, private photo. (Pretesting instructions for antimalarials with the Malaria Consortium, April 2006). Photographer: Ane Haaland. Pages 149, 175. UNICEF East Asia and Paciﬁc Regional Ofﬁce (1985). Programme communica- tion.* Pages: 163, 214. Haaland A (2002). Report to WHO/TDR and Novartis Pharmaceuticals on pretest- ing instructions for Coartem instructions. Page: 187. KEMRI/Ministry of Health (1996). Operational research project on training shop- keepers to treat childhood fevers, Kiliﬁ, Kenya. Artists: Maureen Origumisiriza, Vicki Marsh, Ane Haaland. Page: 204. * Materials and illustrations in these manuals can be used free of charge for non-commercial purposes, when sources are acknowledged. 1 Section 1 )NTRODUCTION 3 3%#4)/.��).42/$5#4)/. %ssential medicines are one of the vital tools needed to improve and maintain health. However, for too many people throughout the world medicines are still unaffordable, unavailable, unsafe and improperly used. An estimated one third of the world’s population lack regular access to essential drugs, with this ﬁgure rising to over half in the poorest parts of Africa and Asia. When avail- able, the medicines are often used incorrectly: around 50% of all medicines are prescribed, dispensed or sold inappropriately, while 50% of patients fail to take their medicines appropriately (WHO 2002a). Since the beginning of the 1980s the essential drugs concept has become one of the cornerstones of international and national health policy – inﬂuencing decision-making in both developing and industrial- ized countries. The selection and rational use of medi- cines are accepted as key principles of health service quality and management in both the public and pri- vate sectors. WHO vigorously promotes the essential drugs concept and the rational use of drugs. National drug policies are promoted by WHO and others as a guide to action and a key framework within which to make the necessary commitment and coordinate the various policy components needed to guarantee access to and rational use of medicines. For essential medicines to contribute to improved health, countries need to develop national medicines policies, ensure access to essential drugs, strengthen drug regulation, and improve rational use of drugs in both public and private sectors, and by both health professionals and consumers. Though much progress has been made in all of these areas, health policy- makers have generally focused more on the provi- sion and regulation of medicines, and on efforts to improve health workers’ prescribing, than on efforts to ensure rational use of medicines by consumers. 7HAT�IS�RATIONAL�USE�OF�MEDICINES� WHO’s deﬁnition of rational use is that: “Patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at the lowest cost to them and their community” (WHO 2001). Rational drug use interventions that focus on health worker prescribing can only partly improve the use of drugs. This is because, as studies on medicine use by consumers have shown, self-medication is the most common form of therapy choice and people often rely on informal drug distribution channels as much as on the medicines prescribed and supplied by trained health professionals. To address the problem of irrational use of medi- cines, health planners and administrators need speciﬁc information on: …than on efforts to ensure rational medicine use by consumers Health policy-makers have focused more on provision and regulation of medicines… (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 4 • the types of irrational use that occur in their country or district, so that strat- egies can be targeted towards changing speciﬁc problems • the amount of irrational use, so that the scale of the problem is known and the impact of the strategies can be monitored • the reasons why medicines are used irrationally, so that appropriate, effective and feasible strategies can be chosen. People often have very rational reasons for using medicines “irrationally”. #ONSUMERS´�PERSPECTIVE��A�DIFFERENT�RATIONALITY Consumers have their own reasons for using drugs the way they do – reasons that are based on social and cultural rules, experience, health beliefs, ﬁnancial means, and psychological aspects. Reasons can include: • People in general treat symptoms, and not the disease. They are not given a chance to understand how the disease works, and how the drugs should be taken to treat the disease, because most health workers and prescribers are not taught how to give such explanations in a way that people can understand, based on their own belief system. • People self-medicate for diseases such as malaria because it is a common disease that occurs often, and drugs are available at the local shops. Malaria is called “fever” in many African languages, and it is treated until the fever goes away – a logical response. • Misuse of antibiotics often happens for the same reasons. People do not understand why they should take a full course (the reason given by the health worker does not make sense to them). A full course is expensive, and people treat until the symptoms are gone. #OMMON�PATTERNS�OF�INAPPROPRIATE�MEDICINE�USE Research over the years has identiﬁed a number of common areas of inappropri- ate medicine use that have a negative impact on the health of consumers. These include: • not taking medicine in the way intended by the prescriber • self-medication with prescription drugs • misuse of antibiotics • overuse of injections • overuse of relatively safe medicines • unsafe use of herbal medicines • use of non-essential combination drugs • use of needlessly expensive medicines. .OT�TAKING�THE�MEDICINE�IN�THE�WAY�INTENDED�BY�THE�PRESCRIBER Health workers tend to stress the problem of consumers not complying with or adhering to instructions on how to take a medicine.1 This has been the focus of many drug use studies (Homedes and Ugalde, 1993). People do not have full 1 Compliance and adherence are words used to describe whether a consumer takes a medicine in the way intended by the health professional who prescribed it or according to the instructions on the packaging. Some people prefer not to use the word compliance because it implies a normative view that the consumer should obey/comply with instructions. The word concordance may also be encountered in this context. It refers to a consultation process between the health professional and the consumer, who reach agreement about the best course of treatment in a way which values the perceptions and opinion of both parties. 5 information about how to take medicines because health workers have too little time to explain, people tend to forget the details of the advice given because the explanation of use was not clear or was poorly understood, or fail to purchase all of the drugs that are prescribed, because they cannot afford them. Patients sometimes stop taking the prescribed drugs or take the wrong dosage. Of course, interventions to improve adherence only make sense if health workers’ prescrib- ing practices are appropriate and rational. 3ELF MEDICATION�WITH�PRESCRIPTION�DRUGS Another problem is that in many countries people can purchase drugs over-the- counter that legally should be sold only on prescription. A study in the Philippines found that people keep copies of prescriptions to re-use (Hardon, 1991). Doctors’ consultations are expensive and repeated use of prescriptions is a way to econo- mize. Self-medication with prescription drugs is especially a problem in developing countries where pharmacies freely supply medicines over-the-counter, as do informal drug shops and small groceries. Sometimes people even self-medicate with prescription drugs on the advice of traditional healers. People keep stocks of leftover medicines in their homes, and re-use them or give them to neigh- bours or relatives who request them. These practices also occur in countries where dis- pensing of medicines is regulated more strictly. The possibility of buying medicines through the Internet means that those available only on prescription in one country can be obtained by post from a country where regulation is less strict. Immigration and peo- ple’s increased mobility mean that more people buy medicines where it is easy to obtain them – or obtain them through family and friends. -ISUSE�OF�ANTIBIOTICS Antibiotics are very important drugs, but they are over-prescribed and overused in self-medication for the treatment of minor disorders such as simple diarrhoea, coughs and colds. When antibiotics are used too often in sub-optimal dosages, bacteria become resistant to them. The result is treatment failure when patients suffering from serious infections take antibiotics. This is of great concern to public health policy-makers. People buy sub-optimal dosages because they cannot afford the full course prescribed, or because they are not aware of the need to complete antibiotic courses. Even in industrialized countries where antibiotic dispensing is better regulated, non-compliance with the prescribed regime is a common prob- lem. People who have not understood the need to complete the course stop using antibiotics when the symptoms disappear, while others take an overdose as they think that this will lead to faster recovery. Studies by Lansang et al. (1990, 1991) and others highlight some of the problems with antibiotic use in the Philippines. In urban settings, 66% of antibiotic pur- chases were made without prescriptions. Customers purchased 10 units (tablets or capsules) or fewer. In rural areas, 57% of antibiotics were purchased without a prescription, but only six tablets or capsules at a time were bought. These ﬁndings indicate widespread sub-optimal use of antibiotics in self-medication. 3%#4)/.��).42/$5#4)/. (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 6 /VERUSE�OF�INJECTIONS Health workers and patients in many countries believe that injections are more effective than tablets. This not only leads to unnecessary expense (in many cases tablets are a cheaper form of therapy), it also leads to unnecessary health risks when the injections are admin- istered in unhygienic conditions or syringes and needles are re-used without being sterilized. A WHO study on injection practices in developing countries found that in Uganda around 60% of patients bring along their own syringe and needle when they visit health facilities or pharmacies for treatment. The instru- ments generally have not been sterilized properly. People keep the equipment at home because they do not trust the injections provided in the health facilities (Van Staa and Hardon, 1996). /VERUSE�OF�RELATIVELY�SAFE�MEDICINES In many countries people believe that they need a “pill for every ill”. At the onset of all kinds of minor disorders they immediately take medicines. Vitamins and analgesics such as multivitamins, acetylsalicylic acid (aspirin) and paracetamol are the most commonly used drugs in many countries. Although relatively safe, they are not without risks. Aspirin can cause stomach bleeding and paracetamol, if taken in excess, can cause death. A study in Thailand found the overuse of analgesics in rural Thai communities for pain relief, related to hard agricultural labour (Sringernyuang, 2000). For the agricultural labourers, a painkiller a day seems essential. It allows them to continue work and have a regular income. Health workers recognize that the practice is unsafe, as it can lead to stomach bleeding, a commonly reported health problem in Thailand. 5NSAFE�USE�OF�HERBAL�MEDICINES In developing countries people use herbal medicines routinely in self-care. Many countries test the safety and efﬁcacy of these medicines, and some of them are selected for inclusion in national health programmes. The production of herbal medicines is commercialized in countries such as the People’s Republic of China, India, Viet Nam and Thailand, and marketing is similar to that for modern pharma- ceuticals. In industrialized countries the use of herbal medicines is also increasing. People believe that they are more natural than modern pharmaceuticals. Some herbal medicines are potent, and their safety is not always as evident as people think. Also they can be dangerous when taken in combination with modern phar- maceuticals. For example, the antidepressant herb St John’s Wort cannot be used in combination with antidepressants such as selective serotonin re-uptake inhibitors (SSRIs). 5SE�OF�NON ESSENTIAL�COMBINATION�DRUGS People tend to take all kinds of cough and cold rem- edies that contain more than one active ingredient. Sometimes these drugs even contain substances that counteract each other: one substance to sup- press a cough and another to encourage it. Such 7 products do not contribute to a cure, are a waste of money and may increase adverse effects. 5SE�OF�NEEDLESSLY�EXPENSIVE�MEDICINES In many countries people rely on brand name drugs when choosing therapies. Pressure from advertising of branded products encourages this trend. Branded products are often more expensive than the same products under generic name. The price of medicines is an extremely important concern for consumers (WHO and HAI, 2003). Also people may not realize that two different brand name drugs may contain exactly the same substance. #HANGING�THE�WAY�MEDICINES�ARE�USED The starting point for any intervention to improve the use of medicines is solid participatory research that identiﬁes problems related to drug use in communi- ties and their possible solutions. A companion manual, How to investigate the use of medicines by consumers, (WHO, 2004) describes in detail how to prepare for and undertake such research together with community members. It covers the ﬁrst three steps in a seven-step process of developing an effective intervention to improve the use of medicines at community level (see Figure 1). This manual takes up the process from the point at which the research has reached its conclusions and recommendations and problems have been identiﬁed, prioritized and analysed. In the manual, we will look at how to move through steps four to seven: selecting, testing, implementing and evaluating interventions. In 3%#4)/.��).42/$5#4)/. &IGURE��3TEPS�IN�AN�EFFECTIVE�COMMUNICATION�INTERVENTION 34%0�� $ESCRIBE�DRUG�USE�AND IDENTIFY�PROBLEMS 34%0�� 0RIORITIZE�PROBLEMS 34%0�� !NALYSE�PROBLEMS�AND IDENTIFY�SOLUTIONS 34%0�� 3ELECT�AND�DEVELOP INTERVENTION 34%0�� -ONITOR�AND�EVALUATE INTERVENTION 34%0�� 0RETEST�INTERVENTION 34%0�� )MPLEMENT�INTERVENTION )MPR OVE AN ALYSIS )MPROVE�INTERVENTION )MP ROV E INTE RVE NTIO N (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 8 doing so, it is vital to remember that along the way it may be necessary to revise the intervention, in the light of monitoring information and feedback from the people in the communities in which the intervention is meant to be operating. Interventions to encourage rational medicine use can be addressed in several ways. Two broad strategic areas are identiﬁed in this manual and they serve as the framework around which the main chapters are organized. These are: • communication strategies • strategies to create enabling environments, including managerial and regula- tory strategies. Chapter 1 explores leading communication theories and highlights the need to combine research, communication, managerial and regulatory strategies to achieve sustainable change at community level. Communication strategies are looked at in more depth in Section 2, with detailed analysis of four possible communication methods or channels to use – face-to-face, drama and folk media, print, and mass media – covered in Chapters 2–5. Section 3 looks at strategies to create enabling environments. Chapter 6 explores the role of the media while Chapter 7 looks at how advocacy and the mobiliza- tion of people, organizations and networks can help to move forward a particular concern. Chapter 8 highlights how managerial and regulatory strategies serve to stimulate enabling environments. Finally, Section 4 brings the thinking together and looks at some very practi- cal and important issues in Chapters 9–11: planning, pretesting, monitoring and evaluation. Chapter 12 draws together the main lessons of the collected experience covered in this manual and related literature. +EY�READING WHO (2004). How to investigate the use of medicines by consumers. Geneva, World Health Organization. WHO (2001). How to develop and implement a national drug policy. 2nd ed. Geneva, World Health Organization. WHO (1993). How to investigate drug use in health care facilities. Geneva, World Health Organization. 9 0UTTING�INTERVENTIONS�INTO�CONTEXT The way medicines are used does not take place in a vacuum but reﬂects profound cultural beliefs and economic, social and political realities. Identifying how to use communication and other strategies effectively to address problems around medicine use practices at the community level requires paying careful attention to those beliefs and realities. Communication plays a large role in attempts to tackle inappropriate drug use in communities. Examples later in this manual will show how a combination of effective approaches can change awareness and behaviour in communities. These methods can improve understanding by health workers about the type of com- munication that works best with young people or other population groups, and can inﬂuence policy-makers. However, far too many communication approaches have failed because they did not pay sufﬁcient attention to the speciﬁc realities, and instead tried to impose a standard solution and deliver a standard set of messages. The alternative is to develop solutions to problems together with the people who live with the problems, and use these as a basis for the communication campaign. Such solutions will usually be more practical, suited to the local culture, be owned by the people, and will be implemented and lead to improved health. Some communication approaches have also failed because they did not take account of the other interventions – managerial and regula- tory – that may be needed to create an enabling environment for change to take place. This chapter will: • show the link between participatory research and communication and other interventions to address community medicine use problems 1 (OW�COMMUNICATION�WORKS ��(/7�#/--5.)#!4)/.�7/2+3 9 (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 10 • help to improve understanding of core communication principles. #HANGING�MODELS�AND�APPROACHES�¯�FROM�MESSAGES�TO�DIALOGUE� Over time, communication processes can be characterized as having moved through the following stages: • from a model of information transmission which aimed information from a sender to a largely passive receiver audience • to a process of behaviour change communication, which encouraged more interaction and involvement of audiences in the development of the messages being communicated • to an emerging concept around social change communication that echoes earlier participatory communication concepts around the need to look not only at change in an individual, but the change that needs to occur in society to enable individual change to occur. Each of these progressions has involved a shift towards greater emphasis on the individual as no longer being a ‘target’, but a critical participant in identifying, analysing and adopting the information that is most suited to his or her own circumstances (Jacobsen, 1997). A recent development that underlines much of the previous experience and learning are the lessons emerging from the communication challenges around HIV and AIDS. There is increasing evidence that much of the communication work around HIV and AIDS has, in the words of a strong research report from the Panos Institute (2004), been ‘Missing the message’. +NOWLEDGE�ALONE�DOES�NOT�CHANGE�BEHAVIOUR Although improved knowledge is essential for behaviour change to occur, there is increasing evidence to show that knowledge by itself may not be sufﬁcient (see Box 1). Many examples from everyday life demonstrate this: smokers do not stop because they know they can get lung cancer. In developing countries, many women do not use contraceptives even if they know about this option, and do not want more children. For behaviour change to take place, several aspects are important: "/8�� ()'(�+./7,%$'%�,%6%,��,/7�"%(!6)/52�#(!.'%� Research around efforts to improve home-based management of malaria in Ghana found that: • 71% of mothers were able to accurately recall how to administer antimalarial drugs correctly but at home only 15% give the correct drug, at the correct dosage for the correct duration • 63% of mothers knew that a child with fever should receive tepid sponging (ill) and antipyretics but only 3% cent actually practiced this treatment. Ford N et al. (2003). Communication strategy for implementing community IMCI. Nairobi, UNICEF East and Southern Africa Regional Ofﬁce. 11 ��(/7�#/--5.)#!4)/.�7/2+3 • On the individual side, the person must understand WHY a change is needed, and the reasons must make sense from his/her point of view (not only from the health planner's or health worker’s point of view). The reasons need to connect to their belief system, and be channelled through credible people. Furthermore, an emotional event is often the starting point for change. • Sometimes, changes in the social construction of the household, community or broader society are needed to enable people to act on new knowledge. Effective communication helps to create the ‘social space’ or ‘enabling environment’ in which changes of practice become possible (Ford, 2003). Many communication approaches fail because they take a top-down approach devised by health managers and professionals rather than responding to commu- nity needs, views, practices and realities. Respect for people’s beliefs and actions starts to build a bridge to a new understanding that can lead to change. Box 2 highlights some principles developed from working with rural women that apply equally to all community interventions. These principles were devel- "/8�� $)&&%2%.4�!002/!#(%3�4/�#/--5.)#!4)/.�7)4(�252!,�7/-%. To reach rural women a change in philosophy is needed. Traditionally, strategies to communicate health messages have been driven by the goals of policy-makers and senior health professionals. A change in perspective is required, starting from where the community is in its thinking and experience. The possibilities open to them for change must also be taken into account. Those who seek to communicate meaningfully need to recognize that: • Local perceptions of health and illness are valid, and should be accepted and incorporated into information design. • Women already perform a health care-giving role that they and their families value. Information should enhance this role rather than undermine it. • Women’s actions are determined by the contexts in which they live. It is important to recognize how gender relations affect their health, and their ability to implement changes in their lives and those of their families. • Rural women’s understanding of health and disease is often dismissed as irrational and words like ‘ignorant’ and ‘superstitious’ are frequently used to describe their behaviour. Research, however, has shown that local understandings of health and illness can be complex and detailed. Given the opportunity, rural women are able to explain their interpretations and observations in ways that are inherently rational. Their reasoning is inductive – based on lived experiences and built up over time, just as modern medicine is. Local perceptions of health and illness should be understood and appreciated. Their basis and the validity they have for local people must be recognized and taken into account in the design of new health information. In many cases people’s behaviour corresponds closely to modern medical ideas. Only certain aspects that are inappropriate or harmful may need to be pointed out. Health information can be designed to incorporate traditional and modern biomedical practices so that it is meaningful within a community’s lives and within its range of possible actions. WHO (1998) The healthy women counselling guide: a model for reaching women. Geneva, UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases. (Female) interviewers with good communication skills – like active listening, a non-judgemental attitude, and patience, can ﬁnd out how rural women understand health issues. (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 12 oped by the UNDP/ World Bank/WHO Special Programme for Research and Training in Tropi- cal Diseases (TDR), based on extensive ﬁeld experience. Any health communication intervention must take context and practice into account, and be sensitive to the possible tension between the health planner’s desired behav- ioural change and people’s own needs and realities. Only if a balance between the two is achieved will the intervention be successful. This is particularly the case when dealing with community-level communication. (EALTH�COMMUNICATION�THEORIES There is a rich body of literature, of varying levels of complexity, dealing with communication. Within this, there is a ﬁeld of practice called development com- munication – literally, the application of communication strategies and principles to the process of development and social change – which has evolved over the past 50 years. One of the leading inﬂuences on development communication has been health communication. While we cannot discuss in detail all the models and approaches that have been used in health communication, Table 1 summarizes some key theories. What has become clear over the years is that there is no single model or approach that is the solution to all health communication challenges (National Cancer Institute, USA, 2003). Different techniques are appropriate in different contexts to deal with different priorities and problems. Selection of the appropriate approach from a ‘menu’ or ‘tool- kit’ of possibilities based on an understanding of both the realities of the situation and the most appropriate change theory to apply is increasingly the way to develop effective communication interventions. This manual will help you to build the skills and experience to make that selection more effectively. In an effort to bring together most of the major theories underpinning behaviour change, a simple framework was developed at a con- sensus conference held in Washington D.C., USA, in 1991 (see Box 3). Of the eight elements identiﬁed, the ﬁrst three are considered essential for ensuring behaviour change. The remaining ﬁve enhance the intensity and direction of the intention to change behaviour. For example, the treatment supporter assigned to a tuberculosis patient (to observe the patient taking her medicine every day) functions to a large extent to support this theory. 1. The patient has a strong interest in taking medicines for 6–8 months to get cured. 2. Environmental constraints: This is often where the problem is – because of stigma. Does he know… …what she needs? 13 ��(/7�#/--5.)#!4)/.�7/2+3 4ABLE��3UMMARY�OF�KEY�COMMUNICATION�MODELS�AND�APPROACHES� THEORY/MODEL DATE THEORISTS KEY ELEMENTS Information 1950s, Shannon-Weaver, Persuasion techniques, uni-directional (from sender to transmission 1960s Lerner, Schramm receiver), linear, (mass) media focused. Diffusion of 1960s, Rogers Early study of individual behaviour, identiﬁed ﬁve stages innovations 1970s of adoption of new approaches: awareness, knowledge and interest, decision, trial, adoption/rejection that has formed the basis of much behaviour change work; recognition that interpersonal communication as well as mass media were necessary. Social marketing 1970s, Kotler, Zaltman, Strong focus on inﬂuencing behaviour, promotion of 1980s McKee, Lefebvre practices/products of beneﬁt to a deﬁned target group, importance of market research and understanding consumer preferences, interaction with consumers and segmentation of target audiences. Behaviour 1980s, Piottrow et al., Strong focus on cognitive theories and models including change 1990s Bandura, drawing heavily on the health belief model, the theory communication Terry et al., of reasoned action and theories of social learning. Has Becker tended to focus on individuals as the unit of intervention and analysis, although more recently, more attention is being paid to social inﬂuences. Participatory 1970s Freire, Snowden Primarily concerned with transforming social conditions communication onwards and fostering community empowerment. A human- centred approach that values interpersonal and horizontal communication and community-based forms of communication that are easy to access for community members. Can include mass media and new technologies, but the issue here is who controls the use of these channels of communication. Health 1980s, Ottawa Charter, Health promotion is deﬁned in the Ottawa Charter as promotion 1990s Jakarta Charter, a ‘process of enabling people to exert control over the Nutbeam determinants of health and thereby improve their health’. Thus, it is not something done to people, but with people. Participation and partnership are valued processes. Social 1980s UNICEF, Aims to increase the problem-solving ability of the mobilization/ Rothman et al. community and to achieve concrete changes to redress social action social injustice identiﬁed by a disadvantaged or oppressed group. Empowerment processes stimulate problem-solving and activate community members. Focuses on demands for action to meet health needs. People living with HIV and AIDS and women’s health advocates are among those who have used social action. Media advocacy is often used. UNAIDS 1999 Airhihenbuwa et al. Identiﬁes ﬁve contexts which need to be considered communication when developing communication initiatives around HIV framework and AIDS: government policy, socio-economic status, culture, gender relations and spirituality. Individual health behaviour is recognized as a component of this set of domains. Communication 2000 Rockefeller A process of public and private dialogue through for social change Foundation which people deﬁne who they are, what they want and how they can get it. It is informed by principles of tolerance, self-determination, equity, social justice, empowerment and active participation for all. It sees people and communities as the agents of their own change, supports dialogue and debate on key issues of concern, and focuses on social norms, policies, culture and a supportive environment. It aims to negotiate the best way forward in a partnership process that ensures that the people most affected by the issues of concern play a central role. (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 14 3. The supporter (who is often a former patient) has the skills, and teaches the patient. 4. The patient gets better (and perceives advan- tages) and gets care and support every day. 5. The supporter and the patient’s family apply social pressure. 6. Taking medicine is OK for the patient's image. 7. The emotional reaction is positive, especially as the patient improves her health. 8. The patient increasingly believes she can be cured, with the practical, emotional and “moral” support of the treatment supporter. "/8�� #/.$)4)/.3�&/2�"%(!6)/52�#(!.'% 1. The person has formed a strong positive intention (or made a commitment) to perform the behaviour. 2. There are no environmental constraints that make it impossible for the behaviour to occur. 3. The person has the skills necessary to perform the behaviour. 4. The person believes the advantages (beneﬁts, anticipated positive outcomes) of performing the behaviour outweigh the disadvantages (costs, anticipated negative outcomes). 5. The person perceives more social pressure to perform the behaviour than to not perform the behaviour. 6. The person perceives that the behaviour is consistent with their self-image and does not violate their personal standards. 7. The person’s emotional reaction to performing behaviour is more positive than negative. 8. The person believes (has conﬁdence) that they can execute the behaviour under a number of different circumstances (the person has the perceived self-efﬁcacy to execute the behaviour). Fishbein, M et al. Factors inﬂuencing behaviour and behaviour change. Final report prepared for the National Institute of Mental Health, USA, theorists workshop. Washington, D.C., 1991. Reproduced in: Changing behaviours: a practical framework. Toronto, The Health Communication Unit, 2004. Available at http://www.thcu.ca/infoandresources/ publications/Changing%20Behavioursv4.2.june.15.04.pdf ,EVELS�OF�IN¾UENCE� Another way of looking at what inﬂuences behaviour emerged in the late 1980s when McLeroy and others identiﬁed ﬁve levels of inﬂuence for health-related behaviours. (McLeroy et al., 1988) These were: • individual or intrapersonal factors – character- istics such as knowledge, attitudes, beliefs and personality traits that inﬂuence behaviour • interpersonal factors – such as the interactions among family, friends and peers that provide social identity, support and role deﬁnition • institutional or organizational factors – such as rules, regulations, policies and informal struc- tures which may constrain or promote particular behaviours 15 ��(/7�#/--5.)#!4)/.�7/2+3 • community factors – social networks and norms, both formal and informal, among individuals, groups and organizations • public policy factors – local and national policies and laws that regulate or support healthy action. The degree to which communication processes deal with each of these various factors is a probable indicator of the effectiveness of the intervention and its likely impact on behaviour. These levels of inﬂuence for health-related behaviours are consistent with the main levels of inﬂuence that have been identiﬁed as affecting consumer medicine use (WHO, 2004): • family/household level • community level • health service institution level • national level • international level. Interventions to improve medicine use can take place at a number of levels. Table 2 illustrates some of the issues that might be tackled under each of these levels. For example, if there is a signiﬁcant problem of unethical drug promotion this could be tackled: • at the national level through the adoption of a code of pharmaceutical mar- keting practices with hefty penalties for infringements • through education at the health institution level through medical schools and professional societies on critical evaluation of drug promotion and awareness- raising of drug marketing techniques and disguised marketing practices • through education in the community (including schools) on the difference between drug information and drug promotion • through local media involvement, using examples • through “shame and blame” activities to publicize at national and interna- tional levels the most blatant infractions and their possible public health and societal consequences in the media. But in the real world such multi-level interventions may be very difﬁcult. We then need to decide whether it is worth tackling the problem at one or perhaps two levels or whether the chances of even a modest impact without a fully supporting infrastructure are too low to make this worthwhile. This weighing up of possibili- ties for a successful intervention is part of your initial prioritization of problems to tackle. Sometimes windows of opportunity occur when political, social or economic change creates an environment ripe for a given intervention. When making this evaluation it is important to look at possible alliances with other stakeholders (see Chapter 7, Advocacy and networking). 4HE�ROLE�OF�EMOTIONS Emotions play an important part in the process of behaviour change. The reasons people decide to change (or not to change) are almost always linked to their emotions. Information or knowledge about the advantage of the change (e.g. to stop smoking) is, although a necessary component, not sufﬁcient to actually lead to the adoption of changed behaviour. A friendly, caring health worker inspires trust, and is more likely to inﬂuence patients to adopt new behaviour. (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 16 4ABLE��-AIN�FACTORS�IN¾UENCING�DRUG�USE�BY�CONSUMERS LEVEL OF INFLUENCE FACTORS FAMILY/HOUSEHOLD • Perceived need for medicines • Ideas about efﬁcacy and safety • Uncertainty about the illness resulting in poly-pharmacy • Cost of medicines • Literacy levels • The perceived power of medicines • Basic health beliefs • Treating symptoms, not disease • Inﬂuence of traditional healers • Ideas and power of older generation COMMUNITY • Drug use culture • Medicine supply system • Information channels • Availability of drug shops HEALTH SERVICE INSTITUTION • Extent to which health workers are consulted • Quality of health worker training and information • Quality of health worker prescribing • Quality of the consultation • Quality of the dispensing process • Reliable supply • Cost of medicines NATIONAL • Implementation of essential drugs policy • Drug regulation • Drug legislation • Drug promotion • Financing and reimbursement • Consumer advocacy • The media • Public education INTERNATIONAL • Health consequences of global trade agreements • Donor support for essential medicines programmes • Global consumer advocacy • The Internet 17 ��(/7�#/--5.)#!4)/.�7/2+3 Understanding how change happens for individuals and communities, and espe- cially the role of the emotions, is critical to successful communication. As early as the 1920s social anthropologists provided important insights to this process. Everett Rogers describes this learning in his work on Diffusion of innovations – the title of a much cited book, now into its ﬁfth edition since 1962 (Rogers, 1962, 1976, 1983, 1995, 2002). His model makes a clear distinction between the ﬁrst two stages in the behaviour change process (Awareness and Interest), which are cognitive (i.e. involves thinking, without any commitment), and the next three stages (Trial, Evalu- ation and Adoption/Rejection), which are linked to the emotions (see Table 3). 4ABLE�� STAGES IN THE WAY AN INDIVIDUAL CHANGES BEHAVIOUR INFLUENCED BY: Awareness Cognitive/ Mass media, events, books, Interest intellectual; “Head” ﬁlms, friends, family, etc. Trial Emotional Emotional/life event Evaluation (“Stomach”, particularly if it involves Adoption/ feelings) people close to you, or Rejection People you respect and trust such as friends, family, professional colleagues It is important to realize that the process of change is not a simple sequential series of steps, one following seamlessly after the other. The sequence moves forwards and backwards over time, and is dependent on a range of external fac- tors. Someone might become aware of a need to change behaviour but do nothing about it for some time. Then some additional information, or another life event may lead to an interest in doing something about it, maybe even an attempt to make a change. The change might not be all that comfortable, so the individual could revert back to the previous behaviour, until the process is rekindled. Box 4 emphasizes the need for an emotional input for change to take place. Messages that only affect our rational mind are less likely to motivate us to act or to change. It takes an emotional response to generate either individual or social change. And in the case of some social change, it will also take economic and political responses as well – making a difference through managerial and regula- tory strategies – to arrive at real and sustainable change. In this manual, we are emphasizing the importance of participatory approaches, of reaching people’s emotions. We stress the need to develop interventions that not only motivate people to take action, but also look at what needs to change in the surrounding community and at the policy level to create an enabling and sustainable environment for change. This includes the need for health planners and communicators who manage programmes that aim at behaviour change to understand their own emotions and processes of behaviour change so that they can facilitate learning on these aspects for the groups they work with (Haaland and Molyneux, 2005). #OMBINING�APPROACHES� Box 5 explores the way several organizations in Pakistan made use of a set of differ- ent strategies and methods to deal with the problems caused by iodine deﬁciency in communities with which they worked. (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 18 "/8�� +%9�,%33/.3�!"/54�(%!,4(�#/--5.)#!4)/. 1. Health communication is more effective when it reaches people on an emotional as well as a rational level. Emotional experience, self-esteem, security, inclusion, affection, control and social approval are among some of the most important factors that facilitate behaviour change, along with self-efﬁcacy and perceptions of control. Communication that evokes empathy and other emotions typical of interpersonal dialogue enhance their impact. 2. Health communication is more effective when it relates to people’s social or ‘life’ contexts. The process of making and maintaining a life change is made within the context of family, community and cultural factors. Incorporating health communication into a life context also may enable people to make changes across a range of health issues. 3. A combination of the effectiveness of interpersonal communi- cation and the reach of mass media communication is needed to change population behaviour. Both types of communication are important and interrelated. Hornik’s (2002) review of health communication and behaviour change outlines a communication model in which mass and interpersonal media operate at the individual, social and institutional levels needed to effect change. 4. Tailored communication is more effective than general messages. ‘Tailoring’ or ‘customizing’ information so that it more closely meets the needs of the recipients has resulted in signiﬁcantly improved communication outcomes. The increasing health disparities among vulnerable groups in many countries points to an urgent need to improve our communication approaches with diverse audiences. 5. Interactive communication is more effective than one-way information dissemination. Passive dissemination of health information is the most common strategy and the least effective. Messages from experts about people’s needs to improve themselves may be unintentionally disempowering. Interaction and participation in both the process and content of communication are key factors. Research shows that when the beneﬁciaries are involved in the design and dissemination of health communication, the outcomes are more likely to be successful. Taken together, these ﬁndings suggest that our current interventions do not effectively ‘touch the emotions’ of people in ways that relate to their daily lives and promote change. In others words, experts have messages to send, but people have lives to live. There is increasing evidence that health communication approaches that are set within multiple social contexts and that engage people interactively and personally are more effective (Emmons, 2000). It is clear that we need to do better. Source: Neuhauser L, Kreps GL (2003). Rethinking communication in the E-health era. Journal of Health Psychology, 8(1):7–23. 19 "/8�� &)'(4).'�)/$).%�$%&)#)%.#9�).�$%0!,052��0!+)34!. Punjab Lok Sujag is a membership-based nongovernmental organization in Lahore, Pakistan, which works in the whole of rural and urban Punjab. Together with its sister organization, Punjab Lok Rahs – that specializes in alternative theatre – it is involved in organizing communities around a number of social development issues. Rahs is the Punjabi word for a traditional form of theatre. Lok Sujag means “people’s awakening”. Sujag has worked on campaigns to improve women’s mobility in urban Lahore, advocacy on access to pharmaceutical products, research and campaigning on breastfeeding and iodine deﬁciency, agriculture and milk economy, cooperatives as an alternative organizational structure, and electronic resource development. It has close associations with a number of civil society organizations and is part of many networks and coalitions. In the late 1990s, while exploring issues of concern to dairy farmers in villages of Tehsil Depalpur, Sujag was asked by the local people to attend to the problem of goitre in the area. Sujag undertook the issue on people’s demand and developed it into a strong campaign to raise awareness about iodine deﬁciency disorders and promote use of iodized salt. Depalpur has a population of some 1.1 million people. Just over 35% of the population have goitre caused by iodine deﬁciency, much of it moderate to severe. Goitres, which manifest as a swelling of the neck, affect women more than men. The most severe consequence of goitre affects children: mothers with goitres are more likely to give birth to children who are physically and mentally stunted and often deaf and/or dumb. Sujag began to develop a campaign against iodine deﬁciency disorders (IDDs) run in 22 villages under a Sujag-Unicef partnership. Unicef was contacted because of its work on promotion of iodized salt. Sujag held formal meetings with the community, organized medical camps and awareness walks and used many innovative ways to disseminate the message chalking (ill). Sujag’s sister concern, Lok Rahs, developed a piece of street theatre on the subject and performed it in villages. Sujag also made interventions to ensure continued supply of iodized salt, such as providing a local vendor with a donkey cart. An important aspect of this campaign has been that Sujag was successful in involving a number of individuals and institutions. The Department of Nutrition, College of Home Economics, Lahore, helped Sujag collect baseline data, while Lahore General Hospital helped it in organizing medical camps in villages and where necessary providing surgical treatment to patients. Two key communication principles that Sujag used were: • all awareness-raising interventions need to be culturally relevant to the area and use people’s language and accent • the awareness campaign cannot be a one-sided public relay of designed messages. Dialogue is important to generate and answer questions. Sujag identiﬁed three groups of people who needed to know different things about IDDs and for whom different communication strategies were needed. 1. Doctors needed to be reminded of the issue in all its scientiﬁc details and be convinced to promote iodized salt every day. Local opinion leaders needed similar information. A face-to-face communication strategy, reinforced with support materials was selected as the best approach. The support of local chapters of the Pakistan Medical Association helped to strengthen the impact. 2. Senior students at colleges and high schools who could be promoters of the use of iodized salt needed slightly less complex knowledge. Information was delivered through a school programme that included knowledge competitions, campaigning in neighbourhoods, report writing and walks and processions. Continued ��(/7�#/--5.)#!4)/.�7/2+3 (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 20 Box 5 Continued 3. The general population needed the most simple and easy to understand knowledge that was conveyed through leaﬂets, wall-chalking, mobile publicity vans and theatre. But information was not enough on its own. Access to iodized salt was essential. Sujag was able to persuade three salt processors in the province to provide iodized salt. Sujag also researched which retail shops were available that could distribute iodized salt. They identiﬁed 2,500 shops in the entire rural area of Depalpur. Both the producers and the retail outlets were sensitized to the importance of iodized salt. Sujag mobilized its sister concern, Punjab Lok Rahs, into developing a 40-minute street play ‘Daroo’ on the subject, which was performed in the villages along with other activities. Rahs has also performed the play in colleges of Depalpur town and held two theatre workshops for village school children. Rahs is developing a local theatre group in Depalpur that could more easily move around, especially to villages, and is working on a puppet play and an audio cassette with songs and short dramas to relay through mobile vans. Overall, the campaign has resulted in a remarkable increase in use of iodized salt in these villages, which is expected to lead to a decrease in iodine deﬁciency diseases. $AROO�¯�THE�PLAY The basic objective of the play “Daroo” (Remedy) is to create awareness about goitre and other iodine deﬁciency disorders and promote use of iodized salt, so goitre and iodine have been personiﬁed as two characters. This animation makes the play interesting and eases communicating a lot of ideas that otherwise would have been boring if not impossible. There is a doctor devoted to the cause of people’s health. He takes a Dholi (drum beater) with him and goes to a village where many people are suffering from goitre. As the Dholi beats the drum, and the doctor engages people in discussion on IDDs, the ‘Iodine’ descends upon them. The spellbound people, including the doctor, fail to recognize her and think she is some supernatural creature or a fairy. However a quack and a spiritual healer realize the “danger”, the fairy poses to their business. The Malang, spiritual leader, is desperately looking for the Iodine wanting to capture her using his magical powers. As the tussle continues, goitre takes its toll on the lives of the villagers. The children become dull and weak in their studies. Their memory is weakened. Nobody is ready to marry the girls with swollen necks. Ugly looking cretins are born to many women in the village. The doctor ﬁnally recognizes the Iodine during one of her mysterious visits and requests her to free one of the villagers of the curse of goitre. She obliges, and the news of the miracle spreads far and wide. Villagers ﬂock around the doctor and the Iodine and just then the Malang’s relentless hunt for the fairy of Iodine also ends. The Malang interrupts the hide-and-seek going on between the goitre and the Iodine. He kidnaps the Iodine but is resisted and blocked by the villagers when he tries to take her away. He recites mantras, which turn the Iodine into a sack of salt. Dejected people encircle the Malang and just when they are about to beat the Malang to death, the doctor interrupts and tells them that all the powers of the fairy of Iodine are there in this salt and they need not to worry about her life. as such. 21 ��(/7�#/--5.)#!4)/.�7/2+3 Here it is possible to see the interaction of a number of strategies. The com- munication approaches focused on both public and health worker audiences. The managerial strategies looked at issues of how to ensure dissemination of iodized salt. The regulatory strategies included ensuring that there was a requirement to iodize salt and therefore some reason for manufacturers to do so. Other enabling strategies included looking at ways to encourage dialogue and debate within the communities to ensure that demands for appropriate products were expressed. This included making use of available networks of contacts and mobilizing allies, including the Pakistan Medical Association and local village leaders. Underpinning this example is the extensive research that was undertaken to identify the prob- lem clearly, to look at what types of communication approaches could be used, and to identify the people and institutions with an interest (stakeholders) in the issue and who might be able to contribute to the solu- tion of the problem. During this process, Sujag built up good relations with local people and gained cred- ibility that enabled it to facilitate the change process with people’s full cooperation. Some clear lessons and basic principles can be drawn from this example which will be referred to and reinforced in other parts of the manual (see Box 6). The type of analysis undertaken by the groups in Pakistan illustrates the importance of building a strategic approach to communi- cation. Strategic thinking lies at the heart of effective communication. A strategic approach to communication moves communication programmes from being a Building good relations often starts with contacting and respecting the traditional leaders in the community. "/8�� #/--5.)#!4)/.�02).#)0,%3�$2!7.�&2/-�4(%�0!+)34!.�� #!3%�345$9 • Research-based intervention • Problem deﬁned in and by the community • Combination of strategies: communication and managerial (supply) • Use of local resources leads to ownership • Use of local artist – celebrates local culture; encourages dialogue and questions and may be cost-effective depending on materials used and on process to deﬁne methods • Interactive process • Process of developing communication materials inﬂuences the use and effect • Balance between being speciﬁc and creating a process of talking about the issue • Targeted approach to each audience • Actors trusted by the community • Practical support to stakeholders • Pre-testing is important • Be aware of non-intended outcomes • Monitor! • Evaluate! • It’s not what you do, but how you do it. Analysis drawn from participants at a PRDUC training course in South Africa, 2004. (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 22 ‘spare wheel’ to be used when all else fails, to being a ‘steering wheel’ that can provide direction for programme activities (Piotrow et al., 1997). This can sound daunting, but it really consists of answering a basic set of key questions, such as these adapted from a Healthlink Worldwide methodology called Quest (Healthlink Worldwide, 2003): • Who (which audiences) are you trying to reach? What do you know about their understanding, information needs and preferences? • Why are you trying to reach them? What are you trying to achieve? What are your objectives? What is the problem that is being addressed? What do you know about the causes of that problem? What do you want the audiences to do? Do the audience experience the ‘problem’ as a problem? Is it a prior- ity for them? Do they want to change? What do they believe is a cause of the problem? What do they want to do or what do they see as a solution? How do they want to achieve the change? • What content needs to be conveyed to achieve the objectives, and to interest and motivate the audi- ences? What is the main area of dialogue that you want to encourage? • How can you best do this with the resources and skills that you have? How can you make the best and most appropriate use of existing communica- tion channels and methods? • When is the best time to interact with these audi- ences? Are there opportunities and related events or activities that could be tapped into? • Where are the audiences? In what settings will communication occur? What are the implications for using different approaches that may be suitable or appropriate? • What feedback are you getting and from whom? Is the communication work- ing? Is it achieving its aims? How do you know? How could communication be more effective? • Who is involved in answering these questions? How involved are the people who are most affected by the problem that the communication intervention is seeking to address? Applying questions like these systematically to communication work leads to more effective communication interventions. +EY�READINGS Haaland A, Molyneux C (2005). Collecting quality information. Training manual on practical com- munication skills for ﬁeld researches and project personnel. Geneva, United Nations Development Programme/World Bank/World Health Organization Special Programme for Research and Training in Tropical Diseases. Healthlink Worldwide (2003). Quest manual: your guide to developing effective health communi- cations. London, Healthlink Worldwide, (more details available at: http://www.healthlink. org.uk/resources/quest.html). WHO (1998). The healthy women counselling guide: a model for reaching women. Geneva, United Nations Development Programme/ World Bank/World Health Organization Special Pro- gramme for Research and Training in Tropical Diseases. Do they see malaria as a problem? Are bednets a viable solution? Can they afford them? Section 2 #OMMUNICATION� METHODS 25 4his Section provides an overview of the different communication methods and ways in which they can be used to address particular community medicine use problems. It sets the scene for how to determine the most appropriate method and highlights some of the advantages and disadvantages of different approaches. The four main methods are examined in detail in Chapters 2–5. &OUR�MAIN�METHODS Communication methods (sometimes called channels) usually fall into four broad areas: • face-to-face activities, sometimes called interpersonal communication • drama and other folk media, sometimes called performance, popular or traditional media • mass media, including electronic media • print materials and other support activities. An effective strategy will usually involve a combination of two or more of these approaches, such as face-to-face and print, as shown in the illustration. Training might be needed to develop or improve knowledge and skills to use the different methods effectively. Participatory learning methods will usually give the best results, and will motivate the participants to use the skills well. Below, we brieﬂy explore the ways in which differ- ent communication methods can be used. Some of the advantages and disadvantages of different methods are provided in the summary table at the end of this Section. &ACE TO FACE�COMMUNICATION This is the most direct form of communication. Face- to-face communication is useful for engaging speciﬁc groups in the community, and is essential for encour- aging behaviour change. It also provides opportuni- ties for the community to participate actively in the dialogue and interaction with the communicator, and helps the communicator learn essential things about how community members view problems and solutions, and what experiences they have. Such dialogue and exchange are essential for community members to consider changing their behaviour. However, a face-to-face approach requires ﬁeld staff with adequate time and strong communication skills. There are also training, transport and materials costs to be met. Face-to-face communication methods are widely used everywhere: in work- places, in health care facilities, in the community, among groups and in training programmes. Chapter 2 provides more detail on face-to-face communication. $RAMA�AND�OTHER�FOLK�MEDIA In communities, a wide range of drama and other folk media exist that can be mobilized in health communication activities. Their impact and popularity are widespread especially in communities with strong oral traditions. The example from Pakistan given in Chapter 1 shows the way in which a socially accept- able communication medium such as theatre can be used to tell a story about a 3%#4)/.��#/--5.)#!4)/.�-%4(/$3 (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 26 problem, portray issues and identify who needs to be involved in a solution, and help to open up a dialogue about how to move forward. Chapter 3 provides more details on drama and other folk media. -ASS�MEDIA��INCLUDING�ELECTRONIC�MEDIA Mass media can be useful for promoting awareness and raising interest in an issue, but do not usually lead to behaviour change. They are good for reaching large numbers of people quickly with general messages. Although the cost is high, the large audience makes them cheap in terms of cost per person reached. Mass media, including television, radio, newspapers and the Internet are discussed in more detail in Chapters 5 and 6. 3UPPORT�ACTIVITIES��INCLUDING�PRINT�MATERIAL You can increase the impact of your communication programmes with well- designed and appropriate print and other support materials. These may be needed to explain difﬁcult points, to help people remember key messages or to serve as a trigger to promote discussion. They are widely used in training and learning situations. Materials can appear in printed form, for example, leaﬂets, wall charts and discussion posters. Games or music/stories on audio cassettes or videos can also be used. Helpful materials may have already been produced by others. However, things developed for other communities may not be understood or accepted by your own community. They will either have to adapted or new material will have to be developed. Printed material is discussed in more detail in Chapter 4. #HOOSING�A�COMMUNICATION�METHOD� The choice of communication method will depend on what you are trying to achieve, the characteristics of your audience, and the resources and constraints you have. Table 4 highlights some of the questions to consider in making a choice. But remember that it is likely to be a combination of methods that prove to be the most effective, as the example of a hygiene promotion programme in Burkina Faso shows (see Box 7). "/8�� ,/#!,�2%3%!2#(��,/#!,�-%$)!�,%!$�4/�#(!.'% Hygiene promotion programmes can change behaviour and are more likely to be effective if they are built on local research and use locally appropriate channels of communication repeatedly and for an extended period of time, says a study from Burkina Faso, reported in the June 2001 issue of the Bulletin of the World Health Organization. Changes resulting from the intervention included increased hand-washing with soap after cleaning a child’s bottom (from 13% to 31%) or after using the latrine (from 1% to 17%). Focus group discussions and a small, population-based questionnaire were used to identify local channels of communication suitable for speciﬁc target groups. Among the channels used were: face-to-face home visits, discussion groups in health centres and in the community, street theatre, local radio spots and programmes, and hygiene curriculum in primary schools. Source: Curtis V et al. (2001). Evidence for behaviour change following a hygiene promotion programme in West Africa. Bulletin of the World Health Organization, 79(6):518–527. http://www.who.int/bulletin/archives/79(6)518.pdf 27 4ABLE��1UESTIONS�TO�CONSIDER�IN�CHOOSING�COMMUNICATION�METHODS AUDIENCES What are the characteristics of the audiences you want to work with? • age • gender • language, including the words they use to describe health conditions or medicines • life experience • education and literacy level • previous exposure to pictures • ownership of radio/TV • listening, watching, reading habits • familiarity with different media, including local and traditional • what do they know, believe and feel about the particular health issue or about particular medicines? • what do they see as being the most important problems with the use of medicines? Is this a priority for them? What do they believe is the cause of the problem? • how strongly held are their beliefs? • how open are the audiences to new ideas? • are there cultural norms around what type of health issues can be publicly discussed? • where do they usually ﬁnd information about health issues and the use of medicines? • who inﬂuences them to take action or change practices or behaviour? • where do they go to or meet regularly? OBJECTIVES Are you trying to: • convey simple facts? • share complex information? • teach problem-solving skills? • train in practical skills? • encourage community dialogue? • facilitate individual or social change? • advocate for policy change? RESOURCES/CONSTRAINTS • how much will different methods cost, including staff and equipment costs, and what budget do you have for the communication intervention? • how many staff and what level of skill are involved in using the method? • will you need trained ﬁeld workers or outreach workers to implement the method? • how much time do you have? How urgent is your time-scale? • are there underlying political or power issues that may emerge as a result of the communication intervention? Are your communicators/facilitators trained to deal with these? Source: Adapted from Hubley J (2004). Communicating health. Oxford, Macmillan. Three key questions that can help you to decide which communication approaches to use are: • what audience(s) are you planning to work with? • what objectives are you trying to achieve with those audiences? • what resources can you mobilize and what constraints do you face? !UDIENCES� You will usually need to reach both primary and secondary audiences. Primary audiences are those who make decisions for them- selves, for example a patient or mother (left). Secondary audiences are those who have inﬂuence over other people’s decisions, for example, the husband of a pregnant woman, a family elder, a community opinion leader (right) or a traditional healer. While some communication may raise general points aimed 3%#4)/.��#/--5.)#!4)/.�-%4(/$3 (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 28 at the whole community, most of it is likely to be focused on speciﬁc audiences. Examples of speciﬁc audiences are mothers of children under ﬁve, husbands, moth- ers-in-law, family elders, people with speciﬁc illnesses, school children, traditional healers, health workers, journalists, policy-makers and community leaders. The clearer you can be in determining speciﬁc audiences, and the more you can learn about what they know and understand about the topic, the easier it becomes to decide how best to communicate with them. A general communication campaign directed at everyone can fail because it does not meet the needs of speciﬁc sections of the community. One approach is to create awareness and interest by developing a general message that is relevant to everyone and promote it through mass media. Face-to-face communication can then be used with speciﬁc audiences to encourage people to change. You should keep your programme simple and aim to reach only two or three audiences at a time. On the basis of your formative research, start with those who you think are more likely to respond positively to new information, a new idea, new knowledge, or who appear ready to change an attitude, practice or behaviour. #OMMUNICATION�OBJECTIVES You cannot change someone else’s behaviour. People have to take the decision themselves to change, and may do so if they are treated with respect, given appro- priate information by a credible person, and the situation involves an emotional aspect (such as a sick child). If you want to support the change of a particular behaviour, you will need to inﬂuence the factors that shape it. This may include knowledge, skills, attitudes, beliefs, values and empowerment. Some methods are more appropriate for particular communication objectives (see Figure 2). For example, simple facts, the name of a medicine or a disease can be communicated using methods such as short advertisements on mass media or posters. However, more complex facts such as the cause of a disease or the life- cycle of a parasite take a longer time to explain – especially if the information you are trying to communicate is different from what the community already knows or believes about the problem. Usually this will require some form of face-to-face communication. Your communication objective may well be to teach a skill. These fall into three broad headings: • decision-making skills such as when you can treat an illness at home, when to go to the doctor and knowing when side-effects require prompt action • communication skills such as explaining a health topic to one’s children or partner • manual skills such as preparing and giving medicines. &IGURE�� #HOICE�OF�METHODS�ACCORDING�TO�COMMUNICATION�OBJECTIVE 3IMPLE�FACTS -ORE�COMPLEX�FACTS $ECISION MAKING�SKILLS #OMMUNICATION�SKILLS -ANUAL�SKILLS !TTITUDES�BELIEFS�VALUES %MPOWERMENT )NCREASING EFFORT�TIME� FACE TO FACE�CONTACT NEEDED�TO�� CHANGE 29 The best way to teach a skill is to ﬁrst demonstrate it. You can per- form a role-play to show good com- munication, show a manual skill, such as making up oral rehydration solution (ORS) or give examples of decision-making. Afterwards let people practise the skill themselves through role-plays or exercises and give them feedback. If the new skill is very similar to skills the community already knows, you may be able to explain the skill using mass media or large-scale demonstrations at meetings. However, if the skill is a new one, some form of face-to-face contact is needed, with opportunities for those learning to give feedback. Beliefs, attitudes and values can include beliefs about the causes of disease, the value of traditional medicine, the importance attached to being respected in the community, the value of following the advice of an elder and the value of being a good mother. These ideas operate at a deeper level than knowledge and are much more difﬁcult to change. Effective change programmes respect and build on existing perceptions and beliefs, attitudes and values and start building bridges to different ideas using participatory processes. Such approaches often result in the people themselves deciding to change, by taking on their new understanding and being empowered in the process. Changing attitudes, beliefs, practices and values must be built on a process of dialogue with the community. Such a communication approach takes time, a very careful plan and people with credibility in and respect for the community culture. $IFFERENT�OBJECTIVES�AT�DIFFERENT�STAGES The communication objectives – and therefore the methods – can change at dif- ferent stages of a communication programme. When changing behaviour, the individual, community or institution goes through a series of steps – sometimes moving forward, sometimes moving backward and sometimes skipping steps. Figure 3 shows the different stages and the need to use different methods for communication. Even when individuals, communities, or institutions adopt new behaviours, they may at times revert to old behaviours, at least under certain circumstances. Understanding where the majority of a group is in the change process is crucial 3%#4)/.��#/--5.)#!4)/.�-%4(/$3 0EOPLE�CAN�MOVE�THROUGH�STAGES�BEFORE� ADOPTING�A�NEW�BEHAVIOUR� -ETHODS�SUCH�AS�MASS�MEDIA�ARE�� USEFUL�AT�THE�EARLY�STAGE�FOR�PROMOTING� AWARENESS�AND�INTEREST� &ACE TO FACE�METHODS�MAY�BE�NEEDED�� TO�BUILD�ON�AWARENESS�AND�STRENGTHEN� RESOLVE�TO�CHANGE�BEHAVIOUR &IGURE�� #OMMUNICATION�OBJECTIVES�AT�DIFFERENT�STAGES�OF�A�PROGRAMME 5NAWARE�OF�ISSUE !WARE�OF�ISSUE )NTEREST�IN�CHANGING� BEHAVIOUR 4RYING�OUT�NEW�BEHAVIOUR %VALUATING #HANGING�BEHAVIOUR -AINTAINING�CHANGE (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 30 when designing a communication strategy. Different channels have been shown to be more effective at different stages of the continuum and for achieving different goals. Communication through mass media can ensure that correct information reaches a speciﬁc population and can model positive attitudes. To motivate an individual or community to attempt new behaviours, face-to-face communication is usually needed. In addition, policies and the larger social environment become more important. When audiences become ready to change, the activities, services or products being promoted must be available to them. 2ESOURCES�CONSTRAINTS Among the questions you should ask are: can you afford it? Do you have access to ﬁeld staff? Can you involve other agencies? Do you have the equipment? Are the right conditions available to use the method in your community? You may ﬁnd yourself in a situation where you are not able to use a method because it costs too much or you do not have access to it. If that is the case, persevere. The following ideas might help: • Try simpler and cheaper methods ﬁrst. Monitor and evaluate their impact. If those do not work, you can then try more expensive methods. • If you do not have access to ﬁeld staff with technical skills, are there other organizations or groups you could involve in your programmes that do have suitable ﬁeld staff? • Can you work to mobilize existing skills and resources in the community to do their own work with only limited input from the outside? • If you do not have money to purchase advertising time, look for ways of work- ing with members of the media to encourage them to cover your topic at no cost (see Chapter 6 on working with journalists). • Don’t give up! Are there sympathetic donors who might be prepared to provide additional funds if you can justify that they are necessary? &IELD�STAFF To carry out face-to-face communication methods you need to have ﬁeld staff available who have sufﬁcient skills. These ﬁeld staff might be people in your own organization, ﬁeld staff from other services, NGOs or volunteers. Start by decid- ing who should carry out the interpersonal communication activities and deﬁne their role by preparing a job description. You should then make sure the activi- ties you want them to do are realistic. You will have to train them to carry out any unfamiliar tasks. Even if they already have good communication skills, you will need to provide some orientation to your programme, including any speciﬁc knowledge required. If you develop any new materials you will need to train your ﬁeld staff to use them. Training will usually require some kind of workshop where the trainees have an opportunity to practise the required communication skills. Chapter 2 on face-to-face communication gives examples of methods for training health workers in communication skills. )MPORTANCE�OF�MONITORING�AND�EVALUATION Keep in mind that there are no guarantees of success. That is why pre-testing communication materials is important (see Chapter 10). What has worked in one country or community may not work in another – but looking at what works in 31 3%#4)/.��#/--5.)#!4)/.�-%4(/$3 4ABLE�� !DVANTAGES�AND�DISADVANTAGES�OF�DIFFERENT�COMMUNICATION�METHODS� METHOD EXAMPLE ADVANTAGES DISADVANTAGES Mass media Television • Broad reach • Television ownership may be • Can use entertainment to restricted to higher-income, convey key ideas urban population • Cost per person reached can • High initial production cost be low • Difﬁcult to meet needs of • Can reach low-literate speciﬁc groups audiences • Lack of immediate feedback • Combines visual images with • Needs electricity access spoken word • Can inﬂuence behaviours that are not deeply entrenched Radio • Very broad reach • Similar problems as TV: • Regional radio provides difﬁculty making content opportunity to broadcast in speciﬁc to different local local languages communities and to obtain • Easy to include content from feedback interviews/music recorded • Lacks a visual dimension in local communities • Radio sets often controlled by men Mass media/ Newspapers, • Reach can be broad • Written material unsuitable for Print posters, leaﬂets, • Can be distributed to highly non-literate communities manuals targeted group and inﬂuential • Reach of newspapers may be people limited • Can include pictures • Some print materials may have • Can provide background or limited distribution detailed information Folk media/ Using folk media, • Takes activities to the • Field staff may not be available (face-to-face) theatre, songs, community and is therefore or appropriately trained dance in community good for difﬁcult-to-reach • Takes longer to reach the settings, for example groups audience bars, roadsides, • Allows for a focus on the • Performances may be markets and public audience’s special needs interpreted differently in places • Can stimulate interaction different settings and discussion • Can be very effective in inﬂuencing beliefs, attitudes and behaviours, providing speciﬁc skills and generating empowerment Face-to-face Individual or • Can be tailored to the • Only reaches those people who small group audience’s speciﬁc needs use services (but through them for example patient • Can be very effective in can reach family members and education, schools, inﬂuencing beliefs, attitudes neighbours) workplace, training and behaviours, providing • Formal setting can inhibit the speciﬁc skills and generating use of participatory methods empowerment • Time may be limited because • Can be delivered efﬁciently of work pressure • Stimulates dialogue • Encourages teacher to learn Large groups • Capable of generating a large • Without advance preparation Public meetings, amount of interest and follow-up may not lead to folk media • Can lead to community lasting change participation • Depends on skilful facilitation (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 32 other places is a good starting point. You will need to build up your own experi- ence based on evaluation of what has worked in your communities, using other programmes as an inspiration. The best approach to take is a ﬂexible one. Prepare a strategy that ﬁts in with what you know about the problem and the community, then implement it and monitor and assess the impact. On the basis of your moni- toring and evaluation you should respond quickly, and adapt and improve your methods and how you are communicating. Monitoring and evaluation are discussed in more detail in Chapter 11. At this point, remember that you should look for both short-term and long-term changes. Short-term monitoring and evaluation is particularly important because you can use the results to improve your programme. However, you have to be realistic about what can be achieved in the short-term and what may require more time. In the short-term you can ﬁnd out how many people were reached by your intervention, and if it had an impact on people’s knowledge and skills. In the longer-term, you can ﬁnd out if the early knowledge gains were sustained and led to changes in behaviour, empowerment and health. In some cases, for example, around issues such as access to antiretroviral drugs (ARVs) for use with people who are HIV-positive, an indicator of impact may be the degree to which dialogue about this issue increases in society. Unless people are talking about the problem, ﬁnding possible solutions becomes more difﬁcult. Another use for monitoring and evaluation is to identify when a communication intervention on its own is not working. This often means that something else needs to happen – a policy change may be needed or other changes may be necessary to improve the management and supply of medicines, or regulate advertising and promotion practices that compete with the intervention. 3UMMARY The choice of an intervention will depend on the type of medicine use problem and the reasons why it exists. Not all interventions are equally effective (Holloway and Green, 2003). Over the years, experience and studies have shown that: • a combination of strategies – for example, communication with managerial staff or those who create an enabling environment – always produces better results • a one-off communication interven- tion is usually not very effective and its impact is not sustainable • focused small group and face-to- face interactive workshops have been shown to be effective, if effective trainers or facilitators are used • the use of print materials alone is not effective • monitoring and feedback and peer review are very effective managerial strategies, but require the agreed use of standards against which to judge prescribing and medicine use • regulatory interventions may have unintended impacts that may be worse than the intended change (substitution of a less appropriate drug or a more expensive one for a banned drug, for example). 33 &URTHER�READING Fresle DA, Wolfheim C (1997). Public education in rational drug use: a global survey. Geneva, World Health Organization. Haaland A, Molyneux S (2006). Quality information in ﬁeld research. Training manual on practical communication skills for ﬁeld researchers and project personnel. Geneva, UNICEF-UNDP-World Bank-WHO Special Programme for Research and Training in Tropical Diseases. Hubley J (2004). Communicating health: an action guide to health education and health promotion. 2nd ed. Oxford, Macmillan. Piotrow P et al. (2003). Advancing health communication: The PCS experience in the ﬁeld. Baltimore, Johns Hopkins Bloomberg School of Public Health Center for Communication Programs. Piotrow P et al. (1997) Health communication: lessons from family planning and reproductive health. Westport, CT, Praeger Publishers. US Department of Health and Human Services (2002). Making health communication programs work: a planner’s guide. 2nd ed. NIH publication no. 89-1493. Bethesda, National Cancer Institute. (Available at: http://publications.nci.nih.gov then perform a search on Publica- tions). WHO (2004). How to investigate the use of medicines by consumers. Geneva, World Health Organization. Women’s Health Project and WHO/TDR (1999). Impact studies of Health Workers for Change. Johannesburg/Geneva, Witwatersrand University/World Health Organization Special Pro- gramme for Research and Training in Tropical Diseases. Women’s Health Project and WHO/TDR (1998). Health Workers for Change: a manual to improve quality of care. Johannesburg/Geneva, Witwatersrand University/World Health Organization Special Programme for Research and Training in Tropical Diseases. 3%#4)/.��#/--5.)#!4)/.�-%4(/$3 &ACE TO FACE�COMMUNICATION 2 Using medicine is very personal. It touches deep beliefs about our health, and ulti- mately about life or death. To change the way we use medicines, we need to talk with a person we trust. This person needs to know about and respect our ideas, and to have good communication and education skills. If we are to take action on new instructions on which medicines to use, and how to use them correctly, or when they are not needed at all, the person should be easy to contact. We may have questions about the drugs, and we may have forgotten exactly how to use them after some time. Face-to-face communication is used in various situations, from direct dialogue within communities, to advocacy around policy, and in pretesting. This chapter focuses on face-to-face communication. This chapter examines: • What face-to-face communication is • Why it is important and what you can achieve with it • How and when to use face-to-face communication • Advantages and disadvantages • How to use face-to-face skills as part of a communication strategy to address medicine use in communities. 7HAT�IS�FACE TO FACE�COMMUNICATION� Face-to-face communication involves two or more people in a direct exchange of views, experiences, information and knowledge. It may be one-to-one, or it may involve groups of people in dialogue. For rational medicine use, the facilitator of the dialogue could be, for example, a trainer, a drug dispenser, a health worker (formal or informal), or a community leader. For good face-to-face communication, the attitude of the dialogue facilitator is as important as his or her knowledge. (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 34 35 ��&!#% 4/ &!#%�#/--5.)#!4)/. Box 8 identiﬁes some key characteristics of good face-to-face communication. The method can be used directly to discuss the use of medicines with a customer or a patient. It can also be used in other situations like supportive super- vision, training courses, or convincing managers of the need for a programme or activity. Face-to-face is a powerful communication method to improve people’s understanding of why and how to use drugs correctly. Lack of communication and understanding will often lead to problems of low adherence to treatment and other misuse of drugs. 3TUDIES�SHOW�THE�IMPACT�OF�FACE TO FACE A review of 37 studies on patients’ compliance with medical treatment in develop- ing countries, all of which studied compliance from the biomedical perspective (Homedes and Ugalde, 1993), states that: • several studies found that “teaching patients in the administration of thera- pies increased compliance” (using face-to-face communication). • poor communication between practitioner and patients was the most frequent problem leading to non-compliance (Mull et al., 1989). • lack of continuity in patient-physician interaction contributed to non- adherence. • most cases of non-compliance were due to patients not understanding the problem and miscommunication between family and health providers (Mar- tinez et al., 1982). • when non-compliers receive education, they comply (Martinez et al., 1982). &ACE TO FACE�ESSENTIALS��ACTIVE�INVOLVEMENT�OF�AND�RESPECT�FOR�PEOPLE In an address to the 1986 World Health Assembly, Halfdan Mahler, former Director- General of WHO, said: “primary health care starts with people and since they have a major role to play in solving these problems they have to be actively involved in doing just that rather than being passive recipients of care from above . for people to be intelligently involved in caring for their own health they have to understand what leads to health and what endangers it . the very ﬁrst element of primary health care is educating people and communities on health matters”. "/8��7(!4�#(!2!#4%2):%3�'//$�&!#% 4/ &!#%�#/--5.)#!4)/.� • Relevant to personal and cultural needs: The content is established through formative or participatory research. • Respect and bridge-building: For people to consider change, the facilitator needs to understand and respect their present practices, and be able to make a bridge from these to the new practices. Understanding reasons for practices is necessary for effective bridge-building. • Skills and credibility: The facilitator is skilled in participatory education and communication techniques, and has credibility in the community. • Key information: The facilitator focuses on key information relating to behavioural change, using simple local language. • Discuss and negotiate: The facilitator listens carefully to the people receiving the information, watches their body language and discusses suggestions for new practices. • Check for understanding: The person repeats key information, for example, about dosage of drugs, to make sure he/she has understood what to do. (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 36 Face-to-face communication will only be effec- tive long-term if developed through interaction with the community. The interaction must build on an understanding of and respect for present practices, and use this as a bridge to explaining new practices (understanding what is important to people, and why). To be able to help a client or customer solve a problem or change a practice (which is usually the aim of face-to-face communication), you need to be able to understand what is important to the person, and see the problem from his or her perspective – to understand WHAT he or she does, and WHY, and HOW the person thinks and acts, and what the reasons behind beliefs and actions are. A sensitive and skilled communicator can link this understanding to the new practice a person is encouraged to use, and help him or her see and recognize connections. If we as communicators only attempt to get people to change one (bad, from our point of view) practice with another (good, from our point of view), without addressing the underlying reasons for the practice, then the change will be super- ﬁcial, and will not last. It is very likely that there will be no change at all. !DVANTAGES�AND�DISADVANTAGE The most important advantage of face-to-face communication is that in principle, it is easy to see whether the communication is working. Feedback is usually imme- diate and it is an easy method to adjust and modify quickly, and make relevant to the people with whom you are communicating. The main disadvantage is that it takes time and is resource-intensive, both in terms of people needed and the costs of reaching people. However, that disadvantage is true of all good communication: it takes time and skilled people, and involves costs if it is going to be effective. Box 9 summarizes the main advantages and disadvantages. 7HERE�AND�HOW�CAN�FACE TO FACE�COMMUNICATION�BE�USED� Face-to-face can be used: 7HERE� • In one-to-one and small groups: the most effective way of using face-to-face is probably in a one-to-one situation, but face-to-face can also be used in small groups. In a larger group, there is less time and opportunity for interaction, and thus less likelihood that all participants have the chance to express their concerns and have them addressed. • In many venues: such as health clinics, pharmacies, local shops, community groups and in households. (OW� • To change practices: face-to-face is an effective method to encourage people to change practices, such as how they use drugs. When used well, it can result in important changes • With other methods: to increase awareness about the need for change, and to give opportunities to discuss the topics. 37 • With educational materials: face-to-face should be supported by educational materials, such as drug instructions or leaﬂets, to help the client or customer remember why and how to take the medicines. The choice of setting will depend on the speciﬁc problem and the audience. Interaction between health workers and patients, usually in formal health facili- ties is one of the most frequent uses of face-to-face communication. This will be explored in some detail in this chapter, but it is worth remembering that other settings offer considerable opportunities for community dialogues around rational medicine use. #OMMUNICATION�AT�HEALTH�FACILITIES Health facilities provide many communication opportunities. Activities can focus on patients who are coming for treatment or their caretakers and healthy people who are making use of preventive services such as child health, antenatal care and family planning. The success of face-to-face communication in a health centre depends on the quality of the interaction between health care providers and patients. This quality may be low because communication skills are frequently not taught during pro- fessional training, and patients may not know how to elicit the information they need in an unfamiliar and sometimes intimidating environment. Improving the quality of communication is an important priority. This means making sure the patient understands everything the health care provider says, remembers the key points and is empowered in turn to provide key information and to ask questions. ��&!#% 4/ &!#%�#/--5.)#!4)/. "/8��!$6!.4!'%3�!.$�$)3!$6!.4!'%3�/&�&!#% 4/ &!#%�#/--5.)#!4)/. !DVANTAGES� • Improves adherence to treatment: Learning about correct drug use in a dialogue with an effective communicator enhances understanding and helps people use drugs better. • Empowers people: Learning why you need to use the drugs in a certain way gives people new knowledge, which they will use to make their own (informed) decisions now and in the future. • Motivates learning: An effective dialogue between the health worker/provider and client/customer can motivate further learning about health. • Encourages changes in behaviour: When people see that the new ways of using drugs actually work, many will leave their previous practices behind and continue to use drugs (biomedically) correctly. • Closer to home: Training face-to-face communicators in the community (informal providers, community health workers) gives people access to quality service closer to home, from people they trust, and who respect them as fellow community members. This reduces the economic burden of having to travel to the clinic when it is not necessary. $ISADVANTAGES�� • Expensive: Since the interaction is mostly one-to-one or in small groups, the number of people each communicator reaches is small. • Requires skills and motivation: Finding and training good face-to-face communicators is time- consuming, demanding and expensive. (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 38 "/8��252!,�3(/0+%%0%23�'!6%�#/22%#4�!$6)#%��4(%�+),)&)�345$9 Research from Kiliﬁ, Kenya, demonstrates the potential of face-to-face communication. In a pilot study, shopkeepers from 23 shops were trained to treat all childhood fevers with a full course of chloroquine, and given reasons why they should do so. Participatory methods were used to improve both knowledge of malaria and its treatment and to strengthen communication skills, so that shopkeepers could engage in effective face-to-face communication with customers. While only 4% had given correct advice on chloroquine dosage before the training, 98% did so after the training (in their shops, under observation). Before training, 32% of the customers bought an adequate amount of chloroquine for the child; after training 83% did so. The biggest and most important change came in the amount of chloroquine that was actually given to the child with fever. Less than 4% of the mothers gave an adequate amount to the child over three days before, and 65% did so after the shopkeeper training. This means the mothers were willing to listen to the shopkeepers, and followed their advice - even when it meant spending more money on drugs. The pilot study showed that a very large percentage (83%) of the customers followed the advice of the shopkeepers. This result is to a large extent due to good training and frequent monitoring, which gave the project a relatively high proﬁle and positively inﬂuenced both shopkeepers and customers. In a follow-up study in Kiliﬁ, local government health workers and community health workers (rather than specialist trainers, as in the pilot study) were training the shopkeepers. Mid-term results showed that 95% of the shopkeepers were giving correct advice about the use of chloroquine. Before the training of the shopkeepers, 5% of the mothers used an appropriate dose of chloroquine over three days for their children with fever. After training, 37% of the mothers gave their children a sufﬁcient dose over three days. By 2001 (the end of the programme), and with the introduction of sulfadoxine-pyrimethamine group drugs in accordance with national policy, this proportion rose to 64%. Overall, the proportion of shop-treated childhood fevers receiving an adequate dose of a recommended antimalarial drug within 24 hours rose from 1% to 28% by 2001. In the qualitative assessment, several community leaders, health workers and traditional healers said there was less malaria among the children in their community since the programme started, and fewer children died from malaria. This ﬁnding is not conﬁrmed statistically, but the comments from the leaders and from other community members were consistent on this point and positive overall. Since the project went to scale, training and monitoring of shopkeepers have been conducted by Public Health Technicians (PHTs) and Village Health Workers (VHWs). The PHTs conduct this training as one of their many duties, and the VHWs are volunteers with no formal background in health or training methods. Both groups receive very basic remuneration for the training they conduct. Considering these limitations, the mid-term impact of 37% of mothers giving their children a sufﬁcient dose of chloroquine still appears high, particularly since this ﬁgure also includes mothers advised by shopkeepers who have not been trained (assistants in shops included in the study). When including in analysis only shopkeepers who were trained, the result is 49% giving a sufﬁcient dose. The training is being monitored to see how it could be improved. The ﬁnal result of 64% of mothers giving the correct dose of sulfadoxine-pyrimethamine to children with fevers strongly supports the inclusion of private drug retailers in control strategies aiming to improve effective treatment of malaria. Marsh VM et al. (2004). Improving malaria home treatment by training drug retailers in rural Kenya. Trop. Med. Int. Health 9(4):451–460. Marsh VM et al. (1999). Changing home treatment of childhood fevers by training shopkeepers in rural Kenya. Trop. Med. Int. Health ,4(5):383–389. 39 Health workers can be very busy and complain that they do not have time to communicate with patients on speciﬁc topics. In such cases, it is possible to train non-clinical staff to lead on communication around rational drug use. Health workers’ attitudes are often a problem. Many health workers treat patients in an unfriendly way, blaming them for their actions. This prevents patients from learning and from being able to take action to use medicines correctly. #OMMUNICATION�THROUGH�INFORMAL�HEALTH�PROVIDERS Many people visit traditional healers or buy medicines from community pharma- cies or shops. In a number of countries, 60–80% of the medicines for malaria are bought in local shops. The example above (Box 10) shows the potential of using this channel to improve rational medicine use for antimalarials. In some countries, for example Ghana and Nigeria, people may travel from com- munity to community selling medicines. Could these informal health providers become involved in your educational efforts? You would have to train them about rational use of medicines and the importance of educating clients about their use. However, you may face serious difﬁculties. Because selling prescription medicines is usually illegal, it may be difﬁcult to set up ofﬁcial programmes to train shopkeep- ers or travelling medicine salespeople. In many countries training of shopkeepers has however become accepted, as research results have demonstrated the positive effect on learning about how to use drugs correctly. Shopkeepers in the Kiliﬁ study (above) had a high credibility in the community. They were motivated to participate in the training because they learnt to treat their own family members more effectively, the training improved their status in the community, and they earned more money (through people buying and taking full courses of the malaria drugs). /UTREACH�APPROACHES Outreach approaches involve conducting face- to-face communication programmes in com- munity settings. This can include home visits to carry out follow-up interviews with patients or to discuss medicine use with individuals and their families. Community meetings and public events provide good opportunities for dialogue using methods such as drama and folk media. It is also possible to reach inﬂuential persons such as community and religious leaders. In addition to engaging with community members directly, you may also be able to work with other community organizations such as youth groups, women’s groups, farmers’ associations and religious groups to identify how to improve rational medicine use. Box 11 describes the way in which communication outreach activities in Indonesia improved the quality of self-medication. 7ORKING�WITH�SCHOOLS� Schools provide a good opportunity to reach children and parents. Schools can inﬂuence health in three main ways: through the provision of health-promoting school surroundings, through school health education and through school health ��&!#% 4/ &!#%�#/--5.)#!4)/. (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 40 "/8�� )-02/6).'�4(%�15!,)49�/&�3%,& -%$)#!4)/.�4(2/5'(�-/4(%23´�� !#4)6%�,%!2.).'�).�).$/.%3)! There are at least five pieces of information required for appropriate self-medication: information about the active compound; indication; dosage and administration; side-effects; and contraindications. However, a survey carried out in Yogyakarta, Indonesia, in 1993 showed that the level of knowledge mothers had about medicine was considered inadequate to support safe and effective self-medication. The most common lack of information concerns the active compound. Mothers only know the brand-name drugs marketed for a certain symptom. The direct effect of this lack of knowledge can be seen in household drug consumption patterns, where several brand-name drugs with the same active compound are used concurrently. This not only wastes money, but could also lead to overdose of powerful drugs, particularly painkillers. !N�INNOVATIVE�COMMUNICATION�STRATEGY Many types of public education have been tried to improve knowledge about self-medication, such as campaigns through the mass media, seminars and articles in magazines, but their impact has been limited. In a large country like Indonesia, with over 200 million people, it is impossible to rely on the limited drug information services available. A better approach would be to use an innovative communication strategy that promotes active learning; facilitates self-learning; empowers the community with skills and a critical attitude in seeking information; and creates information-seeking behaviour. The learning process should also be transferable. Much of the necessary information is already available on drug packaging in Indonesia. If it is used optimally people would have the facts they need for appropriate self-medication. #")!��TAKING�UP�THE�CHALLENGE CBIA is an abbreviation for Cara Belajar Ibu Aktif (Mothers’ Active Learning Method). It is an educational module developed by the Department of Clinical Pharmacology, Gadjah Mada University, Yogyakarta, in 1993, aimed at improving mothers’ knowledge and skills to select non-prescribed or over-the-counter medicines. CBIA uses a problem-based approach and self-learning process. Information printed on the pharmaceutical package is used as training material. The training is intended to empower mothers to seek and critically assess information on the drugs that they commonly use, and to increase drug procurement efﬁciency in households. #ONDUCTING�#")!�SESSIONS The CBIA module uses small-group (6–8 people), interactive discussions. The process can be incorporated in regular meetings of women’s grassroots organizations, as well as in other arranged gatherings. Not only mothers but fathers, the elderly, teenagers and primary school pupils can all participate. Community gathering points, such as houses, mosques and village ofﬁces, are excellent for conducting CBIA. Students or others familiar with the contents of drug packages can be recruited as tutors, and it is also possible to invite tutors from the target groups. Before carrying out the activity, tutors familiarize themselves with the problems relating to each drug package being used in the session. A pharmacist or physician can be invited as a resource person. Each participant is requested to bring all the medicines they have at home, and in addition reusable sets of medicines can be provided. Each group works with one set of around 30-40 preparations in original packages, with price labels, consisting of several classes of medicine, such as antipyretics/ analgesics, vitamins/minerals and cough remedies. The activity usually takes 2–3 hours. A tutor begins with an introduction on the advantages/ disadvantages of self-medication, and then participants are requested to form small groups. Using the medicines, they observe where they can ﬁnd information on active ingredients, group together over-the-counter drugs based on their main ingredients (not the indications), and then discuss the ﬁndings. 41 ��&!#% 4/ &!#%�#/--5.)#!4)/. 4OPICS�TO�COVER Discussion usually covers the following points, (although experience shows that participants can identify others, and sometimes come up with surprising ﬁndings): • Active ingredients are always stated on the package, and this information is hardly ever found in drug advertisements. Incomplete and unclear information in drug advertisements can be clariﬁed by consulting the drug package. • Brand names may be sold in many different forms such as syrup or tablet, with exactly the same active compound. Participants should learn the difference between brand names with Forte or Plus included, and their conventional forms. • Though the brand names for adults and children are often similar, the active ingredients are sometimes different. Participants should be aware of those differences. • Prices vary between the drug forms, for example, syrups may be 10 times more expensive than tablets. • Drug purchasing can be more efﬁcient if people think about the prices in relation to the dose. Brand names with Forte in may be several times more expensive than the conventional one, although there is only a slight difference in the amount of the active ingredients. • For commercial purposes, the names of active ingredients are often hidden in other names, which are not commonly known by the public. For example, 1,3,7 trimethylxanthine is used for caffeine and paracetamidophenol for paracetamol. After completing the discussion, participants are requested to collect the information needed for appropriate self-medication: the active ingredient, indication, dosage and administration, side- effects and contraindications. At the same time, participants examine the clarity and completeness of information found on each package. The expected impact of this exercise is to encourage participants to read all information critically. )S�#")!�EFFECTIVE� CBIA has been ﬁeld-tested and evaluated in a controlled study, in comparison with a large seminar, which is a more common form of education. One hundred and twelve mothers of low to moderate levels of education were recruited for the study, and randomly assigned to three groups. Group A received CBIA, Group B attended a large seminar to train them in the same skills, and Group C served as the control. The results showed that the scores of the ﬁve main components of knowledge increased signiﬁcantly in both Group A and Group B, in comparison to controls, where there was no change. In addition, the increase in knowledge in the CBIA group was signiﬁcantly greater than among mothers attending the large seminar. Furthermore, the number of brand name drugs used in households in a one- month period reduced drastically in Group A ( from 5.3 to 1.5), while in the other groups the number of medications did not change. Not only was the CBIA approach effective in increasing knowledge and reducing the number of products used, but all of the mothers who underwent CBIA intervention found this type of problem- based learning enjoyable. After dissemination of the ﬁeld-test results, CBIA was replicated by interested colleagues in various settings. Feedback on use of the intervention shows that CBIA works well with groups of mothers, fathers, the elderly, teenagers and primary school students. The best results were achieved with mixed groups. Experience shows that a forum consisting of mothers, fathers and family members living in an immediate neighbourhood resulted in a more sustained impact. A practical guide to conducting CBIA has been developed by the University of Gadjah Mada. Source: Suryawati S (2003). Improving the quality of self-medication through mothers’ active learning in Indonesia. WHO Essential Drugs Monitor No. 32. Available at: mednet2.who.int/edmonitor/32/32_12.pdf (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 42 services. Of special importance are the opportunities provided for health education of school children and reaching out to parents through school-based activities in the community. Programmes such as Child-to-Child have prepared activity sheets which suggest ways in which teachers can carry out education about use of medicines. Half the population in developing countries is under the age of 15. The potential for teaching children about the risks and beneﬁts of medicines is enormous in both devel- oping and developed countries. Children are already very active users of medicines and they are also often sent to buy drugs in the shops (Geissler and Meinert, 2001). There is increasing interest in training teachers in ﬁrst aid, referral of sick children and in the use of simple medicines dispersed through a school medicine chest. Schools are also being used for mass treatment programmes such as de-worming, ivermectin distribution (for onchocerciasis or river blindness) and vitamin A and other micronutrient supplementation. "/8��53).'�#!24//.3�!.$�4!,+3�4/�).&/2-�3#(//,�#(),$2%.�!"/54�� !.4)")/4)#�53%�).�37%$%. A mix of face-to-face and print communication in Sweden for primary school children – making use of a photo novel with cartoons and teachers’ guidelines – was found to increase children’s knowledge about the rational use of antibiotics. Teachers found the material easy to use and both teachers and children liked the intervention, particularly as it captured children’s interest. Educational entertainment materials were developed together with children, medical doctors, pharmacists, health communicator, photographer, and designer. The intervention consisted of a one-hour lecture covering infections, treatment, hygiene and pathogens, followed by reading of the cartoons. It was evaluated by knowledge-assessing questionnaires, interviews, and focus group discussions (FGDs). Kristiansson C, Cars O, Torell E, Hartvig P (2004). Children as health information carriers: an “Edutainment” intervention concerning rational use of antibiotics. Presentation at the International Conference on Improving Use of Medicines (ICIUM) 2004, Chiang Mai, Thailand. Available at: http://mednet3.who.int/icium/icium2004/resources/ppt/CH022.doc #OMMUNITY�PARTICIPATION� Community participation approaches depend upon the active involvement of community members. This approach calls on them to take part in the process of planning, implementing and evaluating the communication activities. The starting point for community participation approaches is dialogue with the community to determine their felt needs and concerns. This is followed by participatory learning activities which encourage discussion, the sharing of expe- riences and allowing individuals, groups and communities to discover their own solutions to problems. Recently the United Nations Development Programme (UNDP) and others have been developing successful ‘community conversation’ or ‘community dialogue’ interventions in Africa and Asia to explore sensitive community issues. Box 13 describes some of the impact this approach is having in Ethiopia. While the concept of community participation is widely promoted and can lead to effective and sustainable change, it takes time, effort and care to involve 43 ��&!#% 4/ &!#%�#/--5.)#!4)/. "/8�� %.'!').'�4(%�#/--5.)49�).�#/.6%23!4)/. The Community Conversation approach is being used in Ethiopia to stimulate changes in social norms, values, and customs, and to increase community acceptance of people living with HIV and AIDS. It is based on the recognition that communities have their own capacity to care, change and sustain hope, and that local responses to the epidemic need to take into account the community’s existing social dynamics, relationships and concerns. Trust and respect are critical, so that genuine interaction can stimulate sustainable changes from within the community, related to prevention, care, eventually treatment and reducing the impact of the epidemic. The approach uses participatory methodologies that stimulate a ‘Community Conversation’ and reﬂection on deep issues and concerns related to people’s lives, values, attitudes, behaviours and choices in the context of HIV and AIDS. The aim is to increase understanding of how change happens. The methodologies include storytelling, strategic questioning, active listening, reflection, participatory evaluation and documentation, and they are related to ‘social capital’ and socio-cultural dynamics. Social capital refers to the social and cultural coherence of society, the norms and values that govern interactions among people and the institutions in which they are embedded. The kind and the extent of linkages and relationships within a community are critical determinants of the spread and impact of the HIV and AIDS epidemic. A Community Conversation starts from where people are – from their perspectives of the situation and their interest in change. Participants are grouped and undertake a conversation, facilitated by a well-trained facilitator from among themselves, to reﬂect, discuss and present. Their discussion might address questions such as: ‘How would you describe the nature of the AIDS epidemic in your community/country?’ It is explained that the methodology is like a staircase, taking steps together, learning together and moving towards the community’s goal. Then the following steps in the facilitated community change process are explained, and skills and tools identiﬁed: 1. Relationship-building: necessary for gaining mutual trust, understanding and respect, and so that the community will talk about their real problems. 2. Identification of community concerns: these are general issues that worry or disturb the communities; from these they extract their needs, which are more speciﬁc. 3. Exploration of community concerns: looking for a deeper understanding of the underlying factors causing the identiﬁed problem. 4. Decision-making: based on the community’s identiﬁed concerns and ﬁndings from their exploration of these; known also as the planning phase. 5. Action (implementation): this must involve as many community members as possible so that they can take ownership, and ensure sustainability. 6. Reﬂection and review: participatory processes should be used, with the communities identifying their own changes and indicators of change. The process has achieved remarkable breakthroughs in Ethiopia, providing people with the means of identifying their own problems and solutions. People are now openly talking to each other about ‘taboo’ subjects, understanding which of their cultural norms and values are fuelling the epidemic, and identifying the social capital within the community to overcome them. Changes have included: • shifting perspectives, attitudes and cultural practices on gender issues • taking action to know one’s own HIV status Continued (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 44 communities successfully. Communities can be divided and not have a common purpose. They can be suspicious of outsiders. If you want to use a community participation approach, you must take the time to understand the community and use ﬁeld workers who are good listeners and sensitive to the needs of communi- ties. This process of listening and dialogue takes time. However, the time spent should result in a programme that meets local needs and involves the community in deﬁning problems, the reasons for them and identifying possible solutions. Pro- grammes using a community participation approach therefore have been shown to have a more long-lasting and sustainable impact. One of the key outcomes of a more participatory approach to communication activities should be a greater sense of empowerment among the community mem- bers involved in a programme. Box 14 explains what is meant by empowerment in the context of health. Box 13 continued • learning how to prevent infection and make health services safer • assuming accountability for actions and lifestyles • distinguishing between cultural practices prescribed by religion, and those that have been attributed to religious requirements in error. The methods have been used in two selected areas: Alaba district in the south, and the Borena area in Oromya region. The Community Conversations have led to the abandonment of a number of age- old customs and practices that have been fuelling the spread of HIV. For example, in the Borena area, participants in Community Conversations have decided to abandon wife sharing (Warsa), rape (Jala), multiple sexual partnership (Jalaﬁ Jalto) and other customs that were increasing their exposure. Participants have also become interested in knowing their sero-status. In Alaba discussions about HIV and AIDS are now much more open, and practices such as female genital mutilation, wife sharing, and abduction and sharing of the bride (Jalla), are now being challenged through discussion. Source: Bogale H (2004). Engaging in community conversations. SIPAA News, No. 1. Support to the International Partnership against AIDS in Africa (SIPAA). "/8��%-0/7%2-%.4 An empowered person or community has the necessary understanding of health issues and has acquired any needed skills. However, most importantly, she or he has the conﬁdence to put those two things into practice. The key to an effective empowerment approach is to use face-to-face methods to encourage community participation that leads to understanding problems and perceived reasons for these, ﬁnding solutions and taking action. The community empowerment approach to health promotion is quite different from traditional persuasion-oriented health education. The empowerment approach: • uses a small group face-to-face approach • avoids a top-down model with solutions imposed from above • respects and builds upon the community’s knowledge, perceptions, practices and strengths • encourages discussion and dialogue • helps the community to discover solutions to problems. Empowerment is increasingly seen as one of the most important but difﬁcult objectives for health communication. Source: Adapted from: Lavarack G (2004). Health promotion practice: power and empowerment. London, Sage Publications. 45 3ELF HELP�AND�ADVOCACY�GROUPS� Self-help groups consist of people with a shared interest who come together to support each other. Self-help groups have been formed for many health issues, for example alcohol abuse, weight problems, parents of children with diabetes, and people living with HIV. Sometimes groups are formed by people themselves because of a shared need. In other situations, health workers have encouraged patients with similar problems and their families to meet and support each other. Such groups can be important sources of information and support. However, it should not be assumed that all of these groups operate solely to promote the interests of patients. Sometimes they are heavily sponsored and/or sometimes may be used as “fronts” for pharmaceutical companies interested in advocating the uptake of their products by consumers, social insurance groups and drug regulatory agencies. Advocacy groups aim to inﬂuence the policies of governments and companies and provide information to the public. This is covered in more detail in Chapter 7 on advocacy and networking. ,EARNING�THROUGH�DIALOGUE A study in Kenya and Indonesia (Ross-Degnan et al., 1996) assessed the effect of one-to-one training of pharmacists and group training of pharmacy counter attend- ants. The results show a signiﬁcant increase in knowledge, and a 30% increase in ORS sales in Kenya and 21% in Indonesia. There was also a trend towards increased communication in both countries, and in Kenya a signiﬁcant increase in discus- sion about dehydration during pharmacy visits. The researchers did not measure the long-term effect of their intervention. Another approach, and one which illustrates a different role for health work- ers, is outlined in the case study from Nepal in Box 16. This highlights the way a dialogue process in the community can bring about a change in practice. 3ELECTING�COMMUNICATORS� The people who we allow to inﬂuence us to change are usually important people to us – someone we trust, someone we have known for a long time, or someone we respect for a number of different reasons. The person needs to be someone we can identify with, someone who is close enough to us in status, function, culture, or way of thinking. ��&!#% 4/ &!#%�#/--5.)#!4)/. "/8�� $)!,/'5%�4/�2%$5#%�4(%�53%�/&�).*%#4)/.3�).�).$/.%3)! A series of interactional group discussions (IGDs) involving physicians, paramedics and patients has led to a signiﬁcant reduction in the use of injections in public health facilities in Indonesia. Each IGD of 12 people had 6 prescribers and 6 patients. The session lasted 90–120 minutes and was held in a relaxed informal setting of a restaurant with a free meal provided. The session included an exploration of the feelings of members about being included in the group, discussions of the discrepancies between the prescribers’ and patients’ beliefs and motivations for injection use, the presentation of scientiﬁc materials and a conclusion. An evaluation found that compared to patients not taking part in the IDGs, the programme reduced use of injections from 70% to 42%. Injections of analgesics and vitamins were almost halved. There was also a signiﬁcant decrease in the average number of drugs per prescription. Hadiyono JE et al. (1996). Interactional group discussion: results of a controlled trial using a behavioural intervention to reduce the use of injections in public health facilities. Social Science & Medicine, 42(8):1177–1183. (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 46 "/8��,%33/.3�&2/-�/23�#/--5.)#!4)/.�).�.%0!, A 1982 survey in Nepal showed that 40% of people were aware of ORS, but less than 5% used it when their children had diarrhoea. Diarrhoea was then still one of the major child killers in Nepal. A Redd Barna (Norwegian Save the Children)/Ministry of Health project, asked the following questions: • What will make the 40% change from awareness to action? • Who will encourage them to make this change? • Who are the 5% who are using ORS, and how can we engage them in sharing their knowledge with the others? • In what setting should such a process take place? Auxiliary Nurse Midwives (ANMs) working in the health clinics had a limited role. They were interested in the ORS problem and took part in a two-week course in face-to-face communication methods and skills - including how to run a community meeting. The MOH selected some villages for a trial project. Village leaders gave their permission for meetings with the women. Discussions took place with the traditional healers, who have a lot of power in the villages, and could obstruct – or encourage – the adoption of new practices. They agreed that diarrhoea is a big problem, and that their medicines did not always help. They were interested in ORS, and discussed the ideas thoroughly with the ANMs. They were invited to the meeting that had been called (by the community leaders) to discuss the issues with the women. In these meetings, the ANMs asked women to describe what experiences they had with diarrhoea in the community. Many women stood up and described how their children had died. Most of them had stopped giving the children liquids when they had diarrhoea, because then the diarrhoea also stopped after a while. One or two women stood up and said they had given their children ORS when they had diarrhoea, and the children had survived (these were the “5%” the researchers had been looking for). They were challenged by the others – how could they give more water? Did this not make the diarrhoea worse? Did the mothers-in-law not protest? All the counter-arguments were given, and the ANMs directed the discussion by making sure everybody was listened to, and only one person spoke at a time. The ANMs gave a short input – on why it is important for a child with diarrhoea to get more ﬂuids, and how ORS works to “balance” the child’s stomach and help him/her ﬁght the diarrhoea. There were questions, and more discussion. The women who had used ORS had a powerful argument with them – a healthy child. The other women saw this, and in an environment, (the group meeting, “blessed” by the community leaders) where it was acceptable to discuss these practices a great deal of learning took place. One of the women who had used ORS was then invited up to demonstrate how to make ORS. The other women watched with interest. There was further discussion. The ANM demonstrated once more, and repeated the “recipe”. Simple handouts with a pictorial description of how to make ORS were given out. Two traditional healers were present in the ﬁrst meeting; they stayed at the back and did not contribute. At least two meetings were held in each community. In the second meeting, several more women had tried ORS, and reported that their children were well. One said it was not worth the extra work with having to clean up the diarrhoea, but she was challenged by the others - how could she say that, when the medicine helped the child to survive? In some meetings, the traditional healers also contributed their experiences, and said they had used ORS with their own children – with good results. This was important for accepting the practice in the area. The ANMs also had special meetings with some of the healers to discuss what they could do to help spread the use of ORS in their communities. Continued 47 Ideally, it should be a person we can consult during the process of change (when trying out and evaluating the new practice, we will have questions – and we will have a strong pull from our “old habit” to go back and do what we did before). Sometimes family members will oppose a change, and then it is especially impor- tant to have someone you feel safe with to consult about how you are doing, and to keep giving you good arguments to stay with the new practice. A good face-to-face communicator needs a combination of the right personal- ity and the right knowledge, skills and attitudes. However, very often there is not much choice – your communicators may be the formal and informal health work- ers, the informal providers/drug store vendors or pharmacists. Be aware of what makes a good face-to-face communicator, and aim to move the trainees as far as possible in this direction. Box 18 identiﬁes some of the key characteristics of an ideal face-to-face communicator. The credibility of the communicator is essential to the success of the interaction with clients or customers. It is inﬂuenced by the communicator’s ability to: • understand the person’s background (perceptions, practices, reasons) ��&!#% 4/ &!#%�#/--5.)#!4)/. Box 16 continued In the three project areas, the use of ORS went up from 5% to 60–70% within six months. ,ESSONS�LEARNT�FROM�THE�.EPAL�CASE�STUDY Opinion leaders in the community need to be addressed ﬁrst, to gain their support for the project or idea. The community leaders were contacted to get permission to meet with the women. The traditional healers were contacted to discuss the problem, invite their opinions, and request their participation. Opinion leaders can make a real difference to getting a new practice accepted and used. Frequent meetings to discuss project strategy and progress with the leaders is important. Providing a forum for exchange of experiences – a village meeting of women is a good setting for spreading new knowledge. The positive experience of neighbours using a new practice is a powerful inspiration to change, especially when confronted with the result of the experience – a healthy child. Health worker as facilitator: the role of the health worker was changed, from the “lecturer who knows it all” to a facilitator who encourages women to share experiences and help build each other’s conﬁdence. The ANMs were from the same area, spoke the local language, and were willing to travel to the different villages (on foot). Source: Unpublished report, Redd Barna, Nepal, 1983. "/8�� 0,!.).'�&!#% 4/ &!#%�#/--5.)#!4)/.��).4%2.!,�!.$�%84%2.!,�&!#4/23 The factors the communicator has to understand to be able to inﬂuence someone’s behaviour or practice can be grouped under “Internal factors” and “External factors”. Internal factors (which are “inside a person’s head”) are for example: knowledge related to the action, perceived risks, what consequences the action will lead to, attitudes and social norms related to performing the action, experiences with different forms of treatment, and intent or motivation to change. These factors can be explored during formative research, or participatory research. External factors (outside the individual, those which can inﬂuence a practice positively or negatively) are for example: availability of services, demographic factors, epidemiology, policies, cultural norms, and skills and their consequences. (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 48 • respect this background, and also the reasons why it might feel impossible for the person to follow advice to change • use this background/ideas as a starting point for the education (build a bridge from the informal knowledge to the biomedical knowledge) • be sensitive to the person’s emotional state (someone whose child is very sick will feel very scared, and needs to be treated in a friendly and considerate way) • be available for follow-up advice. 4RAINING�IN�CORE�COMMUNICATION�SKILLS The communicator should have been trained in the necessary factual knowledge and skills to treat the common diseases in the community. The community mem- bers should know that the communicator has these formal qualiﬁcations. However, knowledge without communication skills will not convince community members to change their practices. Setting up training programmes for health workers in communication skills is a necessary – though often neglected – managerial strategy for strengthening rational drug use programmes. 5NDERSTANDING�THE�PROBLEM Understanding the problem of the cli- ent or customer requires three main communication skills: (1) observation (2) asking open questions (3) listening carefully. These are very important skills in face-to-face communication and should be mastered by anyone work- ing with this method. The skills need to be accompanied by a friendly and "/8��4(%�)$%!,�&!#% 4/ &!#%�#/--5.)#!4/2 • Approachable • Makes everybody feel welcome and at ease • Respectful of others’ knowledge and skills • Curious, willing to learn from others • Good communicator and good listener • Inspires dialogue and views • Able to identify problems and solve them constructively • Knowledgeable about the subject • Not afraid to admit to not knowing the answer. Will ﬁnd out. • Can accept and reﬂect on criticism, and does not become defensive • Non judgemental Source: Promoting Rational Drug Use in the Community Course (PRDUC) workshop participants, South Africa, 2004. 49 respectful attitude to the client or customer. An uninterested, unfriendly commu- nicator will not gain the conﬁdence of the customer or client, and will therefore not be able to understand the problem, and inﬂuence him or her to change practice. The communicator who understands a mother’s difﬁculties and her dilemma, and is respectful, sympathetic and understanding, has a chance to get through to her and encourage her to try a new practice. Blaming her for sticking with the old ideas will only make her angry or unsure, and will only make her more likely to stay with what feels safe – doing what she has done before. #OMMUNICATION��WITH�FEEDBACK Communication is a two-way process consisting of giving information to a person, and getting feedback. It is only by getting feedback that you know if the person has understood what you meant to say. See Box 19 for an example of how to build real understanding between two participants in a training workshop. ��&!#% 4/ &!#%�#/--5.)#!4)/. "/8��"5),$).'�2%!,�5.$%234!.$).' Peter: So I understand you came to this training because your boss told you to? Daniel: Yes, he did, but I also very much wanted to come, I want to learn how to implement a community drug education programme in our village, there is so much misuse of medicines. My aunt died after getting the wrong dosage of antibiotics, and many other family members have been very sick. We have to do something! Peter: Yes, drug misuse is a big problem, also in my area. What do you plan to do? Daniel: Well, I’ll tell you. and then I want to hear about your plans! Peter had the idea that Daniel was there because he got an order to go (he assumed). If he had not checked this out (asked Daniel, and received feedback that he also had a strong personal interest), Peter might have treated Daniel as a bureaucrat whose heart was in his career, not in community education (where Peter’s was). Now that they have exchanged ideas, and found out that they share a personal motivation to solve an important problem, their continued communication will be on a much deeper level. To communicate means to exchange, or share. Good communication should lead to a shared understanding – which does not always mean that people agree! By asking about and listening to what the other person thinks and feels (getting feedback), you can ﬁnd out if you have a common goal. If a message is given from one person to another with no feedback, it is called information. This is a one-way “product”. When a health worker (or informal provider) gives a mother instructions about how to use medicines, he gives her information. If he does not discuss the instructions with her, he cannot be sure she has understood – and accepted – what he has said. This is usually the problem with information. Information can change to communication when the person it is given to gets involved and gives feedback. The health worker asks the mother to repeat the instructions on how to take the drugs, and asks her opinion about the new way of using them. Information is ONE-WAY Communication is TWO-WAY (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 50 2ESPONDING�TO�THE�PROBLEM When the problem (and how the customer or client may change his/her practice) has been understood by the health worker or shopkeeper, he/she should respond by using three main skills: • giving accurate and clear advice, and explaining why • discussing the choice of medicines and the treatment with the customer/ client • checking that the customer/client has understood the instructions. Maintaining a friendly and respectful attitude is as important here as when the communicator is trying to understand the problem. 3UPPORT�FACE TO FACE�WITH�OTHER�METHODS Face-to-face is an effective method to inﬂuence people’s behaviour and encourage them to reassess their (medicine use) practices. However, it does not reach many people at a time, and is therefore seen as an expensive method. A programme planner will be faced with the challenge of being “cost-effective” and reaching as many people as possible for the amount of money available. Some additional ideas on how to supplement face-to-face communication on rational medicine use include: • Encourage community groups – to discuss/continue learning on the selected topics. Simple educational materials would be a good support, as would hav- ing health workers or informal providers participate in the group meetings as resource people. A short training programme for the community group lead- ers on how to use the materials to facilitate and encourage group discussion and learning would improve the quality of the subsequent group learning sessions. • Encourage learning in schools – possibly by using the same (or similar) materials for discussion. Teachers could participate in the short training programme, and/or they could invite health workers or informal providers as resource people. • Other channels – the following channels could be used to spread information about the topics, and make people aware of the need to learn. It is important to note that most people would not change their practice after only being exposed to the information through these channels, but – having heard about the topic(s) through these channels – they are likely to be receptive to ideas about how to change practice that is communicated in a face-to-face dialogue. Examples of such channels are: — Discussing the topics in meetings at schools — Discussing at a community meeting — Making a community drama, with subsequent discussion — Making a radio programme (or a series). Research shows that for any face-to-face method, the support of printed materials will usually improve the impact of an intervention. Box 20 shows how face-to-face counselling combined with print materials improved adherence to tuberculosis (TB) drugs in South Africa. 51 #OMMUNICATION�BARRIERS There are a number of possible reasons why face-to-face communication might not work well. The three main ones are: 4HE�ENVIRONMENT • The place where the communication is taking place is too noisy, cold, warm, full of distractions, not private, or does not feel safe. 4HE�COMMUNICATOR • Has an unfriendly attitude • Judges the clients/customers negatively: considers they are ignorant, has no respect for their perceptions and concerns • Does not ﬁnd the real reason(s) for the problem, or understand the needs and concerns of the clients/customers • Uses complicated technical language to show superiority • Does not listen well • Interrupts, argues and is impatient • Jumps to conclusions before the client/customer has ﬁnished explaining • Lacks knowledge – does not know the answers • Does not follow-up to see if the advice is put into practice. 4HE�CLIENT�OR�CUSTOMER • Does not trust the health worker or medicine provider, feels uncomfortable • Is nervous and worried, and is not met with sympathy • Does not have enough money • Has several children waiting at home, without supervision and is in a hurry • Does not feel free to say she does not understand, because she feels the health worker or drug provider is not really interested in her perspective • Does not feel free to ask questions • Feels he or she is being judged negatively (for not coming for medicine earlier, for having used traditional herbs, for having used medicine at home). ��&!#% 4/ &!#%�#/--5.)#!4)/. "/8��%.(!.#).'�!$(%2%.#%�4/�4"�$25'3�).�3/54(�!&2)#! Nurses were trained in patient-centred communication to be able to counsel TB patients. The aim was to enable the patients to understand the treatment process and the importance of adhering to the full course of medicines. A booklet, including a story, provided additional reinforcement and support, and patients were given a calendar so that they could monitor their own progress during treatment and feel that they had some control over their own treatment. A role model was created by the heroine of the story whose experience showed the obstacles to adherence, such as stigma of the disease, depression and side-effects. She overcame the obstacles and was cured. The patients exposed to the communication intervention achieved a mean adherence rate to treatment of 95% with only one patient defaulting. A similar clinic that did not have the intervention had a lower mean adherence rate of 83% with 13 patients dropping out. Dick J, Lombard C (1997). Shared vision – a health education project designed to enhance adherence to anti- tuberculosis treatment. Int.J.Tuberc.Lung Dis. 1(2):181–186. (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 52 • Gets too much information at a time, and no printed information to help him or her remember • Does not understand the complicated language used by the health worker to explain the cause of the disease, which is different from commonly held community beliefs, and simply says the health worker is wrong. It is easy to see how these barriers could – and very often do – stop the client or cus- tomer from learning how to use drugs in a rational way. When planning a training programme, make sure that these aspects are considered and fully included, and due attention is paid to them. Teach the communicator to be aware and make sure he/she clears away as many barriers as possible before starting the training. The work of the communicator is strengthened by others in the community, such as inﬂuential neighbours, women’s groups and community leaders, reinforcing their suggestions for new practices. For example, a communicator might be well advised to consult with the community leaders and other health workers before starting work with the community. If these inﬂuential people support the new practices, chances are high that these will be adopted much more effectively. !DDITIONAL�READING� Aubel J, Rabei H, Mukhtar M (1991). Health workers’ attitudes can create communication barriers. World Health Forum, 12(4):466–471. Homedes N, Ugalde A (1993). Patient’s compliance with medical treatments in the Third World. What do we know? Health Policy and Planning, 8(4):291–314. Hubley J (2004). Communicating health: an action guide to health education and health promotion. 2nd ed. Oxford, Macmillan. Laverack G (2004). Health promotion practice: power and empowerment. London, Sage Publica- tions. Pretty J, Gujit I, Thompson J, Scoones I (1995). Participatory learning and action. a trainer’s guide. Chapter 1, pp.1–12. Participatory Methodology Series. London, International Institute for Environment and Development. ZEDAP (1997). Next is not enough. A training manual to strengthen the interpersonal skills of health workers. Harare, Ministry of Health, World Health Organization and the United Nations Children’s Fund. 53 ��$2!-!�!.$�/4(%2�&/,+�-%$)! 3 $RAMA�AND�OTHER�FOLK�MEDIA )NTRODUCTION This chapter will explore a range of types of folk media, seeing how they can be used in combination with other communication approaches and how they can ﬁt into an overall strategy. It will help you to: 1. Examine a range of folk and performance media 2. Consider the role of these media as part of a communication strategy to address medicine use problems in communities and the potential effect of programmes on knowledge, attitudes and practice 3. Explore what must be taken into account when mobilizing folk media for the promotion of rational drug use. Drama and other folk media – also called popular media – are a vital part of most communities’ culture. They can be both traditional and modern. These media can be community- based or conveyed through mass media. Their impact and popularity is widespread especially in com- munities with strong oral traditions. While they have played a role in pub- lic communication on other health issues, they have not been widely used to promote rational drug use. The idea of combining information about social concerns into popular education is increasingly becoming known as entertain- ment-education (EE) or edutainment. This comes in many forms, including serial dramas broadcast on mass media, cartoons developed in print, interactive radio talk shows and folk media. Framing messages in a popular, entertaining format helps create an environment where people of all ages can carry on conversations about topics raised in the performance. This increases the likelihood of the ideas (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 54 presented leading to action or change. This concept will be discussed in more detail in Chapter 6 on mass media. !DVANTAGES�AND�DISADVANTAGES The overall advantages and disadvantages of using performance and folk media are highlighted in Table 6. Deciding which to use depends on which: • has the most appeal among your intended audience • is the most appropriate method to communicate the ideas • is most likely to enable interactive dialogue. 4ABLE��!DVANTAGES�AND�DISADVANTAGES�OF�PERFORMANCE�AND�FOLK�MEDIA ADVANTAGES DISADVANTAGES • Combines entertainment with education • May simply be seen as • Attracts interest entertainment and not be taken • Reaches large numbers seriously • Culturally acceptable • Health messages may be lost • Easier to explore sensitive issues • Needs multiple performances to • Performance skills likely to be locally available reach large numbers of people • Increases community involvement and participation • Can be expensive • Can be interactive and stimulate discussion • Needs preparation and knowledge • If well done, the audience is more likely to remember the content about the media • Makes attitudes visible • Includes emotional part and allows (integrated) messages When the content of the folk media is well- chosen and followed up with appropriate discussion after a performance, it can help to bring about change in critical awareness of the audience, around how people under- stand problems, the reasons for them, and can stimulate trying out new approaches as part of the solution to the problems. 4YPES�OF�FOLK�MEDIA A wide range of performance and folk media exists in communities that can be mobilized in health communication activities. Such media include: • theatre and mime • puppets • storytelling • songs and dance • magic shows, clowns, comedians. 4HEATRE�AND�MIME Theatre and mime are examples of performance media that have been widely used in health communication. You can use them in many ways. Theatre uses the spoken word, facial expressions, and the interaction of char- acters, including with the audience. It is a ﬂexible medium that can be used in many different locations including theatres, community halls, schools and the open air. 55 ��$2!-!�!.$�/4(%2�&/,+�-%$)! Theatre can involve professional actors, health workers, community members or school children or any combination of them. While the actors might work from a script, that script can be developed by a single author or improvised by the actors – either on their own or in partnership with members of the community. Act- ing, music and dance can be combined to provide both entertainment and edu- cation. The power of theatre for health communication comes from its ability to involve an audience, create characters with whom the audience can identify and to bring important, but often complex, issues alive. When using interactive theatre, the actors can stop to ask questions to the audience, discuss what comes up, and improvise to further illustrate some of the audience concerns. The example of the play about goitre from Pakistan, mentioned in Chapter 1, demonstrates how this can happen. Box 21 discusses the way theatre was used to improve awareness about HIV and AIDS in India. Particularly important was the impact that this approach had on improving under- standing about what it was like to be HIV-posi- tive. Increasing dialogue in a community about a problem such as HIV (ill) is one of the ﬁrst requirements to facilitate treatment of people living with HIV. However, this type of interven- tion needs to be followed up to see whether the intention to do something differently has actu- ally led to change. Mime relies on gestures and facial expressions to convey information. Mime can be useful when audience members do not understand the same language. This form has been used with success by the Jagran Theatre Group in slums and villages in various Indian states. The performance is an informal affair. People learn about an upcoming show by word of mouth and within a few minutes crowds assemble around the troupe. One of Jagran’s plays is called The Monster of Malnutrition. In the story, a father and son are scared by a huge monster. They discover that this is due to their eating habits. As a result, they change their diet to a healthy, "/8�� 4(%!42%�).#2%!3%3�()6�!.$�!)$3�!7!2%.%33�).�).$)! The Nalamdana Theatre Group produced three plays to communicate HIV and AIDS information to men, women and children in inner city slums in Madras, India. A total of 121,000 people attended the one to two hours dramas (average audience was 1000 people for each performance). Questionnaires given to the audiences before and after each performance showed a signiﬁcant increase in HIV- and AIDS-related knowledge in the group after watching the drama, and an increased intention to treat HIV-positive individuals more kindly. Valente TW, Bharath U (1999). An evaluation of the use of drama to communicate HIV/AIDS information. AIDS Education and Prevention, 11:203–211. (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 56 balanced one and are able to kill the monster. The facts of nutrition are introduced in a humorous way. Box 22 looks at the way street theatre in Peru was able to improve knowledge about the contraceptive pill and other contraceptive methods. However, other methods are needed to inﬂuence attitudes and change behaviour. When you know what effect the different methods are likely to have on the audience, you can plan your communication campaign to include the mix of methods needed to reach your objectives. For example, the theatre play in Box 22 could be followed up with a face-to-face intervention through a number of channels to inﬂuence attitudes and behaviour. Theatre can be used to investigate the perceptions of the audience because it deals with emotions. For exam- ple, the Women´s Collective in Matagalpa, Nicaragua, has created different dramas about the importance of women deciding over their own bodies, a fundamental right to gain access to health. After a play about teenage pregnancy that shows the lack of sex education, mistrust within the family and the anguish a teenager goes through, the Collective interviewed women who had seen the play. These were "/8��³-3��25-/523´�).�0%25 A street-theatre play, Ms Rumours, was designed to dispel rumours about modern contraceptive methods among people living in urban areas in Peru. The misconceptions targeted included: the pill promotes cancer, the pill affects the foetus and the IUD promotes abortions. Each performance lasted about 20 minutes and was followed by a group question-and-answer counselling session. The play was performed in parks and squares and also outside hospitals and clinics in front of people waiting for services. It involved four characters: Ms Rumours, a couple in love and a pharmacist. The street theatre showed how Ms Rumours promotes misconceptions and negative attitudes, and shows the pharmacist dispelling those rumours. In a two-year period, the play was performed about 200 times to an estimated total audience of about 61,000 with an estimated 4,500 attending follow-up face-to- face counselling sessions. Approximately four people per performance were interviewed before and after each of 17 performances (a total of 102 respondents). The interviewer asked them whether or not they agreed or disagreed with 11 knowledge and attitude questions. Knowledge statements such as “the pill produces cancer”, “the pill affects the foetus”, “the pill affects the nerves” and “the condom is uncomfortable” changed the most. Attitudinal statements including “the pill is easy to use”, “the pill produces abortions” and “the condom is easy to use” changed little. The authors claim that the street theatre signiﬁcantly reduced misinformation but did not have a signiﬁcant impact on attitudes. Their evaluation suggests that street theatre can be useful for providing information but a more participatory approach is needed to inﬂuence attitudes. Valente TW et al. (1994). Street theatre as a tool to reduce family planning misinformation. International Quarterly of Community Health Education 15: 279–289. 57 ��$2!-!�!.$�/4(%2�&/,+�-%$)! organized women from the 10 rural communities where the Collective works. To be able to talk about the play´s characters allowed them to touch upon taboos and bring forth opinions and contradictions beyond stereotypes and prejudices. 0UPPETS Puppets come in many forms including: simple ones made from paper bags, shadow puppets made from cardboard outlines, glove puppets, string puppets and more complex puppets. The educational children’s television programme Sesame Street has been shown worldwide. It uses complex puppets operated by persons hidden from the camera. Real people sing and talk to the puppets. The characters introduce simple educational concepts such as letters and numbers through song, humour and dialogue. Many communities have traditions for puppet shows such as the shadow puppets of Indonesia and stick pup- pets in India. Even in communities where puppets are not traditional, they have been successfully used in health communication. While puppets are immediately popular with children, adults have also enjoyed them. The strength of puppets comes both from their entertainment value and from their ability to bring out sensitive issues that would be more dif- ﬁcult to discuss if live actors were used, for example about the need to use contraceptives, or about stigma related to TB or HIV and AIDS. Despite this, some care must be taken when using puppets with adults. They may consider puppets only suitable for children and not pay atten- tion when they are used for more serious communication. Also, in some cultures, puppetry is a highly advanced communication form, so how it ﬁts into the cultural tradition needs to be considered. Involving the audience in the planning of such performances will help to establish whether the method is acceptable to them. -USIC��SONGS�AND�DANCE Music, songs and dance can add interest and excitement to any health com- munication activity. They can draw a crowd that may then be willing to listen "/8��0500%43�!'!).34�!)$3 The Puppet Power Team is a project of the Namibian Red Cross Society that spreads HIV and AIDS awareness. The project uses puppets to disseminate information on HIV and AIDS in an informal and often humorous way. The themes of the show revolve around how HIV and AIDS is contracted, can be prevented and how certain behavioural patterns can increase the chances of getting infected. Based in Windhoek, the team performs at schools, mines, prisons, companies and villages around the country. The show often triggers discussions about sex and HIV and AIDS, and during the performance there is interaction between the audience and the Puppet Power Team. Organizers say that the puppet show helps to break the barrier of illiteracy and language when delivering its message to the audience. http://www.comminit.com/africa/soul-beat-42.html (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 58 to a health communication message. The words of songs can be used to convey ideas about health and be easily remembered. Music is very ﬂexible and can be performed live and played on recordings in open air settings, communities and clinics. Many societies have traditions for songs and music so opportunities are created for community participation in singing and making music. In Nicaragua, a song was used to close community theatre performances about essential drugs by AIS- Nicaragua. The theatre performances and song were part of a nationwide campaign to improve the quality of health care and the use of drugs. Each part of the song illustrates a characteristic of essential drugs, the public (community health pro- moter or health personnel) received a leaﬂet including the text of the song and was invited to sing it together with the facilitators and to use the song together with performance for further communication activities. An illustrated 440-page learn- ing and action guide called Buscando Remedio (Seeking a remedy) was produced as further support for local health workers. 3TORYTELLING Storytelling is a part of many cultures. Stories including traditional characters who emphasize aspects of life and highlight morals and appropriate behaviour are common in many countries. Such stories have been used to make abstract "/8��-!$!-�0/+4!�,%!2.3�(/7�4/�02%6%.4�-!,!2)! A woman had a son who was always sick. She sold cans and bottles. Cans and bottles holding some water could be found all over her yard. Mosquitoes used the water as a breeding ground. The woman was surprised that her son was always getting fevers. One day the boy had a terrible headache and a high fever with chills. Madam Pokta went and bought Cafenol (caffeine and aspirin) for the boy but it did not bring the fever down. So she took him to the native healer who took a knife, cut the boy’s chest, and drew blood. A few days later the boy died. Madam Pokta talked endlessly about how she had given the boy Cafenol.but it had not helped. She couldn’t understand why the boy had contracted malaria so often. She thought perhaps the boy was not meant to live. Madam Pokta was bothered for a long time by what had happened. One day she heard about a health worker close to her village and she went to see him. She told him about the death of her son. The health worker went to see Madam Pokta’s house. When he got there he saw mosquitoes everywhere because it was late afternoon. The health worker saw the cans and bottles lying on the ground with water in them. He also saw mosquito eggs in the water. He explained to Madam Pokta that the tins and bottles were breeding places for mosquitoes. He said this was the reason she had so many mosquitoes in her house. He told her that mosquito bites had caused her son to get malaria and die. He said: when the mosquito bites, it puts a poison in the body that causes fever. He told her to bring the rest of her children to the clinic so they could receive a medicine. Afterwards, they all became healthier and happier. Hilton D (1980). Health teaching for West Africa – Stories, Drama and Song, Illinois: MAP International. 59 ��$2!-!�!.$�/4(%2�&/,+�-%$)! concepts more real. Storytelling is a recognized approach to health communication. A common method is to tell a story to a group and then invite the audience to comment on the story and give opinions on what the characters should do. The story may be told using only words, but it is often a good idea to show pictures on a ﬂip chart. Box 24 describes a popular story from West Africa that has been used to communicate about malaria prevention. Stories can also be told in an interactive way. The audience can propose an ending to the story or intro- duce different characters who might respond to the issue being discussed in a different way. -AGIC�SHOWS�AND�OTHER�LIGHT�ENTERTAINMENT In some countries there are traditions of magic shows in markets and public places which can attract a great deal of attention and interest. Box 25 illustrates how traditional medicine showmen can help improve knowledge about breastfeeding and infant nutrition. Traditional performers can be skilled in entertaining people through their words and humour. "/8��-%$)#).%�3(/7-%.�).�-%8)#/ Mexican traditional medicine showmen (merolicos) use ventriloquism, telepathy, snake handling, medicinal recipes and clown acts to attract an audience and sell medicinal products. Initial research showed that many community members trusted the showmen and highly valued their ability to explain ideas clearly. Showmen were observed to talk to as many as 250 people and to sell to as many as 70 people in a period of about two and a half hours. A programme was developed to promote the idea of a ‘magic meal’ to wean babies with the right mix of foods. Five showmen were selected to work with the project. They were chosen on the basis of their observed expertise, their experience in the targeted regions, their past honesty, and their apparent interest in contributing to improved public health education. After the medicine showmen had communicated the message for three months while working, there was a two-month waiting period before carrying out the ﬁeld segment of the evaluation phase. Then 400 hundred women from test sites and 344 women from control sites were interviewed. The data reported focused on breastfeeding hygiene, the ‘magic meal’ and the ﬁrst breast secretion, colostrum. In this project, medicine showmen demonstrated their abilities to effect changes in knowledge. In total, 24% of the mothers retained knowledge about the ‘magic meal’s’ composition. There was a 17% increase in mother’s knowledge about breastfeeding. The medicine showmen were found to be effective in both the rural and the urban areas. A surprising result of the evaluation was that – contrary to what many thought – people with higher levels of education listened to the merolicos, as well as those from the low-income, low-education community. Simoni J et al. (1982. Medicine showmen and the communication of health information in Mexico; Michigan State University, College of Education, Non-Formal Education Information Center. (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 60 Other popular entertainers who can be incorporated into health communication activities include clowns and comedians. In Guatemala, for example, a project is working with indigenous clowns who are travelling throughout the country putting on short performances that introduce issues around HIV and AIDS. This approach was adopted following research that demonstrated a need to raise awareness of HIV and AIDS and develop ways of informing communities in which there is little formal education or access to health services. A key element of the clowns’ performances tackles issues about stigma and discrimination against people living with HIV. The clowns are also involved in working with local com- munity radio stations to develop and deliver radio spots and local radio soap operas to extend the reach of their impact through a widely dispersed rural audience. In Cambodia, comedy is a strong traditional and popular source of entertainment. Local comedians are respected and play a key role in their communities. A project to increase community dialogue about HIV and AIDS worked with 20 local comedians to develop material based on villagers’ life stories. Workshops with the comedians improved their improvization skills and introduced ideas for role plays that enabled the comedians and local villagers to explore key issues. Box 26 highlights some of the lessons that emerged from this project. 2ECORDING�PERFORMANCE�AND�FOLK�MEDIA Live performances of folk media need to be repeated many times to reach large numbers of people. This can be expensive and time-consuming. You can increase folk media’s reach through mass media. For example, you can make a video of a drama or puppet show which can then be shown to others or even broadcast on television. You can record music or a drama on audio cassettes which can be played in public places, clinics, in small groups or broadcast on the radio. Although a recorded performance will reach many people, it will have less impact than a live performance. Another disadvantage is that there is no direct audience participation with mass media. This reduces opportunities to develop participa- "/8��,%33/.3�&2/-�#!-"/$)! • Audiences were not interested in performances that simply tried to deliver a message. When the focus was on telling a story, the performance was less mechanical and more engaging. The health messages were seen as ‘work’, while the dramatization of a situation that threatened health was easier for the villagers to relate to and to understand. • Even the lowest-price condoms were too expensive for the villagers. This ﬁnding emerged through the discussions that accompanied the performances. Villagers said that if they were going to use condoms they would have to be much cheaper. This underlines the point that changing behaviour is not a simple linear process that follows the introduction of new information, but depends on cultural, economic and political factors. • Gender, power and culture were acknowledged as being part of the HIV and AIDS issue for the ﬁrst time. The performances created a space for dialogue and reinforced the idea that it was time to talk more openly about the factors that caused the spread of HIV. Source: www.healthcomms.org/comms/integ/ic-ld-tfd.htm 61 ��$2!-!�!.$�/4(%2�&/,+�-%$)! tory approaches. However, a skilled facilitator can help you use folk media on video or audio cassette to stimulate discussion and community participation. You need to pretest carefully a recording of folk media developed for one audience before using it with a different one. The example of the clowns in Guatemala men- tioned earlier illustrates the way in which live performances can be recorded or incorporated into mass media programmes as a way of increasing the reach of a communica- tion approach. 0ROGRAMMES�THAT�EMPOWER Performance and folk media have been used for community empowerment or social transformation by supporting people to have the conﬁdence to change their situation and the skills to make informed choices concerning their health. The use of performance and folk media for empowerment draws heavily on the ideas of the Brazilian educator, Paulo Freire, and experiments with community theatre programmes in Botswana, Malawi and Sierra Leone and elsewhere. When using drama for empowerment, the performance’s content should be carefully chosen to reﬂect the important issues in a community. This style of participatory perform- ance practices is evolving in much of the recent work being done around theatre for development. It involves enabling local people, through dialogue and improvization, to identify the issues that most concern them, ﬁnds ways to dramatize them and through that process to analyse what, for them, are the key messages. This can then be woven together with ideas and suggestions from health workers or other experts drawing on research. For example, you might have a meeting or carry out a survey including interviews or focus group discussions within the community. You could also involve community members directly in preparing the drama. After the performance, the audience should be encouraged to discuss the content, relate it to their own situation and consider what they can do in their own community to improve the situation. After taking action, the community members must be encouraged to evaluate what they have achieved and to take further action. The empowerment leads to social action, new community actions and relationships, and becomes a social transformation. Box 27 summarizes the stages involved in using drama for social transformation. If you want to use folk media for empowerment and social transformation, you need to involve facilitators who are skilled in participatory work. You must build into any folk media programme that has empowerment as its objective, the train- ing/recruitment of facilitators, opportunities for audience participation and fol- low-up. Box 28 draws this lesson from the experience of using folk media in India to increase awareness about HIV and AIDS. Moving beyond awareness to changes in attitudes and behaviour required additional communication inputs. (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 62 0RODUCING�FOLK�MEDIA�PROGRAMMES 4HE�PROCESS The production process involving folk media is similar to that for any communica- tion intervention. It needs to be based on research into the understanding the community you are working with has about the particular medicine use problem or health issue. Community members should be involved in the development of the drama or the performance so that the content reﬂects their concerns and feelings and their perceptions of the problems, their causes and their solutions. Health workers or other experts should be consulted over the accuracy of the "/8��34!'%3�/&�53).'�$2!-!�&/2�3/#)!,�42!.3&/2-!4)/.� • Research: identiﬁcation of local problems and causes by community members, using participatory methods • Performance: portrayal of local situation, problems and causes • Critical awareness: audience reﬂects on problems, causes and possible solutions • Action: as a result of the reﬂection, community takes action on the problem • Reﬂection: the results of taking action are evaluated by the community, lessons learned and further action planned. "/8��).#2%!3).'�!7!2%.%33�!"/54�()6�!.$�!)$3�).�).$)! An intervention in Karnataka, India, aimed to increase awareness, and change attitudes and behaviour related to HIV and AIDS through the use of traditional folk media in a rural community. The district had a high HIV prevalence rate. To promote community participation, 30 community-based folk groups representing eight traditional folk forms were sensitized and trained on different aspects of HIV and AIDS. This was challenging, since many of them usually conduct only devotional performances. The groups, including both men and women, then developed scripts incorpo- rating messages on sexually transmitted infections (STIs), condom use, the need to reduce stigma and discrimination against people living with HIV and AIDS, and the importance of sexual ﬁdelity. The scripts were then set to folk tunes that were traditional vehicles for spiritual expression. About 125 performances were held within a four-month period, with an average audience size of 500–800. There were high levels of participation by key stakeholders. Opinion leaders, village councils and temple priests who hosted the performances within temple premises, clearly indicated the readiness of a community to talk about a disease that had already claimed many lives around them. The performances were followed by interactive discussions facilitated by outreach workers on various aspects of HIV and AIDS. Lessons learned included: • folk media can facilitate increase in knowledge and awareness • changing attitudes and social norms requires skilled facilitation and different approaches • social and gender hierarchies determine audience participation and message decoding. Sarma N (2004). Folk media for HIV/AIDS prevention. Presentation at the 4th International Entertainment Education Conference, Cape Town, South Africa. http://www.comminit.com/strategicthinking/stee4/thinking-868.html 63 ��$2!-!�!.$�/4(%2�&/,+�-%$)! content. It is essential to pretest the folk medium activity by performing before a sample audience, and making sure the content is entertaining and the health- related information is relevant and understood. #ONTENT�DEVELOPMENT Achieving the right balance between health content and entertainment is crucial. You should allow sufﬁcient time for proper development of the characters in a drama or the plot of a story. The audience should identify with the situation and the persons portrayed. A too-obvious health message can be boring and result in losing the audience’s attention. However, a health message can also become too hidden by a story-line that is entertaining but complicated. A critical issue in planning folk media is deciding on the script’s author. Gener- ally speaking, health workers possess technical knowledge about the health topics. Their expertise usually does not include an understanding of community percep- tions about those issues or music, drama or art. When health workers develop folk media for health communication the result often includes too much health content, does not reﬂect communities’ interests, and is boring. Traditional musicians, actors, puppet- eers and artists are generally creative, good communicators with an understanding of what communities find interesting and entertaining. They have skills in develop- ing plots, music and stories that will hold an audience’s interest. However, if the development of the folk media is left completely to musicians there is a risk that the performance will be entertaining but the health messages may be distorted or lost. You should use a team approach involving both health workers and traditional performers to make use of their complementary skills. Box 29 describes the way local media artists were involved in communication activities in Malawi. 0RETESTING� You should pretest the drama to ensure that the content is appropriate, understandable and accept- able to the intended audience. This involves bring- ing together a group that is representative of the intended audience. After they have seen a rehearsal, the audience can be divided into groups of six to eight people and asked a series of questions about the performance: What did you learn from the drama? (And what else?) What did you like best? Why? Did the drama deal with issues that are important for you? In what way? Can you use anything you saw in your daily life? If yes, what, and how can you use it? Is it likely that you will use it? Why? Why not? (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 64 Did you get the information you needed about the topic? If not, what would you like to know more about? Was there anything you did not like in the play? (What? Why?) Do you have any suggestions about what could be changed? (What? Why?) You should also include questions that check understanding of the speciﬁc health messages in the folk media. What are the symptoms of malaria? What are the danger signs of pneumonia in a child? See Chapter 10 for more details about pretesting. 3ELECTING�PERFORMERS Folk media programmes have used the following approaches to select perform- ers: • Professional actors and singers: Professionals can help ensure a high-quality performance. You will have to ﬁnd funds for them. It is important to check that the health messages of their performance are appropriate and responsible. • Volunteers: This could be a group of health workers that does the drama in their spare time. This is a cheaper option. The quality may not be as high as with professional performers. Because volunteers have other time demands they may not be able to carry out many performances. "/8��7/2+).'�7)4(�,/#!,�&/,+�-%$)!�!24)343�).�-!,!7) Workshops can help tap into local artistic talents. In Malawi, artists were selected for a workshop, based upon their popularity and resemblance to the target audience. Working groups produced communication materials (songs, plays, stories). Facilitators kept groups focused on the theme when artists started to move away from it. The tendency to try to put too much information in a song needed to be addressed and artists needed to be assured that additional information would be covered in other communication materials. The more traditional folk artists, who tended to use simple messages in their songs, understood this principle better than some other professionals, drama groups and pop artists. Another concern was creating messages that appeared to accuse people, implying that they were the cause of the problem. At the end of the workshop more than double the anticipated number of songs were produced and performed publicly. Songs were pretested for clarity and audience identiﬁcation with the issue. After performances, a follow up activity was carried out and contracts were drawn up with the artists for their services, and schedules were set for recording the materials. ,ESSONS�LEARNED A supportive atmosphere, including ﬂexibility, may be even more important for successful work with creative artists than with other professionals. Facilitators should pay attention to the content of message as well as creativity. Positive messages are more empowering than scare stories. #ONCLUSION This experience reﬂects only one event in an entertainment-education process. However, it demonstrates that local experience can be called upon and that basic communication principles can be followed, like keeping messages clear and simple. And just as with modern communication channels, pretesting, research and evaluation of traditional media are also necessary ingredients. Cohen S (2002). Communication/behaviour change tools: Entertainment-Education Programme Briefs No. 1 New York, United Nations Population Fund. http://www.unfpa.org/upload/lib_pub_ﬁle/160_ﬁlename_bccprogbrief1.pdf 65 ��$2!-!�!.$�/4(%2�&/,+�-%$)! • Members of the intended audience: youth group, women’s group, school chil- dren. Involvement in the process of developing a drama can have a valuable impact on the performers’ own lives. Such involvement also creates owner- ship of the process and the drama, and is likely to lead to more discussion of the issues dealt with and increase the likelihood that changes will happen. You need to have a facilitator to work with the community to develop the drama. For the drama to be useful in other communities, it may need to be adapted. #HOOSING�A�LOCATION • Fixed venue: in a community hall, an open meeting, outside a clinic/health centre, at a school or parent’s evening, or in a temple or church. In these situ- ations, the audience is ﬁxed and present for most of the performance which can last for one or two hours. There is more opportunity for dialogue and participation by the audience. • Public place: In streets, markets and other out- side locations. The aim is to catch people who are passing by but who may not stay for long because of other commitments. Performances have to be short or include repetition so that those staying only a few minutes will still get a message. The opportunities for questions and participation by the audience are more limited. • Events: Festivals and other public (or private) events can also be used for performances. %VALUATION The evaluation of folk media involves a number of elements. Identiﬁcation of indicators: • Coverage – how many people watched/heard the folk media? • Short-term impact – done immediately after the performance. What were the increases in knowledge, were the messages understood and accepted, were they relevant to the audience’s needs, were there any negative reactions? • Long-term impact – after two or three months or longer – do people still remember the message, have they started to put the message into practice, was there a change in behaviour, do health facilities’ records indicate changes in use by the community, sales of medicines by pharmacists, amount of dumped, unwanted, expired medicines? Has there been discussion of the issues in the community or among neighbours or family members? One common evaluation method involves interviewing audience members before and after performances. Another approach is holding focus group discussions with audience members after performances. This is useful to obtain in-depth feedback on reactions. Further information about the design and monitoring and evaluation of com- munication interventions is included in Chapter 11. (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 66 !DDITIONAL�READING Cohen S (2002). Communication/behaviour change tools. Entertainment-Education Programme Briefs, No. 1. New York, United Nations Population Fund. Available at: http://www.unfpa. org/upload/lib_pub_ﬁle/160_ﬁlename_bccprogbrief1.pdf Hubley J (2004). Communicating health: an action guide to health education and health promotion. 2nd ed. Oxford, Macmillan. Kakan CA et al. (1988). The use of folk media for community motivation – A process and experi- ence in the promotion of family planning and health. Nairobi, Family Planning Private Sector rogramme/National Council for Population and Development, p. 46. *McIntyre P (1998). Puppets with a purpose – using puppetry for social change. New York: United Nations Children’s Fund. Edutainment for development and sexual health. Sexual Health Exchange 2002, No 1. 67 ��$%6%,/0).'�%&&%#4)6%�02).4�-!4%2)!,3 $EVELOPING�EFFECTIVE�� PRINT�MATERIALS 4 Print materials can be used to support various communication interventions. This chapter looks speciﬁcally at how to develop relevant materials as part of efforts to create awareness and support behaviour change at community level. Other chapters, such as working with journalists and advocacy, will address some other uses of print materials. By themselves, print materials do not change behaviour. However, they are valuable tools to increase awareness and interest in a topic. When materials are used together with other methods, such as face-to-face com- munication, they can inﬂuence attitudes and behaviour. As part of an integrated communication strategy, they make a valuable contribution to changes in policy and practice. Whatever materials you produce, the key steps are the same. Experi- ence and research from around the world have been used to put together this chapter. Box 30, for example, identiﬁes some basic lessons from more than 25 years of experience of reproductive health communication work. The additional reading sec- tion includes several publications and websites that provide further evidence and lessons. This chapter aims to help you to understand and work with the key principles of designing effective printed communication materials. It will help you to: 1. identify the key principles of effective printed communication materials 2. understand the role that print materials can play in an integrated communica- tion strategy to improve rational drug use 3. understand why and how to pretest print material and how those principles apply to pretesting any communication product. By themselves, print materials Together with e.g. Face-to- do not change practice, but… face communication, they can inﬂuence practice (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 68 )NTRODUCTION Before you start developing any type of communica- tion material you should be able to answer six basic questions: 1. WHY? What is the purpose of the material? What is the need for it? What are you hoping to achieve? 2. WHO? Who is the audience? What do you know about the audience? What do they know about the topic? 3. WHAT? What is the content or the main idea that you want to communicate? 4. WHERE? What is the setting where the material will be used? What other materials or activities can support what you are trying to communicate? Is there anything that will work against your efforts to communicate ideas on rational drug use? 5. WHEN? What is the timing for your communication? Does it come before the reader is about to start a new activity? Will it be during an event? Is it a reminder to be left with someone? Is it to introduce a topic, or to reinforce existing infor- mation, knowledge or learning? Are you trying to prevent something from happening, or trying to change an existing practice, policy or behaviour? 6. HOW? What medium is best to use? Print, face-to-face, audio-visual, theatre, radio or other mass media, electronic are some of the options. (Combining different media has been shown to be the most effective way of communicat- ing.) "/8��,%33/.3�!"/54�02).4�-!4%2)!,�&2/-�2%02/$5#4)6%�(%!,4(�#/--5.)#!4)/. Simple, inexpensive print materials can be useful and more cost-effective than more expensive and elaborate products. For example, reminder cards are helpful for use by health workers. Also, graphic materials for home use can be important, especially in empowering women to negotiate their reproductive health needs. Materials like fotonovelas (similar to comic books but using photographs) have been used to assist women in Latin America, for example, to negotiate with their sexual partners. It is important to move beyond the “I need a poster” syndrome in developing print materials. Choosing the right print product can be difﬁcult and requires rigorous exploration and selection. Be sure to tailor materials to the appropriate literacy level, even when developing materials that only contain visuals. Clift E (2001). Information, education and communication: lessons from the past; perspectives for the future. Geneva, World Health Organization. http:www.who.int/reproductive-health/publications/RHR_01_22/information_education_ comunication_lessons_from_past.pdf 69 Printed materials come in all shapes and sizes. They can include: • posters for display in health centres or public places • manuals and guides for health worker and community training pro- grammes • leaﬂets, brochures or fact sheets for prescribers, patients and community members • newsletters and bulletins for a variety of audiences • wallcharts, ﬂipcharts and other communication aids • T-shirts, folders, banners, signs and other promotional tools • reports and articles. Print materials have some distinct advantages, but they also have some disad- vantages, as Table 7 shows. ��$%6%,/0).'�%&&%#4)6%�02).4�-!4%2)!,3 4ABLE�� !DVANTAGES�AND�DISADVANTAGES�OF�PRINT�MATERIAL ADVANTAGES DISADVANTAGES • Wide range of formats • Is susceptible to wear and tear when • Ability to print on different materials used • Very adaptable – can be used on its own to inform • Can be difﬁcult to store (takes up space) (newspaper, newsletter), as support for other activities • Long-term storage may be difﬁcult due to (training manual, campaign material), as a long-term damage caused by damp, heat, dust material (book), as a short-term material (leaﬂet, handout), • Can be costly (depending on the type of can be used for individuals (patient information), or for production and the numbers) groups (posters or ﬂip charts) • Distribution may be difﬁcult (and needs • Can be produced to any level of quality and sophistication to be carefully planned in advance) (from black and white photocopied to full-colour with • Requires a level of literacy or the use of photos) mainly illustrative material for those • Can be produced without electricity (screen printing) with low literacy • Does not require special equipment to use • May come across as impersonal and cold • Can be used again and again by the same user or by • Difﬁcult to interact with different users • Provides tangible examples that people can discuss and relate to An often cited disadvantage of print material is that it is difﬁcult to use with non-literate audi- ences. Research carried out in Ghana, Myanmar, Nepal, Nigeria, Somalia, Uganda and Viet Nam has found that when combined with good face-to-face communication, print material can be effectively used with non-literate audiences. Furthermore, when materials are developed and pretested for use with audiences that have low levels of lit- eracy, comprehension can be very high (ill). Box 31 discusses a small-scale, successful project in Cameroon which demon- strates the value of visual aids and wider-scale communication about how anti- biotics work in the body, using an agricultural analogy, to improve adherence to treatment by patients. "ASIC�PRINCIPLES Effective printed communication material is easy to read, easy to understand, and encourages the reader to take some action and use the information it conveys. Basic principles apply to developing any effective print materials. These principles relate to six main areas: (/7�4/�)-02/6%�4(%�53%�/&�-%$)#).%3�"9�#/.35-%23 70 • planning • identifying and researching the audience • developing the draft material (research, writing, editing, design) • pretesting and revision • production and distribution • post-production evaluation. 0LANNING The six basic questions mentioned in the introduction to this Chapter are part of the planning process for any printe

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