EDITORIAL DECEMBER 2013

How You Say It Matters

By SANDRA HASSAN

Health has been defined in many different ways, and as such so has health education. One definition that has been universally accepted is that provided by the WHO defining health education as “compris[ing] [of] consciously constructed opportunities for learning involving some form of communication designed to improve health literacy, including improving knowledge, and developing life skills which are conducive to individual and community health”. (World Health Organization, 1998)
In this age of raised awareness around public health and the importance of health education and health promotion, and in light of documents such as the Ottawa charter, it is recognized that such programs must be tailored to the needs of the recipients and must take into consideration different social, cultural and economic systems. Yet despite general agreement that health education messages must be “consciously constructed” and account for “cultural systems”, many health education messages are still improperly designed and end up alienating their target audience rather than empowering them to make healthy choices.

The communication of health education messages is a field of study of its own but has yet to attract enough students. Health communication professionals are trained in the different approaches, theories and strategies for effective communication of public health messages. They are also qualified in research, development, and last but not least in evaluation. Currently such professionals are lacking. (Beato & Jana, 2010)

Many different guidelines exist to guide the development of health education programs and messages. The WHO provides several manuals centered on health communication strategy. UNESCO worked to put together a simple 12 step system for developing effective health education strategies. Among these steps you will find emphasis on identifying the target audience and their existent health knowledge, beliefs and behaviors which is where most failed strategies go wrong. (UNESCO)

Maternal health is a headline that touches on many different subjects that are prioritized in today’s public health efforts. In fact, maternal health can be directly linked to at least 3 of the 8 millennium development goals:

1. To promote gender equality and empowering women
2. To reduce child mortality rates
3. To improve maternal health

Within this domain of maternal health, breastfeeding comes up as an important behavior to adopt. The benefits of breastfeeding are many, not least of which is increased immunity of the newborn or the development of a strong bond between mother and child. From a medical standpoint, breastfeeding is a natural process and has advantages that are factual and not open to debate. It should follow logically that informing mothers about the benefits of breastfeeding their babies will almost always lead to them adopting breastfeeding since mothers naturally want what is best for their child.

Unfortunately this logic is flawed because it does not take into consideration the differences in the situations that mothers are living in or their personal beliefs, needs and attitudes. We are going to present the example of breastfeeding promotion in the developed world for working women; specifically an example from a pre-natal class for expecting mothers in Geneva.

A qualified and experienced midwife is giving a weekly preparatory class for expecting mothers in Geneva. The mothers are all university graduates who are employed in intermediate and high-level positions. In the class about breastfeeding, the midwife makes the following statement: “Even if your nipples are scratched or bleeding, you must continue to breastfeed. Even if you are sick, you must continue to breastfeed”. Although none of the attending mothers to be reacts while in the class, almost all of them agree outside of the class that they would never do what was suggested. Words such as “anti-feminist” begin to come up. One of the participants asks “Now that I am a mother, am I no longer my own person? Am I now obliged to sacrifice my own comfort and well-being for that of my child if I’m to be a good mother? And I am not able to make the best decisions for my child without someone telling me what to do?”

A secondary result of this health education message gone awry was the word of mouth that was spread by the mothers to be. Through person to person communication or the use of social media, they spread their disapproval of this approach, and expressed encouragement for women to “remain free” and use one of the many available baby formula products on the market.
To sum up, the breastfeeding message did not only fall flat on its recipients, but also created a chain of anti-breastfeeding messages being spread.

Clearly the message that was intended did not come across to this group of women, and the message that did come across offended them. The value of breastfeeding did not leave an impression on them in the face of their person being compromised and their ability to choose being replaced by a set of pre-defined “right” behaviors that they must abide by in order to be “good” mothers.

Looking at the message the mid-wife was trying to deliver objectively we can observe three important health education messages. The first is that breastfeeding is important, the second that even if the mother is bleeding slightly around her nipples it is still safe to breastfeed the child, and the third is that even if the mother is sick breastfeeding is still a viable option. The phrasing of her message though, including the word “must”, resulted in the mothers feeling that they were less important in the mother/child relationship, and that their ability to choose what was best for their child was being taken from them. A complexity theory approach to this scenario would better uncover the dynamics at play here.

This type of error in the transmission of health education messages is all too common, and in more cases than not is caused by a lack of understanding of the audience. For example, had the midwife used the word “can” in place of “must”, there would not have been such a clash. Other examples of health education campaigns that did not achieve the desired effect include the abstinence approach for teenagers in the US as well as several campaigns on cardiovascular health education. In a review of more than 20 public health interventions, it was found that the attitudes and trends within the population were among the most influential factors determining the impact of the intervention. (Cheryl Merzel, 2003)

It is faulty to assume that basic medical facts about the positive effects of a certain behavior will be enough to convince people to adopt it. Terminology plays a huge role in people’s acceptance of messages being sent to them, which is very much influenced by social and cultural aspects that must always be taken into consideration. Understanding the attitudes that already exist in our audience is also essential in directing messages appropriately. “Effective health communication involves the transformation of health knowledge into messages which can be readily understood, accepted and put into action by the intended audience”. (UNESCO)

Knowledge about health is concentrated in health professionals, and health education is about spreading that knowledge across the population. For people to achieve their full health potential we need to teach them, but no two people learn the same way. If we want our messages not to fall on deaf ears or be misinterpreted then we need to research our audience before speaking to them and develop customized health education messages that will make sense to them.

Bibliography
Beato, R. R., & Jana, T. (2010). Communication as an Essential Component of Environmental Health Science. Journal of Environmental Health, 24–25.
Cheryl Merzel, D. a. (2003). Reconsidering Community-Based Health Promotion: Promise, Performance, and Potential. American Journal of Public Health, 557–574.
UNESCO. (n.d.). Twelve Steps in Health Communication. Retrieved 11 22, 2013, from UNESCO: http://www.unesco.org/education/educprog/ste/pdf_files/health/health12.pdf
World Health Organization. (1998). Health Promotion Glossary. Retrieved 11 22, 2013, from WHO: http://www.who.int/hpr/NPH/docs/hp_glossary_en.pdf.

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