ET

Week 11

Adult Education & Health Communication

  • Views adult education for the poor as an important mechanism of increased community agency and individual self-awareness

  • This is effective only if it works against the traditional model where the teacher knows everything and the students know nothing.

  • As applied to health, this can take the form of health communication where members of a community work together to come up with solutions to local health problems and how to communicate that information.

Health Communication

  • Aims at behavior change, but this often needs to be a gradual, iterative process of getting people one stage towards better health than where they are now

  • The goal of public health is often to get people to do things that they do not want to do.

Stages of Change Model

  • Precontemplation

  • Contemplation

  • Determination

  • Action

  • Maintenance

  • Relapse

  • Exit and re-enter at any stage

Criticism of Behavior Change Theories

  • They focus on the individual and exaggerate individual agency by ignoring socioeconomic constraints.

Key Considerations for Effective Health Communication

  • Trust is important

  • Fallacy of empty vessels

  • Context matters

  • What is compliance?

  • How religion fits in

  • Sense-making

  • Be mindful of stigma

  • Human aspects of illness experience

Fallacy of Empty Vessels

  • Pre-existing beliefs influence how new ideas are accepted!

  • Understanding that people receive health messages within the context of their own beliefs is essential to achieve effective communication between health promoters and the public.

Context Matters

  • How can we understand the other’s point of view when developing health communication programs, rather than expecting your audience to share your point of view?

What is Compliance?

  • Consider how power differential between givers and receivers of health information affect how the message is received

  • Consider the impact it has when providers or health communicators consider a person’s noncompliance as a problem of disobedience

How Religion Fits In

  • Religion includes beliefs that help people make sense of the world in times of crisis, including sickness and death.

Sense-Making in an Inequitable World

  • Health inequalities are influenced by:

    • Power

    • Income

    • Wealth

Be Mindful of Stigma

  • How can health communication campaigns amplify stigma?

Human Aspects of the Illness Experience

  • The illness experience may include social and psychological dimensions – like stigma – that cannot be cured with medicine.

Trust is Important. Lack of trust can lead to:

  • Scapegoating & discrimination

  • Amplified social tensions

  • Hampered reporting

  • Questions about motivations of authorities

Approaches to Health Communication

  • Social marketing

  • Social mobilization

  • Positive deviance

  • Edutainment

Social Marketing

  • Method of health communication that markets health behaviors and products

  • Similar to how commercial advertising markets snacks, cars, dish soap

  • Involves developing a ”brand” that is appealing to the target audience

  • Can pair with information to make health-related products available and affordable (or free) to low-income people

Social Marketing Focuses

  • Identifying the specific target audience segment(s)

  • Describing the benefits you will offer

  • Creating interventions that will influence or support the desired behavior change

The Four P's of Marketing

  • Social marketing is critical because it looks at the "Four P's" and the provision of health services from the viewpoint of the consumer.

  • Product: The desired behavior you are asking your audience to do, and the associated benefits, tangible objects, and/or services that support behavior change.

  • Price: Cost of overcoming the barriers the audience faces in making the desired behavior change - financial, emotional, psychological, or time-related costs.

  • Place: Where the audience will perform the desired behavior, where they will access the program products and services, or where they are thinking about your issue.

  • Promotion: Communication messages, materials, channels, and activities that will effectively reach your audience.

Social Mobilization

  • Focuses on interpersonal communication as the central element in changing people’s health behavior

  • Direct person-to-person health education delivered by trusted peers

  • Works on the premise that people are most likely to change their health behaviors when they are encouraged and supported by a peer that they trust

Successful NGO/UNICEF Social Mobilization Program for Polio Elimination in Uttar Pradesh, India

  • The partners trained thousands of mobilizers from high-risk communities to visit households, promote government-run child immunization services, track children's immunization history and encourage vaccination of children missing scheduled vaccinations, and mobilize local opinion leaders.

  • Materials promoted vaccination awareness and safety, household hygiene, sanitation, home diarrheal disease control, and breastfeeding.

Social Mobilization Example

  • During the 1980s, Sierra Leone used social mobilization to increase routine immunization coverage during the Universal Child Immunization (UCI) initiative.

  • Religious leader engagement was a central pillar of the strategy, which also involved partnerships with the media.

Recommendations for Using Social Mobilization to Create Resilient Vaccination Demand in Low-Resource Settings

  • Focus on what works for that population:

  • Use data-driven messages and engagement approaches, trusted messengers, & preferred communication channels

  • Recruit trusted mobilizers from the local community

  • Promote vaccination where people worship, learn, and play in their communities.

  • Adapt program to changing local contexts, such as increased urbanization

  • Carefully link and coordinate with service delivery to ensure that immunization services are responsive to communities and culturally appropriate

Positive Deviance

  • An approach to health education that builds on what people are already doing that is working well

  • Looks for someone who is doing something that seems difficult (such as a mother who feeds children healthy and nutritious foods with very few resources, or a sex worker who gets clients to consistently use condoms)

  • Then creates opportunities for those people to teach others within their communities how to perform those difficult tasks

Edutainment

  • Behavior change information and ”nudges” conveyed via films, tv or radio soap operas, street theater, and so forth

  • Works on premise that making the communication engaging and entertaining will make the health information palatable and memorable

  • Aims to increase audience members’ knowledge about an issue, create favorable attitudes, shift social norms, and change overt behavior of individuals and communities

Riding High on Taru Fever

  • In the weekly drama, Taru never makes an actual speech or lecture. In your opinion, what might be the advantage of this type of indirect messaging?

  • Just watching a program or movie is a rather passive experience. What do you think might be the advantages of conducting organized discussion groups for encouraging social change?

Epidemics and Blame

  • During the 2014 Ebola epidemic in West Africa, health-care workers attempting to safely remove still-contagious corpses were chased, lied to, and assaulted.

  • A mob attacked a team of eight health-care workers, politicians, and journalists as they attempted to distribute information about Ebola. Two days later, their corpses—including three with slit throats—were found in the septic tank of the village’s primary school.

  • People in Guinea, Liberia, and Sierra Leone had suffered more than two decades of human-rights violations and atrocities at the hands of the military before Ebola arrived, eroding public trust in authority figures. The fact that health care workers, imbued with official authority, were mostly foreigners probably didn’t help inspire confidence among the locals either.

Managing Rumors and Misinformation

  • “Wherever epidemics occur, fear and rumors are often not far behind.”

  • What was the disconnect between the common narrative in US media about Ebola in W Africa and the situation on the ground?

Critical Lesson

  • “Attention to the human aspects of the illness experience is not a strength of biomedicine”

  • How was this exemplified in the W African Ebola crisis?

  • What is this an important aspect for health communicators to keep in mind, in general?

  • Can this be changed, or can this be overcome? How?

Ebola Incubation Period & Symptomology

  • 2-21 days

  • High fever

  • Diarrhea

  • Vomiting

  • Respiratory distress

  • Hemorrhage (sometimes)

Previous Ebola Outbreaks

  • 1976, 1995, 2007, 2018, 2019

  • 1994 (chimpanzee)

  • 2000, 2007

  • 1976

  • 1996

Some Major Occurrences of Ebola Hemorrhagic Fever

LOCATION

DATE

DEATHS/INFECTIONS

Democratic Republic of the Congo

1976

280 deaths / 318 infections

Sudan

1976

151 / 284

Democratic Republic of the Congo

1995

250 / 315

Uganda

2000-2001

224 / 425

Republic of Congo

December 2002-April 2003

128 / 143

Democratic Republic of the Congo

2007

187 / 264

Uganda

December 2007-January 2008

42 / 131

  • Average CFR = 50%

2014-2016 West African Ebola Crisis

  • Total cases: 28,646

  • Total deaths: 11,323

  • CFR = 40%

Ebola Vaccination

  • 2 regimens

    • Ervebo

      • Used during active outbreaks in a ring vaccination strategy

      • Licensed in 2019 for adults over 18 who are not pregnant or lactating

    • Zabdeno + Mvabea

      • Prophylactic

      • Doses given 8 weeks apart

      • Licensed in 2020 for individuals over 1 year of age

Ring Vaccination in Outbreak Response

  • Strategy to vaccinate contacts of known cases

    • Contacts: w/in last 21 days, lived in the same household, were visited by the patient after they developed symptoms, or visited the patient or were in close physical contact with the patient's body, body fluids, linen or clothes.

    • Contacts of contacts: Neighbours, family, or extended family members at the closest geographic boundary of all contacts, plus household members of all contacts who do not live in the same locality as the patient.

    • Health care workers and frontline workers responding to the outbreak who may be in contact with Ebola patients.

  • The ring captures a social network of individuals and locations that may include dwellings or workplaces further afield where the index patient spent time while symptomatic, or the households of individuals who had contact with the patient during the illness or after his or her death.

  • Each ring may be composed of an average of 150 persons.

West African Ebola Crisis

  • Patiently & sensitively distributing accurate info re: Ebola treatment & prevention did work & was more effective than attempts to debunk witchcraft & traditional medicine

  • Messages like “science and medicine are our only hope” and “traditions kill” follow logically from clinical and epidemiological framings of contagion— but pay little attention to the historical, political, economic, and social contexts within which they are delivered

W African Ebola Crisis

  • Engagement across communities with flexible protocols that communicate problems, request help in developing local solutions, and enable their implementation are likely to be more effective in changing high risk practices than standardized approaches.

  • What are the obstacles within the global health communities for decision-makers to (a) recognize this and (b) fundamentally integrate it into program planning for either long-term responses or emergency response?

2025 Ebola Outbreak in Uganda

  • 8th Ebola outbreak in Uganda

  • 1st to emerge in the capital, Kampala (pop 6M)

  • Index case: 34yo nurse working in children’s ward of national hospital, diagnosed after death

  • Seeded 2 clusters: extended family (n=4) & hospital (n=3)

  • Subsequently, cases have spread to 3 of Uganda’s 10 cities

  • Co-occurring with mpox outbreak

  • Infected individuals are being treated successfully at remdesivir

Schedule for Remainder of Semester

  • Week 12 Infectious Disease in Historical Context, the Opioid Crisis, and Global Abortion Policy (4/15 & 4/17)

    • Johnson, The Broad Street Pump (p. 16-22)

    • Barry, The Influenza Epidemic of 1918 (p. 23-29)

    • Please see Blackboard for 4 additional readings for our new topics

    • Discussion section: Cholera in Haiti

  • Week 13 Health Systems & Programs (4/22 & 4/24)

    • B & C, Synopses and Conceptual Tools for A History of Health Institutions and Programs & Health Systems and Aid (p. 337-343 & 379-384)

    • Greenough, Coercion and Consent in Smallpox Eradication (p. 355-367)

    • Remnick, Hundreds of Thousands will Die (on Blackboard)

    • Additional readings TBD

    • Discussion sections: Prioritization in Global Health

  • Week 14 Global Mental Health & Global Health Ethics (4/29 & 5/1)

    • B & C, Synposis & Conceptual Tools for Ethics, Projects, and Human Rights

    • Patel, Treating Depression Where There Are No Mental Health Professionals (p. 424-427)

    • Farmer et al., Structural Violence & Clinical Medicine (p. 324-332)

    • Brown & Closser, Global Health: Your Life, Your Life Decisions, Your Moral Obligations (p. 480-490)

    • Additional readings TBD