Journal of Health Care Communications Open Access

Introduction

The overwhelming penetration of technology in rural communities, along with the preponderant desire of health workers for sophistication in communication have combined to suppress interest in using indigenous African communication systems (IACS) as conduit for the health message in the rural milieu. This research probed the health message in rural women’s understanding of health. The Johns Hopkins University Center for Communication Programs (CCP) [believes its “theory-based and evidence-driven” activities produce “measurable impact on health outcomes” by “using a combination of innovative technologies, established systematic processes and] the power of social interaction” as pivotal in health communication (ccp.jhu. edu viewed Thursday, April 21, 2016).

Assuming that kind of centrality of communication in the women’s understanding of health, the research examined, among others, context in the design of, and exposure to; the health message. Thus, what the study expected in Freireian terms was, with IACS available, accessible and compatible in the rural setting, the “shared” and not “disseminated” message [1].

Background

Since the 1970s and 1980s, some critics (Ugboajah, Wilson),searching for an alternative to the modernization paradigm of technologically mediated development communication have proposed adopting the IACS. Meanwhile, communication is deemed crucial in improving women’s health as recognized by United Nations [2] millennium development goal (MDG) 5: “improve maternal health.” That goal has been one of the least surmountable among the eight goals. The relevant health message, communicated to the rural women for easy understanding, would prompt them to manage a healthy living; thus, the need for this research.

The Literature

LeDeuff’s view that communication is culture-defined is confirmed by the different situational findings in Asia [3-6] arguing “Asiacentricity,” Paul and Lin [7] and Miike who found indigenous low-tech communication had contributed to sharing the health message).

It is similar in Africa as found by [8-15]. Contributors to the volume such as Riley cite IACS (asafo, adziwa, puberty rites and proverbs) health message applications in relation to “killer” childhood diseases including polio, measles tuberculosis, whooping cough diphtheria and tetanus. In the same volume, Morrison, observes family planning education through theatre. Like Morrison, Kuadey [16] reported the use of markets to communicate family planning education. Epskamp tracks combating AIDS through theatre across Nigeria, Malawi, Mauritius and Namibia. Nabasuta describes a Ugandan Mityana Women’s Club songs that promoted healthy nutrition and childcare. Another study by Ngabirano showed how local language theatre was adapted to radio as soap opera in broadcasting messages that fought alcoholism.

Thus, all observed the successful use of IACS in sharing health messages among rural populations including women. Indeed, IACS tend to exploit their compatibility with the social characteristics of the host community. Van den Bagaert [17] discovered “primary health care as rural communication.” Everything communication in the minds of the pro-IACS scholars is everything the local culture context.

However, these findings notwithstanding, George [18] recently observed that health messages lacked local content. That situation calls for confirmation or refutation of the optimism expressed in the IACS as health message carriers for women at a time sophisticated communication systems such as social media [19] are the focus of health communication research.

In sum, what looks like dated 1970s and 1980s literature is rather more an indicator of the inaccessibility of communication technology to the rural people and they being left behind because the indigenous media are not being used in the effort to spread the health message among rural communities, especially their women.

Methodology

Forty in-depth interviews were conducted, by graduate nursing and communication studies students with rural women (25 sedentary and 15 “kayayee,” urban located transiently migrant) in Ghana. Using a semi-structured interview guide, the women were asked to describe health messages they had been exposed to, the sources of those messages, and the channels that bore them. The women were also asked to explain their understanding of health. In addition, a checklist was developed to track the various means of communication used by health workers of organizations such as the MOH, GHS and WHO in the transmission of health messages to the women. Notes on the interview setting and any communication nuances, such as health mobilization for sanitation and the use or non-use of the malaria protecting mosquito nets, were taken. The research scene was “cased” [20] for the results to reflect the rural woman in the rural scene and the rural woman in the urban setting.

Transcribed responses to interview questions were organized, processed and analysed with the aid of the ATLASti software. Themes, including understanding of health, message types, sources and conduits were developed. The resultant categories were systematically organized as description and explanation of the responses. Check-listed observations were summarized into a table. Notes taken are used here to support the in-depth interview responses and the observations recorded with the checklist.

Interviews were conducted by the principal researchers and trained graduate students. There were no interview refusals. However, not all the interviews were conducted in the local Twi language of the sedentary village women or the Dagbani of the rural migrant women in the urban location. This is because both groups spoke very little or no English. Questions and responses, thus, sometimes needed translation (interpretation). It took some persuasion for the migrant women to agree to be interviewed mainly due to their vulnerable situation, which made them apprehensive and suspicious of strangers asking them personal questions. Nonetheless, they would agree to participate once they saw others willingly and voluntarily answering the interview questions. There was some degree of interviewer bias as the nursing students tended to elicit more elaborate health answers whereas the communication student seemed to have emphasized that aspect of the study. In future it may help reduce the bias by pairing nursing and communication students to conduct the interviews.

A Framework for Analysis

Communication theories and models have tended to revolve around the audience (e.g. uses and gratification), channel (e.g. cultivation) or message (e.g. semiotics). Others, perhaps minimally, consider context by proposing social characteristics (such as language and cultural practices) as key influencers of the communication act. Yet others, grassroots mobilization proponent Paulo [21] included, have argued “demassification” of communication within the community context.

Indeed, communication occurs within space and spatial conditions have implications and consequences for audience, message and medium. The nature of the context is intertwined with audience characteristics while any message formulated in disregard of the social-cultural space risks failure. Researchers on media characteristics link functional capacity of the medium to conditions prevailing in the socio-cultural location of message communication. One of the strongest criticisms against the innovation diffusion theory has been its neglect of context.

The argument is that the mass media are of consequence within the low technology social environment only when their incongruent (impersonal) characteristics can be modified to induce message sharing rather than message dissemination. In the rural community milieu, a message needs not be carried through sophisticated media to achieve the desired effect.

This research was guided by a relook at finding a stronger space for context or setting as the fourth dimension or influence when communication is interpreted as the generation of meaning. The argument is that communication is as much an issue of the audience, channel, and message as it is of context. As proponents [22] of the cultural studies approach would argue a desired alignment of audience, medium and message is as useful as the context in the dynamics of communication.

Messages require a conduit to link source and destination. A message of living in good health from whatever source aimed at a community of women is a message only when it becomes visible and available to them. It might, then be accessed and incorporated into their health knowledge repertoire and understanding of health. In looking at the health message, then, one is also concurrently examining the means and modes for sharing that message. This would include the “grandmother tale” [23], or the grandmother sourced knowledge. To that end, a platform for analysis is created in the characteristics of the message as determinants of means for carrying it. Paul and Lin [7] propose the low-tech endogenous indigenous communication when Paulo [21] would contest message “transmission” and prefer “sharing.”

Interview questions sought the women’s knowledge of, and experience with, various forms of communication. The questions were guided by existing media-based theory which identifies various modes. From the literature, one is looking at “exogenous” media [7] such as print and electronic or their hybrid, multimedia, convergence and connectivity. Otherwise, the newspaper and magazine (print), along with radio and television (electronic), are together labeled “traditional media.” This research anticipated all of these as the technologically mediated health message.

This is despite the identification of IACS as other and, perhaps, more appropriate means for sharing health messages in the rural community. Paul and Lin [7] characterize indigenous communication as being embedded in the community and having value of its own right. As such, it has high credibility, is an important conduit for change and enables the collection and sharing of information. They add that indigenous communication offers opportunities for participation by the masses in their own development. The two proceed to admonish “inappropriate development effort” if indigenous communication is ignored. Indeed, the pair is emphatic that the “exogenous” technologically mediated media “have limited range.” The study expected that the exogenous would dominate channels for communicating the health message by the health workers; albeit more for contemporaneity than effectiveness; and set that as the framework for analysis. This is in spite of the fact that ideally, the message should determine the medium most appropriate to carry it for maximum impact.

Findings 1: The Health Message

The study was interested in messages designed to provide or add information that would deepen rural women’s understandings of health. It was to highlight message characteristics as a guide to channels that would most appropriately avail the message to the women and resonate with them. Among such characteristics were the source, subject, purpose, channel, flow pattern, feedback, visibility and the language of communication. Latently at the backdrop were the social and cultural conditions of the women. The fact of the migrants had only a sleeping place and not a home, and the villagers having homes with economic and educational conditions barely better than those of the migrant kayayee, implicated the space context.

Message source focused on local generation of content. Knowing the purpose of a message, (inform, educate, entertain, or stimulate) could also help with health issues of local concern. The message directional flow pattern: one-way, two-way, top-down or bottom-up; and whether it was direct to the receiver or required intermediation were all critically observed. Together with feedback capability of the medium and language of communication, they were to help observe interactivity. Message visibility (manifest or latent) was important in as much as accessibility was useful to know. Informant responses are summarized in Table 1.

Table 1: Observed exogenous (originating from outside community) health messages.

Message source

Table 1 shows the typical health message originated from the top and outside the community. Ministry of Health (MOH) and its agencies along with NGOs were the main sources of messages. Ghana Health Service (GHS), which is the implementing agency for the MOH was responsible for the design of most of the messages, with a few by its parent ministry, MOH. Some of the messages were attributed to external organisations such as WHO, USAID, UNICEF and the Global Fund. The Ghana Sustainable Change Project (GSCP), disease specific Ghana Filariasis Elimination Programme of the MOH as well as the Poisons Information and Control Centre had messages restricted to the field. In the message analysis, knowing the source (in Table 1 from outside the community) was found useful in ascertaining relevance by showing congruence (endogenously within) or incongruence (exogenously without).

However, some sources of messages, in the women’s experiences, were less manifest as were their messages. Examples were the Queemother’s private talk with the girl undergoing puberty rites and the “grandmother tales.” Such useful messages remained private with the individual and hidden from everyone else. The exogenous channels were unsuited for conveying such messages.

Subject of message

It is of no surprise that messages should centre on malaria. Many of the informants made reference to the disease. In the context of the women’s milieu, more importance was likely to be attached to malaria (TV3 news, Monday, April 25, 2016 reported over 29,000 cases per day nationwide) and family messages but less so tuberculosis (TB), and guinea worm which did not exist in the area. Ebola, being watched at the time, needed to be communicated more aggressively and with greater intensity.

Purpose

Many of the messages (Table 1) were categorical and left little room for reflection. They prescribed, instructed, advised or directed. They hardly raised consciousness, let alone conscientize. An exception may be: “Are you and your baby protected from malaria? Let’s come together and drive malaria away.” Nevertheless, even that is only just.

Channel

The Community Health-based Planning and Services (CHPS) Compound in-charge summed up channels of communication: “People (including women) in the community get/obtain health education information throu gh the following: mobile phone, posters, home visit, television, radio, the oman Information Centre (name of mounted public address system), durbar, outreach, static, OPD, [and] school health service.” She also mentioned child health clinic and teen clinic as other channels.

The study further check-listed more devices for carrying the health message. Among them were the sticker, flyer, radio, television, social media, all technologically mediated.Obviously, the channels for communicating the health message were elitist. They were not directly accessible to the women. They were available only at the CHPS Compound or with the nurse to carry along during her outreach. Only a single poster was found in one house in the village. The woman in whose home it was found could interpret the pictures but not the accompanying words. In the city, the public health nurses knew the migrants’ temporary places of abode and could have sought permission to mount the posters there or give copies to the migrants. Whenever a technologically medium was mentioned, it was likely to be radio.

Flow pattern

The message flow pattern (Table 1) suggested “dissemination” which Paulo [21] distinguishes from “communication.” Messages (as appear on flipchart, flyer and others in the table) are designed by the knower with little or no regard for those who are its expected beneficiaries. It is packaged the way the communicator sees fit (such as in social marketing); with an assumption that it would attract the intended audience. The approach contraries the shared message whereby message and audience characteristics dictate the channeling of the message. The message is made to be sensitive by taking cognizance of a need to mesh with the cultural setting.

Feedback

Message dissemination is less feedback inducing than message sharing. In many ways, dissemination is synonymous with pumping the message. The strategy is to bombard using the power of the media and assume the message would reach its destination and have impact. Yet messages which do not consider feedback, risk getting lost. Take the message: “Are you and your baby protected from malaria?” Rather than present it to induce feedback, it is stated rhetorically. Only one interviewee, out of the many, claimed to have phoned into a live radio programme. Messages were not formulated and propagated to attract feedback.

Visibility

Message visibility involves openness or availability to see or hear without noise. Messages were grouped into the manifest and the latent. For those carried by exogenous media, they would be open; but even that, only available at the CHPS Compound. To the non-literate, the message would be visible but inaccessible. In the case of the “grandmother tale,” as was often wont to be carried per IACS, the message was restricted in its circulation and often hidden in the answer of the informant.

Language medium

As a key to message understanding, language aligns generation and use of the health message. Congruence in message language and community language is critical. The women were not literate [24] and, therefore, unable to access messages in English. That notwithstanding, English was the dominant language medium of communication (Table 1). The printed material such as posters, flyers, stickers were virtually in English. Just one, out of 24 others was the message in both English and Hausa; although the most popular radio stations broadcast in the Akan language (GMSIP). A Twi (Akan dialect) radio talk show host, Delay, bluntly stated that English was of no commercial value to her [25]. The flyer language “lymphatic filariasis,” would be better expressed in the local language. In English, the flipchart was limitedly accessible in a two-step interpretation. It is difficult to imagine how the virtually all illiterate women would use these messages to understand health.

The nurse used the local language in what looked more IACS in her “outreach” work. Still two-step, it does match the direct communicator-audience interaction that overcomes intervention noise risks. Any impact would have to be from the nurse whose messages would not always be in sync with that of the Ministry. For example, where MOH and GHS were thinking health is wealth, the women spoke health is work; a disconnect indicator of absence of MOH/GHS messages in the women’s construction of health.

Interactive Communication Modes

However, in addition to the various forms of communication identified by the health worker, other modes of (more interactive) communication were check-listed in an inventory. The study encountered IACS examples of the Kwasi [1] event, games, performance and venue driven IACS and Des [26] lowtech instruments such as dawubɔ (gong-gong beating). IACS formats also included small group conversation among kayayee and village nkwankwaannuse (tree shade), as well as funeral, marriage and other ceremonies.

Among other less manifest modes of IACS found, and in use in the community, was the hidden “grandmother tale” messages latently shared between and among grandmother, mother and grand/daughter. Forms of Kwasi [1] performance (play acting by talented schoolchildren), venue (nkwankwaannuase or under tree shade or palace gatherings), event (Akwasidae festival of gathering and bragro girls’ puberty rites) were present. Health issues such as teenage pregnancy, abortion, HIV/AIDS, family planning can potentially be effectively addressed through bragro. Games (oware, dame or draughts as well as boys and girls football clubs) existed in the community;

Informants sometimes cited grandmother shared health messages indicating that as etched in their memory for easy recalling in a fast memory mode. The “grandmother tale” types of health message (from elderly women during bragro) were subliminal. The bragro event was found to incorporate intensive woman health education and seemed well-suited for the generation and spread of the reproductive health message. An informant wouldn’t add “grandmother” when answering a question asking for sources of health information but would recount that messaging experience in some other response such as an advice she has received from someone else.

Further characteristics of the health message discovered by the study highlight the health messaging challenge; particularly, regarding future design of the more purposeful, inclusive and all-encompassing message. Not enough of the manifest messages captured the substance and relevance of the latent or hidden message or messages of the “grandmother tale” type; the informally, indigenously affine interaction between and among personal relations. Interpersonal communication is often projected as the basis of all effective communication. Intra-family communication is, thus, usually important if the full impact of a message is to be realized.

Media sourced messages tend, at best, to have limited effects by communicator and receiver language incongruence. They are likely to be acted on mostly after some form of interpersonal processing. In this study, the productive health message (that designed of health, about health and for health), however, seemed to be hidden. Most probably, it was sourced by informants from elsewhere other than from the official MOH/GHS sources and serendipitously unearthed from the women’s responses.

Such messages, together with those interactively originating from doctors and nurses, appeared to have been internalized (based on the easy recall) as a woman’s health knowledge repertoire and thus, aiding her definition of health. The interactivity projects the importance of delineating message sharing from the technologically mediated dissemination model that was being practiced.

Couching the message in English did not help the women in appropriating it to help their understanding of health. Sometimes a message was a silent intrapersonal effect; when a “kayayoo” and a villager informant both attributed ill-health to sunlight effect on their bodies. Per Table 1, though, the printed English word on a sticker, billboard, or poster was virtually the sole medium.

The medium and message seemed aligned. One-way messages travelled uni-directionally (posters, television, radio, or other) or at best two-step (flipchart). These were the official health communication by the MOH and its implementing agency the GHS as represented by the CHPS compound. The messaging system clearly lacked interactivity or what some like Linje [27] call “engagement.”

Discussion: Understanding Health

From Table 1, the health message was largely disseminated in a “massified” social marketing format; although some of the women found their own way of processing the radio messages (Table 2). Messages seem basically instructional and prescriptive; demanding of recipients to act and not, for example, find out, analyse, think or make suggestions about things. Intended receivers were not challenged to positively exploit their experiences. It is the typical encyclopaedic or Paulo [21] “banking education” approach to communication which assumes a knowall message source and a know-nothing message destination. “Prevent cholera;” one would ask how. Many of the messages, such as “Malaria kills, don’t take it for granted;” and “TB is curable, use DOTS,” are terse phrases which instruct without explanation; nor are there any built-in opportunities for explanation. What is not explained cannot be understood. Malaria and TB need explanation to be understood by the women and that was lacking in the messages.

Table 2: Messages women were typically exposed to.

The women’s attempts at defining or explaining health hardly initially mentioned diseases and ailments. For example, one would have expected that given the MOH/GHS barrage of messages on malaria and TB, these would reverberate in responses. The echo was virtually non-existent.In communication analysis, theory is often anchored on one of the three aspects: audience, medium and message. Our focus on the message means for the message to resonate with our women audience, message characteristics would determine the appropriate medium. One is looking, then, more at the audience friendly IACS vis-à-vis the sophisticated technologically mediated. Radio being the most frequently mentioned mass medium, little wonder Ngabirano [1] found the radio soap opera useful in the fight against alcoholism.

Whatever the impact of the MOH/GES messages as channeled, the informants (both sedentary and migrant) who were just eking out a living, seemed to link health to work. In their responses, wellbeing of the person was almost always an afterthought in their understanding of health. Being able to work was usually the initial response to what it meant to be healthy. Economic issues had so dominated their lives that they would talk first about economic wellbeing before physical and other wellbeing.

A close look at the health messages does not seem to have left the women with much choice. Messages have more meaning if they are linked to something the receiver can relate to. Perhaps if messages evoked a direct link to ability to go to work, greater attention would be paid to it rather than simply warning, threatening or cautioning in a vacuum. The abstract message needs concretizing in message design to avoid detachment and distance between messenger and receiver.

A medium with one-way flow features would not deliver effectively a message that is of a two-way sharing design. A message which asks the audience what is available in their milieu for combating malaria would likely be usefully shared through a feedback (not unnecessarily delayed but timely) enabling format. It will not be of much use to ask without a response. Whether there has been a request or not will depend on a response to the request.

Means hybridization in the Des [26] diachronic/synchronic approach is technology-driven with low tech instruments replacing high-tech gadgetry. Kwasi [1] indigenization is a departure. In it, he maps out clusters of means in four areas: events, games, performance, and venue. Venue is about place as communication launch pad. Communication naturally generates as people gather in a place. Once two or more meet or assemble communicative interaction results.

To require a public health worker intermediation between the communicator and the destination is to deprive areas without the intervener access to the health message. The cost of the “massified” social marketing is obviously ironically excluding the intended message recipient from access to the message. The women appeared in double jeopardy by health worker absence and message loss. In this mode, the identified channels were solely useful as tools for the health worker. The women were more interested in being fit to work and not the inability to work consequences of whatever disease or ailment.

One should not overlook criticism against the “grandmother tale” type of content and other IACS by Nath & Rudra [28] who observed adverse effects of some herbs on anaesthetics, although grandmother will argue the nutrient (vitamins and other minerals) rich Kwahu nsusuaa and abE duro for breast milk supply; as Christine [29] and Tamuno et al. [30] had. Indeed, they observed:

Women tend to rely on herbal medicine …most salient application for these plants was women’s health, which included plants for strengthening pregnant women, female infertility, abortion and puerperal fever. The most frequently sold medicinal product pteleosis bark was used to cleanse the uterus” [31].

However, their examination of “herbal medicines and their importance to anesthesiologists,” also found: “many of the herbal medicines were quite toxic and had adverse effects and harmful interactions with conventional drugs” [31].

Point is, grandmother talk is not necessarily always positive and therefore requires examination to be adopted as beneficial message. However, an assumption is that trial and error over time was enough scientific experimentation to establish containable side-effects. A real threat is the negative effects on herbs by excessive use of fertilizer, herbicides and weedicides along with other environmental pollutants in the village situation.

Looking Ahead

Obviously, the centralization of message design and means to convey the message unsuited the availability of knowledge to inform the women’s understating of health. Perhaps, a centripetal approach needs consideration. An institution of a community health information group (CHIG), composed of core opinion leader specialists such as the Queenmother, the health worker and a person, well versed in communication could assist mould the friendly health message as of, by, in and for the community. As an authority on the health issues built into puberty rites [32,33] and the Queenmother would be central in assembling health knowledge, processing (consider community group dynamics) it, identifying the most effective means for sharing it, and monitoring the sharing within the community. Herbalists and others with relevant knowledge may be consulted. Messages so developed could be distilled at the district level (to be audited for message accuracy as well as context relevance, before they would be released. The group would also be responsible for localizing messages generated from outside the community such as on an ebola, or bird flu. As well, a district message bank would form from which other communities may draw.

Research (such as GMSIP, 2009 and Table 2 here) usually cites the radio as the most popular of the “traditional media.” A MOH/ GHS radio programme presented by, for example, the nurse broadcaster with a nurse-organized community interactive group listening would be far less costly, inclusive and of greater positive effect than the social marketing approach presently practiced. This could further be expanded into a kind of a media mix approach, to propagate messages which draw on community indigenous knowledge and knowers to enrich health communication content.

Recommendation

Recently, a health official advocated “local content messages” to “contain” a meningitis outbreak [18]. It is about time Ghanaian health authorities seriously considered collecting “grandmother tale” health conversations, stories, knowledge, and advice for designing the health message. In the village, sources of important women-related health information were discovered in the Traditional Birth Attendant (TBA), knowledgeable elderly women, and the Queenmother. Such knowledge could be processed into messages for radio, television and even social media (programme) content after filtration through group discussion to refine. Women’s groups (Mmaa Kuo, Christain Mothers, kayayee gathering such as Mugambi in Ansu-Kyeremeh 2005 cites in Uganda) are natural voluntary health talk mechanisms that need to be exploited. Further research could identify women’s groups and IACS applications.

Summary

This study found mainstream disregard for the adoption of IACS, acknowledged as with potential to help the women studied in their understanding of health. The women’s experiences showed IACS were more likely to encourage the health message to be shared for greater impact rather than disseminated using fancy technology mainly to satisfy project reports. Going forward, one expects a message designed to be shared and not for dissemination; to pursue congruence of language of sharing with audience characteristics. Sharing would need to include all available forms of communication that enable all for whom the message is intended to be included in its design and access. Moreover, the resultant interactivity would stimulate feedback to establish a cycle of inclusive health message sharing and not exclusive dissemination.

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