Issues in Health Communication in India: a Stakeholders Perspective Essay

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Working Paper: MICORE/SDC/002 Issues in Health Communication in India: A Stakeholders Perspective Dr. Satyajeet Nanda1 Ms. Aparimita Pramanik2 Ms. Aarzoo Daswani3 August 2008 Dept. of Social and Development Communication MICORE (Mudra Inst. of Communications Research) 3rd Floor, Rangkrupa Complex, Near Parimal Garden Ahmedabad-6, India; Email: s. [email protected] res. in 1 2 Associate Professor and Head of Dept. Research Associate 3 Research Assistant Acknowledgement

The authors are thankful to all the participants of the Consultation Workshop (round table) on ‘Issues in Health Communication in India: Stakeholders Perspective’ Ahmedabad; 6th June 2008, for their honest and valuable inputs during the deliberations and post-workshop suggestions that has enriched the design of this report. They are Dr. Arbind, Dr. Rupa, Ms. Bhakti, Mr. Ramolaben, Mr. Jignesh, Dr. Rakesh, Dr. Manjul, Dr. Prashant, Dr. Renuka, Mr. Laxman, Ms. Radha, Dr. Shivang, Dr. Parek, Dr. Shilpa, Dr. Rajika, Dr. Thomas, Dr. Lalitha, Dr. Jagruti, Dr.

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Shishoo, Mr. Joshi, Dr. Rajesh, Mr. Arun, Ms. Rutool and Mr. Sengupta. We are also thankful to Dr. Ang Peng Hwa and Mr. Alan D’souza for their valuable suggestions on the report. Thanks are due to all Research Associates and support staff of MICORE for their help in convening the workshop and processing works related to preparation of this report. 2 List of content I: INTRODUCTION II: OBJECTIVES III: METHODOLOGY 3. 1 Research Design 3. 2. Analysis Plan 3. 3. Limitations 3. 4. Organization of the report IV: Page No 4-8 8 9-10 DISCUSSION 10-21 4. 1.

Conceptual Framework of ‘Issues in Health Communication in India- A Stakeholders Perspective’ 4. 2. Profile of the Stakeholders 4. 3. Understanding Issues in Health Communication and Critical Review 4. 3. 1. Retrospect & Prospects of Health Communication 4. 3. 2. Health Communication for Social & Behavioral Change 4. 3. 3. Community Needs Assessment and Dissemination of Research output 4. 3. 4. Tools & Process of Health Communication in Service Delivery 4. 3. 5. Communication in Health Curriculum 4. 3. 6. Communication in Alternative Medicine System 4. 3. 7.

Communication on Health Financing 4. 3. 8. Pharmaceutical communication 4. 3. 9. Communication on Occupational health 4. 3. 10. Communication on Environmental Health & Sanitation 4. 4. Stakeholders’ views on components of Health Communication 21-30 4. 4. 1. Importance of health communication 4. 4. 2. Target, tools, components and communicators 4. 4. 3. Design of communication program 4. 4. 4. Public health system communication (External and internal) 4. 4. 5. Hospital communication (Internal and external) 4. 4. 6. Use of health communication 4. 4. 7. Barriers in health communication 4. . 8. Communication in health curriculum 4. 4. 9. Pharmaceutical communication 4. 4. 10. Issues beyond health 4. 4. 11. Contents of all Stakeholders 4. 4. 12. Priority Research Areas 4. 5. Emerging issues in Health Communication in India 30-32 CONCLUSION 33 V: REFERENCES APPENDIX-1: Conceptual Framework APPENDIX-2: Workshop Schedule Plan 3 Issues in Health Communication in India: A Stakeholders Perspective “Within the health communication field, communication is conceptualized as the central social process in the provision of health care delivery and the promotion of public health.

The centrality of the process of communication is based upon the pervasive roles communication performs in creating, gathering, and sharing “health information. ” Health information is the most important resource in health care and health promotion because it is essential in guiding strategic health behaviors, treatments, and decisions. ” (Gary L. Kreps, 1988) I. INTRODUCTION ‘Communication’ is the process of transferring information from sender to receiver with the use of a medium in which the communicated information is understood by both sender and receiver.

In this process all the components such as information, sender, coding, medium, decoding, receiver and feedback are very important. There are various theories based on different contexts such as, mass communication, individual communication, written, verbal and non-verbal etc. Different communication theories also explain about how different components of the process are important and again in which circumstances. Communication programs have been designed for various purposes. Often the interpersonal communication has been used for Personality Development and Communication Skills.

In terms of mass communication, today, the media plays a very important role in every individual’s life. Initially, common people were not very bothered about what the media was doing and media was strictly restricted to the government and the business houses. But today, every common man’s problem is constantly reflected through media. And there is hardly any section of the society or any issues that are not taken up by the media. In fact, media has become a platform where common men can raise their problems and demand justice to any issue that is in circulation.

Media has indeed become an integral part of a common man’s life. There is couple communication used for better marriage relationship. Hazard or disaster communication is one area very important and popular with wake of workplace safety as well as unforeseen problems. There have been major advances in communication technology over the course of the 20th century. We are invited to think that new forms of communication will deliver a better world. Recently all the hype has been about what computers and networks will make possible: new forms of community and identity.

But are we really entering a new age or have we heard all this before? In this program we’ll go back in time and explore the hopes and fears expressed about high-tech communication like the telegraph and radio, before returning to cast a critical eye over claims being made today. World War One saw the use of propaganda as a formidable tool of war. Radio made it possible to communicate simultaneously with millions of people. Meanwhile, the newly emerging mass society presented new challenges for government, commerce and culture. It was in this context that communication emerged as an area of study in the 1920s and 1930s.

In this line few introductions may be taken from some keys figures in early communication research including Harold Lasswell and his studies of propaganda, and Paul Lazarsfeld a pioneer of radio audience studies. If communication is all around us how do we take a step back and start to think about it? One way is to develop models of communication. The best known of the early models was developed by Shannon ; Weaver in 4 the late 1940s to analyze the operation of national telephone grids. But soon it was taken up as a general model of communication – as a family of communication models known as transmission models.

This program examines the idea of the transmission model which was big in the 1950s and 1960s but has since fallen out of favors with researchers. The semiotic approach sees communication as a mutual negotiation of meaning rather than a linear transfer of messages from transmitter to receiver. The notion of ‘meaning-construction’ has been influential in the study of media and communication. What exactly did the semiotic theorists Saussure, Peirce, and Barthes mean? What is the ‘sign’, ‘the signifier’, and ‘the signified’?

The program examines the strengths and weaknesses of semiotic analysis through the example of billboard advertising. One view of communication is that it reproduces power relations. A simple yet illuminating example involves the courtroom in which the voices of police, lawyers, judges, and defendants will be heard and understood within established frameworks of meaning. But what if some of the ‘actors’ cannot be heard, or are ‘misheard’, because they arrive from outside the accepted framework? For example how are Aboriginal Australians heard in the court setting? And what does this say about communication as a site of power relations?

Organizational communication is an important focus of media and communication studies. The way people communicate within a defined space is fertile ground for analysis. Changes to spatial arrangements, network structures, and working arrangements will launch many-layered communication strategies some of which will be successful, whilst others will fail. ‘Health communication’ has developed over the last twenty-five years as a vibrant and important field of study concerned with the powerful roles performed by human and mediated communication in health care delivery and health promotion.

Health communication inquiry has emerged as an exciting applied behavioral science research area. It is an applied area of research not only because it examines the pragmatic influences of human communication on the provision of health care and the promotion of public health, but also because the work in this area is often used to enhance the quality of health care delivery and health promotion. To this end, health communication inquiry is usually problem-based, focusing on identifying, examining, and solving health care and health promotion problems.

Within the health communication field, communication is conceptualized as the central social process in the provision of health care delivery and the promotion of public health. The centrality of the process of communication is based upon the pervasive roles communication performs in creating, gathering, and sharing “health information. ” Health information is the most important resource in health care and health promotion because it essential in guiding strategic health behaviors, treatments, and decisions (Kreps, 1988).

Health Communication in its literal form links the domains of communication and health and is increasingly recognized as a necessary element of efforts to improve personal and public health. Health communication can contribute to all aspects of disease prevention and health promotion, and is relevant in a number of contexts. There are various theories of Health communication. They describe different contexts and components of the process in which different factors play role and ultimately decide the nature of communication.

Some of them are Elaboration Likelihood Model, Health Belief Model, Protection Motivation Theory, Social Cognitive Theory, Social Support, Theory of Planned Behavior/ Reasoned Action, Transactional Model of Stress and Coping etc. Health Belief Model (HBM) is a psychological model that attempts to explain and predict 5 health behaviors. This is done by focusing on the attitudes and beliefs of individuals. The HBM was first developed in the 1950s by social psychologists Hochbaum, Rosenstock and Kegels working in the U. S. Public Health Services.

The model was developed in response to the failure of a free tuberculosis (TB) health screening program. Since then, the HBM has been adapted to explore a variety of long- and short-term health behaviors, including sexual risk behaviors and the transmission of HIV/AIDS. The HBM is based on the understanding that a person will take a health-related action (i. e. , use condoms) if that person: • • • feels that a negative health condition (i. e. , HIV) can be avoided, has a positive expectation that by taking a recommended action, he/she will avoid a negative health condition (i. . , using condoms will be effective at preventing HIV), and Believes that he/she can successfully take a recommended health action (i. e. , he/she can use condoms comfortably and with confidence). There has been multiplicity of communication programs across the globe. Empirical studies and programs have found out the determinants and correlates of communication. A study in USA on Doctor-patient communication (John 2008) examined nonverbal communication in relation to Electronic Medical Record (EMR) use during the medical interview.

Six physicians were videotaped during their consultations with 50 different patients at a single setting Veterans Administration Hospital. Although some ineffective or detrimental nonverbal behaviors seemed inherent with EMR use, such behaviors varied according to degree. For example, three different office spatial designs were identified and named “open,” “closed” and “blocked. ” The “open” arrangement put physicians in a position to establish better eye contact and physical orientation than did the alternative “closed” and “blocked” office configurations.

Physicians who accessed the EMR and took “breakpoints” (short periods of no computer use and sustained eye contact with patients) used more nonverbal cues than physicians who tended to talk with their patients while continuously working on the computer. The author suggests how breakpoints can help reduce information loss that may be associated with EMR use. Finally, long pauses in conversational turn-taking associated with EMR use had an unexpected, positive impact on doctor-patient communication.

High EMR use physicians had patients who asked more questions and participated more in the medical interview than did low EMR use physicians. The EMR tended to slow down the medical interview and gave patients a chance to think about their circumstance, symptoms, and other questions about their medical condition. Nonverbal phenomena (slow turn- taking and reduced eye contact) that are typically associated with less effective interpersonal communication were related to an increase in positive verbal exchange.

India too has witnessed some such programs on various issues. World Bank’s HNP has undertaken a study (2005) on communication in public health programs: the leprosy project in India. It has been envisaged that the use of communication by the leprosy program in India offers valuable lessons for other programs, both in terms of its successes as well as the challenges ahead. The information, education and communication component has made a significant contribution in reducing the prevalence rate of leprosy cases.

It has raised awareness about the signs and symptoms of leprosy and the importance of seeking early treatment, and reduced the social stigma associated with the disease. In recent years, the program emphasis has shifted to early voluntary self-reporting. The Government of India has set itself the goal of eliminating leprosy at the national level by December 2005. In the last vital year, cost-effective communication efforts are planned and sustained in collaboration with key partners to improve 6 service delivery to hard-to- reach groups, motivate general health system staff, and ensure district-level political support.

A study by Waisbord, S (2008) on India, Pakistan and Nigeria has shown that communication programs have made important contributions to polio eradication, but overall results have not been reviewed. This study synthesizes evidence-based studies and explores the links between communication and disease control programs. The findings suggested that polio partners only belatedly have recognized the relevance of communication programs only after the PEI confronted a number of social problems, mainly resistance and negative rumors about polio vaccine.

To deal successfully with these issues, a serious consideration of communication issues and the shift from an informational to a social behavioral approach to communication are required. The PEI offers important lessons for other global health programs: communication and social aspects need to be addressed early in the design of the intervention, and social and cultural expectations related to vaccination and other health issues need to be identified and properly integrated.

Another study the BSS survey 2003 on general population and youth (Thwe et. al. 2005) revealed that Revitalization and scaling-up the HIV and AIDS Information education and Communication (IEC) campaign against HIV and AIDS can be done by: evaluating current IEC strategies, identifying innovative mechanisms to disseminate key HIV prevention messages, and by targeting IEC to vulnerable groups such as out-of school youth and women in reproductive age group.

For quite sometime the health communication has been restricted to more of an academic exercise or executive routine. So, an insider’s perspective or “emic” approach to see health issues and conceptualize them into programs has been almost missing. Most of the time, the planners have designed programs in view of the so called ‘Experts’ approach (Nanda, 2007). Hence, a deviation to this is felt necessary to bring all the potential stakeholders to a common platform and understand issues in Health Communication in its totality.

This may lead to a holistic approach of understanding the issues and may incorporate both emic as well as etic approaches. At community level, health communication can be used to influence the public agenda, advocate for policies and programs, promote positive changes in the socioeconomic and physical environments, improve the delivery of public health and health care services, and encourage social norms that benefit health and quality of life.

The World Health Organization (WHO) in its revised explanation has included Spiritual and Social wellbeing and not merely the physical and mental wellbeing in the definition of “Health”. The definition was updated in the 1986 WHO “Ottawa Charter for Health Promotion” to say health is a “resource for everyday life, not the objective of living”, and “health is a positive concept emphasizing social and personal resources, as well as physical capacities” (WHO, 1986).

Against these backdrops, MICORE within its broad agenda of Social and Development Communication, held a Round Table workshop on pertinent issues in health communication validated by all potential stakeholders. This would serve as a Consultation Base for future regional or national seminars and research studies. 7 II. OBJECTIVES: The Round Table endeavored to cover as many possible themes and sub-themes around the issues of health communications in India.

They have been arranged in four broad themes in the form of four technical sessions: Session-1: Retrospect ; Prospects of Health Communication Session- 2: Tools ; Process of Health Communication in service delivery Session- 3: Communication on Alternative health care system Session- 4: Frontiers of Health Communication In view of the revised definition of health by the WHO which provides a broader base, it has been endeavored to cover the important components of health communication in the current workshop.

The technical sessions of the workshop comprise of the important sub-themes, such as: • • • • • • • • • • • • • • • Historical perspectives Emerging issues in health communication in India Communication for social ; behavioral change Community need assessment/ demand studies Dissemination of research output Internal (intra and inter- departmental) communication on service delivery External Communication Infra- structure (Public ; Private) on service delivery Health Education (curriculum) on Communication Issues “Beyond Health” (Social determinants of health) Alternative Medicine system Life Style ; Well Being Health financing communication Pharmaceuticals communication Occupational health communication Environmental Health ; Sanitation

All the issues covered in the workshop were discussed by stakeholders in the light of • What are the current issues in health in Indian context • How do you deal with / how they should be dealt • Ethical aspects of the issue (caste, religion, gender etc. …) • Legal aspects of the issue • Policy implications • Cost implications (both service provider and users perspective) • Suggestions / recommendation and their feasibility for implementation The over all objective of this workshop was to catalyze all possible stake-holders brain storm through mutual exchange of ideas and experiences and validate the issues in a common platform. 8 III. METHODOLOGY: 3. Research Design: The current study follows a diagnostic research design, where various issues on health communication were brought by possible stakeholders to a common platform and validate immediately through discussions. The study employs a consultation workshop in the form of a round table as the tool for research into various issues involved in health communication in India. This is a one-day workshop consisting of a series of moderated discussions with experts from various stakeholders such as Government, NGOs, Funding Agencies, Practitioners, Media, Academicians, Researchers, Pharmaceuticals and Consumer (service users) to generate issues and concerns that again were validated through brainstorming.

The ideas and views of stakeholders at various levels based on their practical experience and specific research projects were presented before other stakeholders and opened for discussion. All discussions pertained to their importance to health communication in India. The whole exercise of presentations and discussion were video recorded for subsequently analysis and cross reference. This process has helped us to dig out the issues from all stakeholders, validate there itself. At the end of this exercise, all the issues are consolidated by panel discussion again allowing the stakeholders along with the experts so as to work out further research agenda. 3. 2.

Analysis Plan: The report undertakes a 4-tier analysis of information for all issues in two major sections, In the first part, 1. The issues were studied in-depth in terms of its conceptual meaning, rationale for study. 2. The issues were examined in terms of its relevance across the globe and in particular to India by undertaking a detailed literature review of studies in different countries of the world as well as Indian provinces. 3. A critical analysis was carried out on the news clippings related to the issues discussed by stakeholders. These news clippings appeared in 2 of the premier national newspapers for a period of 6 months. In the second part, 4.

A stakeholder wise analysis was carried out on various issues discussed in the workshop from the unedited transcriptions of the video records. During the analysis, each of the issues were cross examined by the standpoint of each stakeholder in terms of its similarities and differences so as to get a comparative picture of the particular issue. Further, to strengthen the viewpoints, the stakeholders were contacted subsequently to substantiate their inputs. 3. 3. Limitations: Like many other research tools and techniques, this study also have got some inherent limitations although not affecting much to the final output to any significant level. But they need to be familiar with so as to take precautions while generalizing the inferences. Some such limitation could be, 1.

Health communication being a vast area of study, within a shorter time frame of one 9 day, all issues related to this might not have been captured in the discussion or design of the workshop, although care has been taken to cover most of the important issues. 2. Again, the available time slots for deliberations might have to some extent affected the content. 3. There could be many different stakeholders based on different classification, but this workshop has endeavored to capture the inputs from most possible categories based on their availability. 4. Possible background (technical know-how, socio-cultural etc. ) differential of various stakeholders might have influenced the views expressed. 4. : Stakeholders’ Views on Components of Health Communication: Detailed analyses were carried out on deliberations by all stakeholders during the workshop. All the views expressed were subjected to disaggregate analysis by different components of health communication following the objective of this study that is to get all discussions only around communication aspects rather than system or any products. Although analyses are not exclusive or exhaustive to all components of communication, it has been endeavored to decompose the complete workshop discussions into most possible facets of health communication in terms of their important in Indian context.

The components have been analyzed by stakeholders’ views and are presented below. 4. 4. 1. Importance of health communication: The academicians expressed that communication has been identified as basic right in the Indian constitution. Although different health system development programs (HSDP) have upgraded different communication infrastructure, it has not helped people for optimal utilization of services. Academicians expressed that health communicators have been existing for quite some time in Indian health programs for last 60 years in different form/names, such as Gram swasthya Mitra, Gram swasthya rakshak and village health committee etc. The research question is, what works and in which circumstances i. e. credibility / applicability of the communication medium and differential in decision making in different intervention programs. They also revealed that medicine from doctors and hospitals are not utilized due to lack of awareness / communication, in spite of the fact that health programs have been supported by communication infrastructure and people response to health communication. People from government also support the idea that lack of communication exist more in grass root level and this lead to underutilization of services. Mass communication programs can solve these problems. Communication should take place everywhere and every time so as to ensure continuity.

People from Industry also support that government policy has not reached the people to an optimal extent due to problem in communication. Academicians expressed that teaching program on health communication in India does not practically exist in most places. Both academicians as well as people from funding agency agree that communication is considered to be a necessity only when there is a problem, thereby undermining its very preventive role. Health communication helps in finding the risk factors rather than only health problems. Health communication also helps to identify “one’s own problem”. This view is also supported by people from alternative media that intra-personal communication is very important.

Some practitioners consider communication to be a psychological event and emphasize that ‘when’ (time) is an important component of communication in addition to ‘how’ and ‘with 10 what ways’ as 3 major characteristics of communication. They recognize that communication in general is greatly lacking in Indian programs. 4. 4. 2. Target, tools, components and communicators (training/ involvement): The NGOs as an important stakeholder expressed that communication tools developed particularly for rural people works better, when they are based on the involvement of health workers and members from community of study (formative research). This was also expressed by alternative media and members from consumer group.

The NGO persons also reveal that communication tools such as folk songs, posters, community radio program and short films are found to be more acceptable to rural people. Health communications particularly for adolescents are found successful through tools such as wall painting, booklets and posters. This is supported by academicians and people from government and alternative media. People from Electronic Media suggest that need assessment in terms of target group, area, specific requirement and issues are necessary, before designing communication programs. Then the information based on assessment should be passed-on to media. After the communication by media there is a need to get feedback from people by evaluation which is missing and hence required to be studied further.

They feel that communication should be carried out by persons closure to people viz. , teacher, ASHA etc. In the same line people from NGO also feel that ASHA and trained Dai (community midwives) can be utilized for health communication at grass root. People from media focus the need for communication of positive stories by both public and private media, NGO and researchers. The successful communication models such as Dai and ASHA worker should be passed to media so that people can know about them. The idea was also supported by academicians. Sensitization of people from media and health system is required to change the mindset of service providers.

Communication for out-reach community is very much essential so as to bring down the community specific problems to a greater extent. The people from industry feel that little is being done in communication programs, and this may be because of finance and policy restrictions. They feel different tools of communication should be utilized for different subjects and target groups for e. g. , audio-visuals communication, which was also supported by NGOs. Some practitioners feel, media should provide communication to people through programs on dental health care. However, criticism could be the chance of poor technical know-how among media persons may lead to incorrect or incomplete communication aggravating the existing problems.

Academicians strongly believe that open and transparent communication materials could help service providers to follow standard guidelines rather than spending time on clarification. 4. 4. 3. Design of communication programs: The design of health communication is very important in terms of its impact on target population. People from government feel the communication programs should be designed for specific purpose viz. , listening, speaking, writing, reading and reasoning. However, industry persons move one step further identifying the need for communication on specific issues rather than broad topics for example, ‘information on Gujarati community being more vulnerable to heart disease’.

Practitioners feel that communication should be designed in a holistic manner integrating different health problems rather than focusing on any individual health problem. It 11 is also believed across stakeholders that health messages are better communicated when they are presented in integrated form for e. g. , to start with primary health care, then on reproductive health and finally on HIV issues. Same is supported by people from alternate media. People from government emphasize that design of health communication programs should be based on demand from the people. So do the academician and industry people feel that demand could be hidden sometimes due to a disadvantaged socio-economic background, hence there is a need to generate as well as scan the demands.

In terms of nature of communication programs, academicians suggest that care should be taken in designing mass communication or interpersonal communication programs based on the need of people/ target groups as well as the issues concerned, because some issues are person specific where as some are common for mass. It was suggested that communication should be given as in full rather than piece-meal. Take the case of IFA tablet, which is meant for all women above 14 years of age as well as people with anemia. However, rural people consider it to be taken by pregnant women only. Some people do not take this due to blackening of teeth and stool considering something gone wrong. These happen because of mis-communication or incomplete communication regarding the medication. Practitioners express that interpersonalcommunication is the best mode for psychological health issues.

Some academicians suggested that the design, mode and agency (communicator) of health communication should be different for different population viz. , industrial or non-industrial population. The communication (message) for rural/agrarian population should have following characteristics ¦ simple (to read and understand) ¦ standard (common and constant) ¦ should be communicated through interpersonal communication (sometimes propaganda) ¦ the message should be communicated to people through leader (social, cultural, economic etc like religious or clan head) of population setting (rural area) For urban or industrial population however the health needs being diverse in nature, hence communication (message) should have different characteristics than rural people viz. ¦ the problem specific information ¦ should be communicated through iterative consensus, that means specific information should be given after sufficient consultation rather than continuous discussion ¦ the message should be communicated to people through media, government and health research institute It was revealed that recently urbanized people (migrants from rural area viz. , such as slum dwellers) do not appreciate complex messages and they are the ones having disproportionately higher prevalence of risk factors. The NGO people also feel that the internal-communication among people at different level of social-economic and technological development, should be designed in a sensitized manner so as to satisfy the needs and respect the emotions.

The Practitioner and NGO people cautioned that lot of care should be taken while communicating with rural people on technical aspects of health or medicine. Other wise the lower level of literacy may lead to misunderstandings. Some practitioners feel that ‘health’ should be communicated not only as the absence of current well being but also absence established risk factors. In case of environment health 12 programs, academicians feel that communication between promoters and implementers should also be shared with people both individually as well as jointly. The people from funding agency suggested that there is a need to strategize the communication in terms of target and then to decide the form of communication viz. interpersonal, written or mass communication, which was also supported by Academicians. Mass communication (campaigns) can solve the problems in a big way. The funding agencies emphasized that the medium of communication need to be designed depending on the criticality of the problem (environmental threats to child health). For malnutrition, diarrhea and sanitation related problems, communication on personal cleanliness could play important role. This view was supported by academicians in terms of communication on cleanliness of public places for a better environmental health. Some practitioners suggested that communication on alternate medicine should be given in details i. e. in terms of its mechanism for example, combination of certain medicines could have positive as well as negative effect. They also emphasized that the communication given to people should be associated with full rationale so that people can decide in terms of accepting the information. Communication should clearly focus on harmful effects of the products and after care and hygiene. 4. 4. 4. Public health system (External and internal): The communication in public health system is very important because the targets groups are vast in size and heterogeneous by nature. Hence, a lot of care needs to be taken and well designed health communication has to be disseminated.

The external communication in public health system is the one, where communication of the health system takes place with the people at large and mainly the patients. The internal communication take place between the health staffs at different level . As the background of all these people are different hence there is need to have different system of communication. In terms of internal communication, the people from government health system revealed that communication in public health system flows from state to district and then block health officer, medical officer, sub centre, anganwadi worker, ASHA to gram arogya mitra and ultimately public. Communication takes care of two components such as admin and technical, and major focus is on technical aspects.

All health workers at different level are given regular training about national level programs and micro planning for the year. This communication includes the amount of work load (say target) at different level for the whole week. Communication (repeatedly told) is given on Anemia control program, MCH, safe delivery, safe drinking water. The criticism here could be, all the programs covered in such communication seem to be of varying nature thereby limiting the focus on subjects. Communication programs are monitored and facilitated by frequent visits and using modern communication technology (cell phone). However, academician caution that all infrastructure for “Health Communication” should have an “ethical code” in place for not contradicting WHO’s commandments.

In terms of external communication, the people from government health system revealed that information about registration of pregnancies are given through its formal ICE activity following a lifecycle approach. Communication is given on different aspects of ANC for mother and child health care such as iron folic acid, diet, rest, institutional delivery, vaccination of child right from first trimester. However criticism here could be communication may have a 13 differential effect due to varying level of educational of the receiver and capturing capacity in terms of amount of information given. People from government health system also told that every month or every week once a day, Mamta Devas is organized and observed.

Communication is given on how to use the existing health schemes viz. , the institutional deliveries and Chiranjevani Yogana and janani suraksha yogana (health insurance). Academician and Alternative Media presented examples of health staff attending communication programs as well as implementing them. 4. 4. 5. Hospital communication (Internal and external) Practitioner viewed Hospital communication as facilitating access and information to patients and families about its patient care services in terms of a. identification of audience b. predetermined documented communication strategy c. information on services such as area of medical facilities, working hours and process of delivery d. rocesses of services e. information about alternative sources(places) of care Practitioners suggested the uses of vernacular languages and use of visuals of different target audience such as a. Local population though NGO b. Out of state population c. International patient d. Focused patient (heart, cancer) e. Medical community at different level f. Insurance company g. Prospective investors Practitioners suggested the uses of tools, Boucher, fillers, advertisement, media(print, electronic, internet, tele-medicine, public program, med. conference). They identified some Challenges such as a. build a robust health information system that provides equitable access b. evelop high-quality, audience-appropriate information and support services for specific health problems and health-related decisions for all segments of the population, especially underserved persons c. train health professionals in the science of communication and the use of communication technologies d. evaluate the interventions and e. promote a critical understanding and practice of effective health communication through research. 4. 4. 6. Use of health communication Academicians are of the view that most of the time communication is attributed to intervention for behavior change in terms of attitude and values, although actual mechanism for doing so is still unknown.

But government officials opined that communication should be in direction of desired change and based on pre determined goal and this idea was supported by industry people with the view that health communication is important for social and behavior change of people rather than the system. 14 Academicians identified two major components of communication such as; the actual target group (risk population) and proper use of communication delivered. It has been considered that majority (3/4th) of all problems related to health utilization can be solved with proper communication. Hence, there is a need in terms of its contents, delivery, utilization and management. It also suggested that communication can be used for informative, motivation /sensitization, preventive and curative aspects of health.

Finally, it has been recognized that communication should take care of holistic views concerned with stakeholders’ viz. , public, client as well as of service provider. Regarding the use of communication, few Practitioners agreed that health communication is useful to remove stigma. Everybody should be sensitized to communicate their problems which are referred as “education of awareness”. There should be a human medium like ASHA in NRHM or any other person through which communication can be made. Effective health communication helps in ‘prevention’ component of psychological health care which in turn proves to be useful for treatment and rehabilitation.

It was also suggested that media should promote confidence rather than following some new lifestyle at the cost of general health, viz. , media has a major role in communicating people to “age gracefully”. Alternative Media feels that print and electronic media should provide communication programs on positive and negative aspects of different medicine system. 4. 4. 7. Barriers in health communication Representatives of NGOs feel that for internal communication between health staff i. e. , from specialist level to grass root level, some barrier exist in terms of language difference, e. g. , different form of colloquial language, difference in technical qualification e. g. gynecologists to untrained Dai (community midwives), varying choice of communication mode (open or class room training), influencing the mindset of system (government and non government) geographical/cultural variation viz. different taluka or district within the same state. Officials from government health system also talked about these constraints while academicians discussed about the culture of service provider. Officials from government reveals that communication barrier exist in terms of cultural, physiological, class difference, environmental, custom, belief, religion, language, economic and social categories. Academicians also support the idea with regard to pharmaceutical communication among different social culture economic group may lead to some misunderstandings. Practitioners feel that communication may be affected by role models and age.

Lack of communication on side effect or harmful effect, alternative medicine can lead to distorted information. Communication gap exists between practitioner and government (policy maker) may lead to some of the problems viz. , no insurance and hence lower use of alterative health care system Academicians identified that problems in communication between health service provider and service user could be because of insufficient time induced by work overload. For example, doctor patient communication in government hospitals in India. 4. 4. 8. Communication in health curriculum Academicians put forth that communication on pharmacy has been identified as an important 15 omponent in health care industry as well expressed their concern regarding communication skills not included in pharmacy curriculum. There is a need to incorporate clinical pharmacy in curriculum where patient counseling can be taught. Clinical pharmacy communication gives information on beneficial and adverse effect of drug, administration of drug. There is a need to incorporate communication in the beginning of pharmacy education. There should be internship associated with health education where communication can be learnt with other health workers and public in hospitals. Communication research should be documented and disseminated to people, practitioner and agencies through various meetings and conferences.

Media people expressed that health education on different issues not necessarily only ‘sex education’ should be introduced in school education. 4. 4. 9. Pharmaceutical communication Regarding pharmaceutical communication practitioners expressed that there could be negative effect of marketing communication of certain products related to dental health on teenagers because of incompleteness of information. NGOs also supported that often pharmaceutical communication in India are associated with incomplete and incorrect information and merely used for marketing products. Academicians suggest that communication on medicine dispensing by government health system could be broadly of two categories such as ‘communication to doctors’ and ‘communication to consumer’.

The health systems communicate to doctors on dispensing the essential drug as prescribed by WHO, but actually implementation takes some time due to mind blocks of doctors associated with previous system of drug prescription. The gap between communication from system to doctors lead to irrational dispensing of rational drug. In terms of communication of health service provider (pharmaceuticals) with the consumer, the use of vernacular language may play a better role, which was also realized by some practitioner and media at some point of time. However, in population with a significant proportion of illiteracy, this model may not have a higher positive impact.

In terms of communication based on demand from the health service user, doctors can convince the literate people relatively easy. Whereas for illiterate people (service user), doctors needs to communicate in details about the mechanism of treatment, diagnosis and also how medicines work on the human body. For example, 1. A person with TB (still considered taboo in rural area) comes to the doctor, the latter tells the patient as he got a very bad cold, should go for test and come back after which doctor can suggest the course of medicine so that patient becomes alright in next 6 months. 2. Another example is where the doctor prescribes a 5 to 7 days antibiotic course to patient without explaining the reason.

But the patient follows 2 days course and stops. Doctor should have communicated to the patient that in 2 days the disease can only be controlled and to prevent the disease, full 7 days course needs to be completed. 3. Another example is, unlike before the year 1995 when Tamil Nadu health system was dispensing open tablets with different colors, now it’s given in wrapped form with different color of the wrapper. This change (form of non verbal communication) has helped building trust of people particularly rural or illiterate on the efficacy of drug. In addition to this, the use of symbol and diagram for communication with illiterates are very useful. 16

In terms of pharmacist communication on drugs, some of the components are very important such as a. style of writing should be clear b. it should be clear which time of the day it should be taken, after or before food, with or without food/water or any other thing c. gap between subsequent drug administration d. Verbal checking (feedback monitoring) after communication is needed e. the communication environment should be cozy and the communicators should develop a feeling of respect f. the environment should not be over crowded so as to ensure freedom and privacy in communication g. proper clothing and presentation of communicator (pharmacist) are the means of non verbal communication play important roles in ensuring professionalism h. erbal communication should begin with proper drug history of the patient and should note properly information about the illness, medicine taken and person allergic to some medicine i. for written communication in pharmaceuticals, there is a need to take care of proper labeling of instructions, dosage, frequency, adverse effects, precautions etc. , j. both for verbal and written communication on pharmaceuticals, awareness should be given on certain changes on post medication need not be worried about, k. pharmaceutical communication like general health communication should be clear in terms of person specific information rather than common (even if within the same family) and l. for voluntaries in pharmaceuticals, the health communication should be clear in terms of side effects and hazards.

Researchers said that the magnitude of communication in pharmaceutical in terms of the nature of the drug and procedure and precautions of the drug are very important which in turn may lead to more harm than good effects in human body. The incidents of drug misuse and shocking consequences revealed by different studies frequently emphasize that there should be proper communication system between doctors, patients and drug supplier, these are the three apices of the triangular model. In pharmaceutical communication process, most doctors get information from drug supplier and main information come from dictators and hence the complete and correct information do not reach to the patient. So patients should be provided with package inserts for pharmaceutical communication.

This may be useful in developing a proper communication mechanism between doctor and patient particularly when there is lack of time (as has been identified a common problem in government hospitals). In pharmaceutical communication, the information on storage condition should be clearly given. It has been emphasized that pharma communication should comprise of the full information (output) from research reports. Pharma Industry representative described marketing process of scheduled drug communication between doctors and pharma companies takes place through medical representative (MR). So indirectly MR establishes a communication link between doctors and patients. Hence the quality of MR in terms of education, training and awareness can affect the communication process (‘noise’ and ‘encoding’ components of conventional theories).

The communication between doctor and MR can be affected by lack of sufficient time which may lead to 17 incomplete information. This has also been identified by academicians in the context of doctorpatient communication in government health system. Another important facet of pharmaceutical communication is training of MR on how to be heard and communicate better. The problem of communication may arise when there is a compromise of huge or sharing of information by doctor and MR. Another problem could be surrogate advertisement which again may be associated with incorrect and incomplete information. This was also supported by media persons. 4. 4. 10.

Issues beyond health Academicians expressed that often people refer health as synonyms of medicine, doctor and hospital and in turn miss some of the other important factors associated with health. Hence, it is important to understand the issues beyond health e. g. , social determinants of health, alternative health care system and lifestyle etc. This idea was also supported by NGO representatives with the need for study of issues beyond health is existing from quite some time in society. Print media people emphasize that doctors are one of the essential components of communication on sex ratio. Print Media representative believed that communication is very important for certain social issues and particularly extremely useful for ‘skewed sex ratio’.

Besides doctors, there is need of a strategic communication program to change the psyche of people and civil society in terms of • how to prevent people not to kill girl child/ foetus • how to access the doctors or proper (take care of ethics) service and • how to prevent people not to go for wrong/unethical health services. Representative of pharma industry emphasized on the role of print and electronic media in providing communication on different issues in an ethical manner. They can exercise the liberty of alteration/deletion of the content before communication. They also realized the need to change the mindset of people through proper communication. Communication is required for doctors not to provide unethical service to people. People from print media, industry and academics feel that explicit external communication has little role on social issues as lot of awareness should come from within. Some Practitioner of Alternative therapy expressed that 1.

There is a need for communication with public at large regarding possible electromagnetic effect on health of people living near electric infrastructure(flats, building, public roads near sub-station, high power transmission lines) 2. Communication on pollutants affecting human body. (Also supported by academicians) Few academicians also support the above idea that there is a need to focus on communication on accessing the right authorities regarding health hazards. 4. 5. Emerging issues in Health Communication in India: After a thorough analysis based on the critical review of inputs from various sources such as prior studies, media articles and stakeholders views, the real issues were validated and the emerging issues are worked out. 8 Issues for further research/action 1. Study on communication Gap (Internal and external) 2. Doctor Patient Communication 3. Integrated model on health communication 4. Communication on Life Style Versus Health 5. Changing the mindset of people regarding health communication (culture, social, economic) 6. Impact of Communication by traditional folk form 7. Success and failures stories in Communication program 8. Pharmaceutical communication (Doctor, people, policy) 9. Communication on Occupational Health 10. Communication Need Assessment 11. Communication for outreach community 12. Component analysis of Communication Programs (BCC, IEC etc. 13. Health Communication on Non Utilization of Facilities 14. Ethics in health Communication 15. Communication on Alternative Medicine 16. Communication on Preventive aspects of Health 17. Communication studies on stigma related to HIV/AIDS 18. ‘Communication’ in health curriculum/training Stakeholders NGO, practitioner, Funding agency, Academicians, Researcher, Media Academician, media Government, industry, practitioner, media, alternative media, NGO Media, practioner Media, Academician, Industry, NGO, Government News Clippings and TVC Practitioner, Researcher, NGO, Govt. practicitioner, Researcher, Industry Alternative media, NGO, Media, Govt. Academician Media, Practitioner, Researcher, NGO, Academician Academician, Media, Pharmaceuticals, Practitioner, Researcher Academician, Media, Academician, NGO, Media, Media, Government, Practitioner, NGO Researcher, Academicians, IEC official Govt. , Academician, Industry, Consumer Academician, industry, Researcher, NGO Industry, Practitioner Academicians, Funding Agency, Practitioner, Media Consumers, NGO, Academicians Academicians, Media, Industry 19 Industry, Practitioner, Research Researcher Consumer Govt. , Funding Agency 19. Dissemination of communication research 20. Credibility of Health Information 21. Holistic approach to Health 22.

Health ; Hygiene Awareness in terms of Environment 23. Communication on public health programs to people 24. Skewed Sex Ratio and Gender Sensitization 25. Communication studies on stigma related to mental health services 26. Communication on Health Financing 27. Contribution to health information by Private channels 28. Feedback ; monitoring mechanism in Health Communication 29. Need for formative Research in Health Communication 30. Non-transmission mode of Communication 31. Awareness on Dental Health 32. CSR on health communication by pharma industry Media, Consumer, Academician Researcher, Alternative media, Academician Academician, practitioner Academician, Funding agency Govt. Academician Media, Academician Practitioner Researcher Academician, Industry Media, Practitioner Media NGO Media Practitioner Alternative media Some more priority research areas • • • • • • The amount of health education, in school (primary and secondary) how and from where they are communicated so that further communication material can be developed. There should be studies to find out communication needs of people particularly from rural areas on different aspects of health There is lack of study on effectiveness of communication. Hence more research should take place in this area. There is a need to find out cross cutting area of communication for research rather than specific areas.

There could be large scale study to find out what works and what does not work in communication interventions Small scale study may be done on o a stakeholder communication need o stakeholders willingness to participate in communication study and campaign o willingness to take part in communication gap study and readiness to pay for it 20 • • • • o study of positioning on health communication in health education syllabus, in health education and training inst Study on credibility of source of information Need to communicate on the available services and access to them Study or program should be designed on care and support for HIV affected people through partnership of stakeholders where all ideas can be incorporated from academician to researchers to NGOs and media. patient education by any government or specialist agency can lead to sustainable communication program on health V.

Conclusion: The discussions regarding health communication issues in India signifies that the root causes of health issues are numerous and related to individual behaviors, provider knowledge and attitudes. Organization of the health care system, and societal and cultural values have to be well documented in communication, particularly to deal with inconsistent access to health care due to cultural variations. It is discussed that matching the cultural characteristics of targeted populations with public health interventions designed to affect individuals within the group may enhance receptivity to, acceptance of, and component of health information and programs.

In this regards integrated approach of health communication is consistent with the documented evidence that factors such as belief systems; religious and cultural values, life experiences, and group identity act as powerful filters through which information is received. It is important to consider these factors in the development of health communication strategies. In terms of nature of communication programs, it is suggested that care should be taken in designing mass communication or interpersonal communication programs based on the need of people/ target groups as well as the issues concerned, because some issues are person specific where as some are common for mass. In the course of discussion in this workshop common consensus felt that lack of information is one of the prime factors affecting government sponsored programs.

To take the message of health insurance to a much wider audience, appropriate communication strategies have to be devised. Clear and compelling messages have to be conveyed through the appropriate media (electronic or print). Care should be taken to avoid any gap between the communicator and the audience – in other words, messages should be given in the audience’s frame of reference and in a format and fashion that is both understandable and appealing. Health literacy – the ability to read, understand and act on health information – is one of the least recognized yet most widespread challenges to achieving better health outcomes and lowering health care costs in different parts of our country.

There is need for incorporating health communication related curriculum in the text books to educate students in different stages. Effective health communication programs are built on sound research and evaluation. Meaningful research and evaluation are not afterthoughts but integral parts of initial program design. Research provides the ideas and tools to design and carry out formative, process, and outcome evaluations to improve health communication efforts, certify the degree of change that has occurred, and identify programs or elements of programs that are not working. Research 21 and evaluation systematically obtain information that can be used to refine the design, development, implementation, adoption, redesign, and overall uality of a communication intervention. Good provider-patient communication contributes to quality care and improved health status. Effective communication underpins prevention and screening efforts at the clinical level, when providers have the opportunity to engage in one-on-one counseling and supply information that is culturally and linguistically appropriate and delivered at the person’s health literacy level. Diagnoses and treatments require doctors to negotiate a common understanding with patients about what is to be done. The quality of provider-patient communication can affect numerous outcomes, including patient adherence to recommendations and health status.

Appropriate information and communication with a provider not only can relieve patients’ anxieties but also can help patients understand their choices, allow them to participate in informed decision – making, and better manage their own health concerns. Majority of issues related to health can be solved with proper communication in terms of its content, delivery, utilization and management. Effective health communication helps in prevention component which proves to be useful for treatment and rehabilitation. Communication should be strategizing for target group and then its form should be decided i. e. interpersonal, mass communication or written based on needs and issues concerned. Communication between promoters and implementers should be shared with people.

It is found that communication tools such as folk songs, posters, community radio program and short films are more acceptable to rural people to communicate health messages. Positive stories by any NGO, public and private media or researcher should be communicated to general public. Health communication is also useful to remove problem like stigma, skewed sex ratio, malnutrition, diarrhea and sanitation related problem, alternative health care, public cleanliness, environmental health and many other. Also there exist communication barrier like cultural, physiological, class difference, environmental, custom, belief, religion, language, economic and social categories.

People often refer health as synonyms of medicine, doctor and hospital and disassociated its important factors. Although different health system development program exists but it has not people to optimally utilize the service due to lack of awareness/communication. Package inserts should be provided for pharmaceutical communication. Communication skills should be positioned in health education syllabus. Print and electronic media should play important role in providing communication on different issues in ethical manner. Thus major change depends upon effective communication. Finally, the workshop discussions unfolded the various facets of communication very well validated by different stakeholders.

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Funding Agencies Research Communication on Alternative health care system Pharmaceuticals Practitioner Target Segments Frontiers of Health Communication delivery Government 26 Appendix-2 A Consultation Workshop (Round Table) On ‘Issues in Health Communication in India: A Stakeholders Perspective’ Venue : MICA, Shela, Ahmedabad, Tel: 079-32416988 Date : 6th June 2008, Friday Social ; Development Communication Unit Mudra Institute of Communications Research (MICORE) Opp. Parimal Garden, Ahmedabad Registration: 9. 30-10. 00 Tea and Snack: 9. 30-10. 00 Inaugural Session 10. 00-10. 30 Session themes Participants 1. 2. 3. 4. 5. Technical Session-1 : Retrospect ; Prospects of Health Communication (Time: 10. 30-11. 45) 1. Dr.

Arbind Sinha, Professor, MICA Historical perspectives of health 2. Ms. Rupa Mehta, Doordarshan communication in India 3. Dr. Rakesh Vaidya, Chief District Health Emerging issues in health communication Officer in India 4. Ms. Bhakti Shah, SEWA Health Communication for social ; behavioral 5. Ms. Ramola Trivedi SEWA Health change 6. Mr. Jignesh Patel, Darpana Academy Community need assessment/ demand 7. Mr. Luxman Meena, Abad NP+ studies Dissemination of research output in health communication Tea: 11. 45 Technical Session- 2: Tools ; Process of Health Communication in Service Delivery (Time: 11. 50-12. 50) 1. Dr. Rakesh Vaidya, Chief District Health Officer 1. Internal (intra and inter- departmental) 2. Dr.

Manjul Joshipura, Doctor, Apollo Hospital communication in service delivery 3. Dr. Jagruti Patel, Assoc. Professor (Pharma), 2. External Communication (Public ; Nirma Univ. Private) in service delivery 4. Dr. Prashant Bhimani, Mental Health Center 3. Communication covered in Health 5. Dr. Renuka Patwa, SEWA Health Education (curriculum) 6. Mr. Luxman Meena, Abad NP+ Lunch: 13. 00-14. 00 Technical Session- 3: Communication on Alternative Health Care System (Time: 14. 00-15. 00) 27 1. Issues “Beyond Health” (Social determinants of health) 2. Alternative Medicine system 3. Life Style ; Well Being 1. 2. 3. 4. 5. 6. 7. 8. Ms. Radha Sharma, Journalist, ToI Dr.

Shivang Swaminarayan, Sintex International Dr. Prerak Shah, Ayurvedic doctor Dr. Shilpa Parikh, Dental specialist Dr. Rajika Kacheria, Cosmetologist Mr. Pritviraj Sengupta, Advertisement Agency Col. Subhash Chadha, Alternative therapist Dr. Irfan Khan, Taleem Research Foundation Tea: 15. 00 -15. 15 Technical Session- 4: Frontiers of Health Communication (Time: 15. 15-16. 30) 1. Dr. Thomas Mathew, Assistant Professor, SPISER Health Financing 2. Dr. N. Lalitha, Associate Professor, GIDR Pharmaceutical communication 3. Dr. Jagruti Patel, Associate Professor, Nirma Univ. Occupational Health 4. Dr. C. J. Shishoo, PERD Environmental Health ; 5. Mr.

PR Joshi, Zydus Cadila, Pharmaceuticals Sanitation 6. Dr. Rajesh Beniwal, NIOH 7. Mr. Arun Mudgerikar UNICEF-WES 8. Ms. Rutool Sharma, Asst. Professor, CEPT Panel Session: Consolidation of discussions towards future research agenda (Time: 16. 30 – 17. 15) Validation of inputs from different stakeholders for consolidation Panelist: 1. Dr. Ang Peng Hwa, Dean School of Communications, NTU, Singapore 2. Dr. Arbind Sinha, Professor, MICA 3. Mr. Alan D’Souza, Acting Dean, MICORE 4. Dr. S. Nanda, Assoc. Professor, MICORE 5. Ms. Rupa Mehta, Doordarshan 6. Dr. Manjul Joshipura, Apollo Hospital 7. Dr. Renuka Patwa, SEWA Health Vote of Thanks Snacks End of the workshop 1. 2. 3. 4.


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