Communication for health promotion is a complex process often affected by limitations within communication theory. Linear models of communication give primacy to the communicator and see communication as a largely objective process. Often referred to as `communicator-message-receiver' (CMR) models, they incorporate the communicator as a primary agent in determining the nature of information and the mechanisms for information flow.
Application of CMR models within health promotion contexts typically incorporate expert-led message development with contextual evaluation. Such approaches may also include pre-testing with representatives of intended audiences. Conventional CMR approaches emphasise how meaning is made, rather than how messages are understood by ordinary people. Conventional communication models are sometimes supplemented with Text-based semiology, but neither provide for sufficient collaboration between communicators and receiver/readers.
Peiceian-based semiotics, however, offers a culturally open method for understanding both the making and the interpretation of messages, from an infinite variety of different class, political, language and historical contexts (Tomaselli 1996).
`Action media' is presented in this paper a methodology for the development of media products that integrates the interests of both the communicator and representatives of target audiences within a health promotion context. The methodology has its roots in `participatory action research' (PAR) approaches and incorporates qualitative contextual research with a media development process. The methodology is described in detail and includes a range of examples of activities and media products developed for the promotion of socially marketed condoms in the Soweto township near Johannesburg, South Africa.
It is not intended that the PAR methodology discussed here be perceived as an exclusive and absolute means for the development of health promotion materials. Rather, it adds to the range of methodologies health promoters can apply in media development, whilst also providing important insights into context-based activities that are consultative, collaborative and empowering.
CMR and Semiotic Approaches
Theories that focus on communication as a linear process are not entirely unified, but are typically represented as `models' of communication. An example can be found in Shannon and Weaver's `mathematical theory of communication' which is depicted as follows: (Fiske, J (1982:7)
Similar models are propounded by Gerbner, Lasswell, Westley and Maclean, and Newcomb (Fiske 1982, pp6-39) In general, the models see information flowing from a communicator to a receiver, with the potential for distortion (noise) between the two -- for example static on a telephone line, or the absence of a common language.
These models tend to have a common-sense appeal in that they endorse the notion that communication is about how effectively a communicator transfers a message to a receiver – ie. the communicator is a key actor in the communication process. Thus, the CMR models are largely about the process of communication and provide for a mechanistic analysis that seeks to scientise communication (Tomaselli and Shepperson 199*).Certain approaches to semiotics, on the other hand, provide for a radical inversion of the CMR models, placing deeper import on communication contexts and placing emphasis on the receiver (or reader). Semiotics allows for acknowledgement of the reader's subjective interpretations of messages (Tomaselli 1996).
Semiotics is often referred to as the `study of signs' for semioticians have tended to focus on the process of construction of meaning -- thus, language is a sign system where words stand for tangible objects or ideational constructs. The word tree, for example, stands for a real world tree. Semiology provides for a similar approach, but focuses more closely on the internal systems and rules within language related to the process of meaning-making (Tpomaselli and Shepperson 199*). Both semiotics and semiology provide for an ideological dimension to communication.
It is beyond the scope of this paper to provide detailed analysis of these methods. However, they provide and important backdrop, and the comparative table may be useful in understanding the differences (Table 1).
Whilst the comparative Table is not wholly comprehensive, it however does provide some insights into the theoretical bases of communication. More importantly however, it underscores the problematic of two antithetical methodological strands, with little common ground or theoretical bridge in between.
For the practice of a dialogical communication to occur, practitioners need to incorporate methods which allow for a balance between the interests of communicator and those of receivers (readers).
Health promotion provides a useful analytical context for communication practice -- a context which in turn allows for the development and refinement of replicable methodologies. Obviously `health promotion' is not without it's ideological dimensions and political baggage, but in general its premise is that individuals are able to utilise information about their health and available health resources, to make beneficial health choices.
Health promotion is seen as an integral part of primary health care systems where information and resources are integrated into a holistic health infrastructure and where particular emphasis is placed on making resources accessible and relevant. Primary health care objectives and services include: (Population Communication Services (1993) `Reaching Young People', Packet Series 5, John Hopkins School of Public Health, Baltimore, p1.)
analysis of community needs related to health – for example, prevalence of waterborne diseases, prevalence of unplanned pregnancieshealth education and promotion – for example, HIV/AIDS awareness, lobbying against smokingpreventative services -- for example, immunisation, provision of condoms, ante-natal and post natal care
curative services – for example, therapeutic treatment of illness, surgical management of traumarehabilitative services – for example, physiotherapy and counselling
Typical methodologies for the development of health promotion communication are professionalised and tend to be based on CMR theories, with the addition of feedback and research elements to facilitate the refinement of communication messages. Activities would include assessment of audiences and needs, development of materials by health and communications specialists, pre-testing of materials by professional researchers, refinement of products and distribution. For example, analysis of research data may show low levels of child immunisation. The initial communication requirement would be raising awareness and promoting services. Health and communications professionals would work together to assess potential target audiences, develop key messages and concepts, pre-test these with representatives of the target audience, and then go on to develop finalised media products.
There are a number of shortcomings to this approach. Health and communications professionals tend to occupy somewhat different socioeconomic contexts to broader target audiences and material development is often skewed by their perceptions of how messages should be framed, what media and media products should be utilised and so on. The incorporation of message and product pre-testing helps to contextualise products. However, pre-testing is limited by an inherent assumption that communication is an objective process, and further, that products can be understood independently of contexts. Participants in pre-testing sessions are limited in terms of choices, and responses to words and images tend to be over-elaborated within analysis that is divorced from context. In a health context for example, a health worker might discuss a therapy with a patient, and supply a descriptive leaflet as a reminder of the key points and as a source of supplementary information. Testing such a leaflet outside of the intended use context can result in inappropriate commentary and may result in uneccessary changes to the draft product.
Products that emerge within such approaches are typically unidirectional in terms of their messages, and tend towards issuing of imperatives. Linney (1995:18)) describes such materials as `one way' and lists typical components as:
Issue orders and instructions
Are `aimed' at target audiences
Do not involve local people
Are produced outside local communities
Show solutions to problems
Do not promote critical awareness
Whilst there is some narrowness in such communication, this is not to say that communication utilising this approach is not without value. Campaigns utilising such methodologies do achieve tangible results, and in many ways are similar to models used in commercial advertising -- they raise awareness and link people to resources. Clearly however, there are considerable limitations in terms of audience/community involvement and opportunities for organic needs assessment and message development are lost.
In recent years there has been a trend towards the development of media utilising alternative approaches that seek to incorporate deeper audience participation. These approaches have tended to have their roots in Freireian theories around visual literacy and critical thinking.
The Action Media methodology has grown out of my own diverse work in contextual communication in South Africa and has largely focussed on the development of materials for sexual and reproductive health. In this country, the rapid growth in HIV infection has provided added impetus to health promotion around sexual and reproductive health, and has allowed for broader focus on sexually transmitted diseases, unplanned pregnancy and abortion, and growing emphases on related areas such child abuse, rape and sexual harassment.
The Action Media approach involves a process that allows for integration of perspectives of representatives of target audiences -- a process that allows for deep reflection around issues that affect their lives -- and a process that allows for the incorporation of linguistic and cultural perspectives relevant to the target audience. This allows message development to become an organic process.
The methodology is such that it engenders action amongst the participants and this impetus can be harnessed in subsequent activities at the individual, group, or local community level.
The process has been developed and tested in a range of health promotion contexts related to reproductive and sexual health with groups of adolescents and young adults and has been a key component in activities related to the social marketing of Lovers Plus condoms under the auspices of a national non-governmental organisation – the Society for Family Health. Social marketing refers to a process of health promotion that uses techniques borrowed from commercial marketing and commercial infrastructures to realise health benefits. In the case of condom social marketing, lower to middle income groups are targeted through sale of condoms at subsidised prices, and reach is maximised through sale in diverse outlets such as spaza shops (informal shops in townships), shebeens (informal bars in townships), bars, taverns, filling stations, hair salons, commuter sites as well as supermarkets, chain stores and pharmacies. An allowance is made for mark-ups at wholesaler and retailer level to ensure sustained distribution within the commercial infrastructure.The Action Media methodology has its roots in a range of social theories (and practices) that fall within the ambit of the Cultural and Media Studies paradigm. These include understandings of communications processes, semiotics, culture, ideology and social change and participatory research.
Action media provides a framework for dealing with the divergent emphases of communication theory and brings together imperatives of the communicator, on the one hand, and readers on the other. At the same time the methodology allows for a number of tangential benefits in terms of critical awareness and action.
In overview, Action Media as it pertains to health promotion, has the following elements:
Identification of significant health challenges -- for example, the prevention of HIV/AIDS, sexually transmitted diseases and unplanned pregnancy amongst adolescents and young adults.
Identification of sufficiently homogenous groups within defined geographic areas -- for example, college students, youth formations in townships.
Collaboration with individuals within each context to co-facilitate workshops -- for example, lecturers, teachers, administrators and health workers
Recruitment of 15-20 participants on a voluntary basis for participation in a series of four 3-hour workshops. These incorporate educative focus group sessions that engender high levels of participation and reflection. Other elements include activities such as games, role-plays, songs, distribution and demonstration of condoms and media development. There is also an opportunity for evaluation.
The media products that emerge typically reveal deep insights into perspectives of the target group, are immediately relevant to the participant's peer communities, and may be relevant nationally as health promotion products. At the outset, it is intended that the products be integrated into existing infrastructures, and be utilised as a cornerstone for other community-based activities.
In the case of reproductive health, participants in the process became strongly committed to safer sexual behaviour and promotion of peer awareness. In the case of one group of participants who were tracked longitudinally, there is evidence of committed behaviour change. The methodology differs considerably from producer-centric approaches in that it sees contexts of media utility as dynamic, and furthermore, sets out to generate media products that are supportive of action, rather than simply as vehicles for information.
During the research process, promoting participant endorsement condoms was a particular objective of the research interaction. Emphasis on the development of critical perspectives allowed participants to explore their own practices, and many indicated that they had shifted their attitudes towards condoms and their sexual practices (albeit on the short term). This is somewhat different from research processes that are simply about understanding perspectives of particular groups, and that are not educative within themselves.
This process is often complex and it is during this session that researchers have to incorporate their own media perspectives and experience in refining the ideas that emerge into workable products. Quite often, group proposals are fairly naive from a media point of view, and interactive debate is encouraged between researchers and each group of participants. It is also not uncommon for ideas to incorporate contextual “realities” such as sexism or racism. Concepts for products thus emerge as a mixture of ideas and discussion between researchers and participants, as well as interpretations by the artists and designers who act on the brief.
The Action Media methodology may, at first sight seem fairly complex. There is no doubt that it requires specialised skills and resources. However, it is in many ways far simpler, and more time- and cost-efficient than conventional approaches, and it offers potential to produce immediately relevant and viable media products. When compared to conventional expert-driven process it has some distinct differences and benefits. These include:
Participants learn how to think critically and are considerably enriched in terms of critical awareness about serious health issues that affect their lives. This approach is grounded in perspectives drawn from Participatory Action Research (PAR) and Freire’s notions of dialogue and critical thinking. Shoepf et al 1988) describe a process followed with commercial sex workers in Zaire as follows: "Grounded in principles of group dynamics, experiential training begins with the principle that people already know a great deal about their situation. Group leaders assist people to develop a `critical consciousness' leading to co-operative social action and self-reliance'.And as Friere describes it:
"... the process in which people, not as recipients, but as knowing subjects, achieve a deepening awareness both of the socio-historical realty that shapes their lives and of their capacity to transform that reality" (Carr and Kemmis 1986).
Researcher / facilitators are able to extract qualitative data relevant to broader research and planning activities. Many qualitative researchers rely on short duration, single interactions with respondents in tightly controlled situations. The deeper, longer series of focus groups, which are part of Action Media elicit a considerable body of information that is relevant both for contextual activities and to understandings of particular sectors within communities.
A core group of highly aware individuals is created to the benefit of their immediate peer group and community. Clearly the workshops generate considerable impetus and the energy of participants can be channelled into subsequent activities that contribute to peer awareness and can be integrated into transformative activities. This is not always easy to achieve, given that most activities require infrastructure and commitment by parties beyond the media development context. Integration of existing resources into the process is beneficial at the outset -- for example, social marketing programmes, peer education programmes and the like.
The products that emerge are deeply contextualised in terms of imagery, language, and potential utility. Pre-testing is not required as the methodology incorporates extensive analysis of imagery and messaging into the media development process.
The products tend to be discursive, to raise questions and to stimulate debate. This is considerably different to the issuing of imperatives or instructions that are more typical of conventionally developed media.
The products are directly applicable in the context of the group or community within which they emerge and can be directly applied within a health promotion context -- particularly when they can be linked to tangible products, resources and services (eg. condom social marketing). Interestingly, many of the products developed using this methodology have been used beyond the immediate contexts within which they were developed. Examples include incorporation of the national flag into the shape of a condom under the banner "Viva Condoms" and the development of "Lovers Straight Talk", a comprehensive question and answer booklet on sexuality for adolescents -- both of which have been used as part of national activities.
Products that emerge through Action Media do not always fit into conventions of political correctness. Some of the products developed during the Soweto workshops reveal a lived environment of sexist practice, whilst the separately developed “Viva Condoms” image was viewed by some as an appalling degradation of the new national flag. Within the development of such products it is not the task of researcher /facilitators to “censor” products, but rather to open debate around contentious issues and seek resolution within the group that can be applied to the media products. It is important too, to move beyond the scientised CMR perceptions that see products as having singular meanings, or as functioning as direct communication. The power of media products lies not in the direct intention of their messaging, but rather in the contexts within which they are viewed and used. If a media product generates discussion and debate, its relevance within a societal context is multiplied several fold, and is far better than products that seek simply the transfer of specific concepts from communicator to receiver.
Content and Context
The Action Media methodology is positioned largely within the framework of semiotic analyses of communication and can be seen as a process of applied semiotics that allows for signs, messages, readers and contexts to interrelate. The media products that emerge have considerable value when analysed within cultural and ideological frameworks that incorporate notions of a "struggle for meaning". Much of the developmental work around the methodology has focussed on adolescents and has provided an important voice to young people in contexts where they are typically disempowered The methodology is the antithesis of top down approaches, allowing instead for collaborative effort and empowerment in the creation of media products.
The ideological contexts of the participants cannot be ignored either, and products emerging through the Action Media methodology are often revealing of this context. As Tomaselli (1996**) puts it: "If ideology accounts for the ‘lived’ relations between people and their world, then we must accept that meaning is saturated with the ideological imperatives of society". Action Media also describes an interesting tension between the two strands of communication theory. On the one hand Action Media describes a process of efficiently producing extremely accurate media products by overcoming limitations inherent in the application of CMR approaches that utilise professionalised conceptualisation and pre-testing. When analysed within a semiotic perspectives however, it becomes clear that media products must be viewed dynamically and that the subjectivity of readers must be clearly understood. Media products function within contexts, and are read from diverse subjective perspectives. We cannot assume an objectivity within media products that makes meaning and interpretation absolute. As Tomaselli (1996: **) observes: "Readers appropriate the meanings which best fit their imaginary solutions as interpreted by their individual, cultural and class experiences. These interpretants coincide most closely with their individual subjectivities."
At best, media products provide a stimulus for a range of possible interpretations on the one hand, and a range of contextual applications on the other. In the case of “mass” media products, it is impossible to assume uniform interpretations. Even at the level of the individual, subjective responses can be framed by contextual factors, and meaning and interpretation may shift over time. If we imagine a teenager in Soweto listening to the two “Action Media” radio commercials on community radio, his/her interpretation may be influenced by a number of factors including, for example: What opinions are held about community radio? How often is the commercial heard? What programme content frames the commercial? If in the company of friends, does the commercial elicit discussion? If in the company of a parent, does the commercial elicit discussion? Are conflicting subjectivities resolved? Is the desired adoption of condoms achieved or is existing condom use endorsed?Meaning and interpretation need to be seen as dynamic processes, even at the level of an individual. Assumptions underpinning processes of media development need to incorporate subjectivity, dynamism and diversity amongst intended audiences, no matter how homogenous they are assumed to be. Media products should also not be seen as “stand-alone” interventions -- an assumption that is embedded in CMR perspectives. Instead, media products need to be continually applied and contextualised within the resources and services available within communities. Condom promotion for example, needs to be closely tied to availability of condoms within a community. Synergy amongst media products should also be sought out -- for example, between radio commercials, posters, point of sale materials.Within the complex contexts of media development, the Action Media methodology provides insight into the potential for integration and empowerment of individuals and groups within target communities. It demonstrates a replicable process that provides for the development of deeply contextualised media products on the one hand, and qualitative undertandings of community contexts on the other.
Finally, it is important that the Action Media methodology is perceived as malleable within the principles that frame it. Researchers, facilitators, resources and contexts frame the application of the methodology and colour the products that emerge. If communication and meaning are framed as dynamic and subjective, then processes that seek to generate meaning should be seen dynamically too.
I am indebted to workshop participants and co-facilitators for important insights and contributions made during the development of the Action Media methodology.
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