A Case Study of Sesame Workshop’s Cleaner, Happier, Healthier Intervention in Bangladesh, India, and Nigeria: Reporting on Exposure and Impact
Dina L. G. Borzekowski
The Cleaner, Happier, Healthier hygiene intervention was developed and tested in 2013, featuring the Sesame Workshop characters. Through broadcast television, four public service announcements (PSAs) addressed washing hands with soap, using a latrine, wearing sandals, and drinking clean water. The main audiences were young preschool children and their parents or guardians.
Research occurred in Bangladesh, India, and Nigeria, exploring the reach and impact of these PSAs. Although low percentages, from well-drawn samples of extremely vulnerable populations in these countries, reported awareness and recall of these messages, such percentages can reflect large numbers of viewers. Considering data from the participating children, measures of knowledge and attitudes were associated with engaging in several of the behavioral outcomes. As well, awareness and recall of the PSA messages predicted “all the time” for several of the hygiene behaviors. In contrast, parents’ reports of PSA awareness and recall were not associated with reports of children’s hygiene behaviors.
Conducting reach studies is extremely difficult, especially in developing countries and communities. Despite the challenges, this study is encouraging. Participants reported seeing the messages, and in several models, this “reach” predicted reports of hygiene and health behaviors. Lessons learned from this case study and research can offer valuable insight into the production of future health PSAs, especially with harder-to-reach populations.
Shawn Meghan Burn
Bystander intervention is a form of helping that occurs when onlookers intercede to provide direct or indirect aid to a victim. When bystanders step in to prevent or reduce harm to others, they act as agents of primary and secondary health prevention. But theory and research suggest the bystander intervention process is complex and multiple social-psychological and situational barriers imperil bystander action. Bystanders are often ill-prepared to intervene when others are at risk for emotional or physical harm. They may not notice that someone needs help due to distraction from self-focus, engagement in social interaction, intoxication, or aspects of the situation like crowding or noise. Due to inadequate knowledge, bystanders may misdiagnose the situation and believe intervention is unnecessary. The negative consequences of nonintervention may be unknown to them such that the situation fails to increase their empathic arousal and motivate their action. Lacking knowledge, they may not recognize the seriousness of the situation and or the potential costs of inaction, and so are insufficiently alarmed. Pluralistic ignorance can arise when multiple uncertain bystanders conceal their concern and hesitate to act, assuming others’ inaction means intervention is inappropriate or unnecessary. When there are multiple witnesses, bystanders may assume their help is unneeded, place intervention responsibility on others, or feel less responsible for helping due to diffusion of responsibility. When the victim is not a member of their in-group, or is assumed at fault for their predicament, they may feel less empathy and a reduced responsibility to help. Or, bystanders may assign responsibility for intervention to the victim’s friends or fellow in-group members, or to those “in charge” of the setting. Even when bystanders realize help is needed and take responsibility for helping, they may not act if they do not know how or lack confidence in their ability to successfully carry out the actions required to help. When they have the skills, they may not help if they perceive the costs of action to outweigh the benefits of action. Audience inhibition arising from group norms supporting inaction and from bystander worry about what others will think about them if they act unnecessarily or ineptly can prevent bystander action by increasing bystanders’ perceived helping costs.
Recognition of bystanders as a potentially valuable public health asset has increased interest in promoting bystander intervention. Bystander intervention promotion and communications empower bystander action by combating intervention- and audience-specific barriers to bystander intervention using targeted information, communications, and skills training. Theory and research suggest that effective promotions and communications foster context-specific attitudes, beliefs, norms, and skills such that bystanders: (1) are able to quickly and accurately identify a situation as intervention-appropriate; (2) experience action-motivating arousal (including empathy) in the face of the event; (3) have positive attitudes towards intervention and perceive the benefits of action as outweighing the perceived costs; (4) are empowered to act and feel confident in their ability to effectively intervene (bystander efficacy); and (5) are resistant to evaluation apprehension and norms contraindicating action. Effective bystander intervention promotion draws on social psychology and communications studies, and best practices for health promotion and prevention programs. The application of social marketing and formative and summative program evaluation methods enhance the potential of bystander intervention promotions and communications to empower bystander action.
Roxanne L. Parrott, Amber K. Worthington, Rachel A. Smith, and Amy E. Chadwick
The public, including lay members who have no personal or familial experience with genetic testing or diagnosis, as well as individuals who have had such experiences, face many intrinsic decisions relating to understanding genetics. With the sequencing of the human genome and genetic science discoveries relating genes to cancer, heart disease, and diabetes, the scope of such decisions broadened from prenatal genetic testing related to reproductive choices to genetic testing for contributors to common causes of morbidity and mortality. The decision about whether to seek genetic testing encompasses concerns about stigma and discrimination. These issues lead some who can afford the cost to seek screening through online direct-to-consumer sites rather than in clinical settings. Many who may benefit from genetic testing lack awareness of family health history that could guide physicians to recommend these diagnostic tests. Families may not discuss health history due to genetic illiteracy, with the public’s genetic illiteracy increasing their illness uncertainty and decreasing the likelihood that physicians will engage in conversations about personalized medicine with their patients. Physicians may nonetheless order genetic tests based on patients’ symptoms, during preoperative workups, or as part of opportunistic screening and assessment associated with a specific genetic workup. Family members who receive positive genetic test results may not disclose them to life partners, other family members, or insurance companies based on worries and anxiety related to their own identity, as well as a lack of understanding about their family members’ risk probability. For many, misguided beliefs that genes absolutely determine health and disease status arise from media translations of genetic science. These essentialist beliefs negatively relate to personal actions to limit genetic expression, including failure to seek medical care, while contributing to stereotypes and stigma communication. As medical science continues to reveal roles for genes in health across a broad spectrum, communicating about the relationships that genes have for health will be increasingly complex. Policy associated with registering, monitoring, and controlling the activities of those with genetic mutations may be coercive and target individuals unable to access health care or technology. Communicating about genes, health, and risk will thus challenge health communicators throughout the 21st century.
Religion encompasses many forms of communication: between groups, within groups, and with God (or other deities). Such communication can be especially powerful when group members highly identify with their religious group and the beliefs therein. Equally, it can be divisive, as evidenced by religion-based intergroup conflict and intolerance (which often overlaps along ethnic or political lines). However, not all religious communication is verbal or explicit. Religious individuals also commonly transmit their beliefs, values, and identities through symbols, physical spaces, and music. Likewise, communication with God is often pursued with silent prayer, meditation, or ritual, which also serve to reinforce one’s spirituality alongside religious group boundaries. Taken together, these varying forms of communication have implications not only for religious intergroup relations (e.g., intergroup contact or conflict), but also for intragroup relations (e.g., the strengthening of social ties) and individual health outcomes (e.g., effective communication with health care providers and coping practices). Given the importance of religious identity for many individuals, the benefits for individual well-being and intragroup relations, and yet the intergroup strife that religious group divisions can incite, the ways in which we communicate our religious group identities deserve closer attention.
Robert M. McCann
Research into age and culture strongly suggests that people of different adult generations, regardless of culture, typically regard others and act in ways that display bias in favor of one’s own age group. While people across cultures share some basic patterns of aging perceptions, there is considerable variance in views on older people from one country to the next. Over the past two decades, the tenor of communication and aging research has shifted dramatically. Traditional research into aging across cultures painted a picture of Asia as a sort of communicative oasis for elders, who were revered and communicated to by the younger generations in a respectful and mutually pleasing manner. Compelling evidence now suggests the opposite, which is that (interregion variability in results notwithstanding) elder denigration may be more pronounced in Eastern than Western cultures. Accelerated population aging, rural-to-urban shifts in migration, new technologies, rapid industrialization, and the erosion of cultural traditions such as filial piety, may partially account for these results. Additionally, there are well-established links between communication and the mental health of older people. Specifically, communication accommodation in all of its forms (e.g., over accommodation, nonaccommodation, accommodation) holds great promise as a core predictor of a range of mental health outcomes for older people across cultures.
A community of practice (CoP) situated in a health and risk context is an approach to collaboration among members that promotes learning and development. In a CoP, individuals come together virtually or physically and coalesce around a common purpose. CoPs are defined by knowledge, rather than task, and encourage novices and experienced practitioners to work together to co-create and embed sustainable outputs that impact on theory and practice development. As a result, CoPs provide an innovative approach to incorporating evidence-based research associated with health and risk into systems and organizations aligned with public well-being.
CoPs provide a framework for constructing authentic and collaborative learning. Jeanne Lave and Etienne Wenger are credited with the original description of a CoP as an approach to learning that encompasses elements of identity, situation, and active participation. CoPs blend a constructivist view of learning, where meaningful experience is set in the context of “self” and the relationship of “self” with the wider professional community. The result is an integrated approach to learning and development achieved through a combination of social engagement and collaborative working in an authentic practice environment. CoPs therefore provide a strategic approach to acknowledging cultural differences related to translating health and risk theory into practice.
In health and risk settings, CoPs situate and blend theory and practice to create a portal for practitioners to generate, shape, test, and evaluate new ideas and innovations. Membership of a CoP supports the development of professional identity within a wider professional sphere and may support community members to attain long range goals.
Irina A. Iles and Xiaoli Nan
Counterfactual thinking is the process of mentally undoing the outcome of an event by imagining alternate antecedent states. For example, one might think that if they had given up smoking earlier, their health would be better. Counterfactuals are more frequent following negative events than positive events. Counterfactuals have both aversive and beneficial consequences for the individual. On the one hand, individuals who engage in counterfactual thinking experience negative affect and are prone to biased judgment and decision making. On the other hand, counterfactuals serve a preparative function, and they help people reach their goals in the future by suggesting effective behavioral alternatives.
Counterfactual thoughts have been found to influence an array of cognitive processes. Engaging in counterfactual thinking motivates careful, in-depth information processing, increases perceptions of self-efficacy and control, influences attitudes toward social matters, with consequences for behavioral intentions and subsequent behaviors. Although it is a heavily studied matter in some domains of the social sciences (e.g., psychology, political sciences, decision making), counterfactual thinking has received less attention in the communication discipline. Findings from the few studies conducted in communication suggest that counterfactual thinking is a promising message design strategy in risk and health contexts. Still, research in this area is critically needed, and it represents an opportunity to expand our knowledge.
Creating Authentic and Lasting Community Relationships to Enhance Awareness and Understanding of Cancer Research
Linda Fleisher, Evelyn González, and Armenta Washington
Building and sustaining relationships fundamentally requires mutual trust based on authentic and reciprocal communication. Successful academic and community partnerships require a deep understanding of the needs of all stakeholders facilitated through dialogue and ongoing communication strategies. This dialogue is especially crucial to address health disparities and bridge the divide between academics and other professionals and the communities they serve. Innovative and sound health communications and community engagement approaches can help to address this divide. For those working with communities to improve health, Community Based Participatory Research (CBPR) principles can serve as a compass to guide those efforts of building on the strengths and resources within the community and ensuring co-learning to address social inequities. Moreover, using innovative and interactive health communication strategies, such as community forums, photovoice projects, and the development of culturally sensitive and relevant messaging, can empower and engage the community, facilitating long-lasting relationships between the academic institutions and communities that ultimately address the unique concerns and values of those most in need.
Mohan Jyoti Dutta
This is an advance summary of a forthcoming article in the Oxford Research Encyclopedia of Communication. Please check back later for the full article.
Health and risk are constituted globally amid structures of unequal flow of labor, capital, commodities, and communication, shaped by the material inequalities in the distribution of resources. Globalization—the accelerated flow of goods, people, services, and capital across spaces—has been accompanied by large inequalities in economic access to resources; inequalities in access to health opportunities, health resources, and health care services; and inequalities in health outcomes (reflected in mortality and morbidity rates). Disparities in health outcomes observed within and across nation states are shaped by economic inequalities, noting the structural determinants of health, the inequities in access to health services, as well as the local-national-global policies that constitute health. Drawing upon the foundations in postcolonial and Subaltern Studies theories, the culture-centered approach (CCA) examines the communicative processes by which marginalization takes place in global contexts and the ways in which health risks and vulnerabilities are constituted amid material inequalities in distributions of resources.
With an emphasis on the processes of erasure of diverse voices, the CCA asks the question: What are the processes, strategies, and tactics through which the voices of subaltern communities are erased? The access to communicative spaces, platforms, strategies, and tools is shaped within material structures, thus shaping messages, processes, and discourses within the agendas of powerful political, social, and economic actors with economic access to resources. The disenfranchised, with limited access to the communicative spaces and to the spheres of voicing, are often absent from the discursive spaces where health policies and programs are discussed, the sites where interventions are planned, and the processes where communicative strategies targeting them are carried out. The agency of the subaltern is erased from the sites of recognition and representation where policies are debated, decided upon, implemented, and evaluated.
Connecting communication to materiality, the CCA suggests that erasure of the subaltern sectors of the globe is tied to their material disenfranchisement. Materially disenfranchised communities are missing from the policy platforms that target them through a wide variety of interventions. To understand the unequal distribution of health resources and opportunities, we need to closely examine the inequality in opportunities for having a voice and for participating in decision-making structures and processes. Putting forth the argument that inequalities in health outcomes need to be situated amid economic structures that determine how health resources will be distributed and the ways in which these mechanisms will be discussed and determined, the CCA foregrounds strategies for listening to voices that have hitherto been erased. Through strategies of listening, locally grounded understandings are placed within the discursive spaces of policy formulation and program development. In understanding the health experiences of communities that experience poor health outcomes, the emphasis is on creating spaces for listening that foreground local experiences, interpretations, and understanding. Alternative imaginations of the political economy of health are rooted in the voices of local communities at the margins, foregrounding contextually embedded interpretive frames for organizing health, healing, and curing.
Communication is understood in relationship to materiality, acknowledging the interplays between the symbolic and the material in generating health risks and vulnerabilities, and further suggesting strategies of resistance and participation that seek to invert these inequities by foregrounding subaltern rationalities of health and wellbeing. The presence of subaltern voices brings forth alternative imaginations of health, offering new theoretical frameworks that point toward alternative ways of structuring health, economics, and politics. Attending to differentials in distributions of material and communicative infrastructures, the CCA resists the marginalization of the subaltern sectors through the foregrounding of opportunities for local grassroots participation, in the definition of problem configurations and in the corresponding articulations of locally meaningful solutions. The presence of subaltern voices in discursive spaces offers alternative logics of political and economic organizing that challenge the commoditization of health as private property and suggests ideas of health rooted in community life, sustainable practices, and cooperative economies. Local interpretations of health are foregrounded, situated in relationship to the structures within which these meanings are constituted and fostering openings for imagining new structures of health grounded in local understandings. These local understandings offer entry points of solidarity for re-envisioning global practices that challenge the hegemony of neoliberalism as a universal solution to health and development.
The design and dissemination of health and risk messages invariably involves moral and ethical issues. The choice of the topics, the focus on particular recommended practices, the choice of particular groups to be the intended recipients of the messages and their inclusion in or exclusion from the message development process, all raise ethical issues. Further, the persuasive tactics used to influence people to change their attitudes and beliefs and to adopt recommended changes in their lives also raise ethical concerns. For example, persuasive tactics may infringe on people’s privacy when people view images they may find intrusive, offensive, or cause them distress. Tactics that “tug” at people’s emotions may infringe on their unhindered ability to make a conscientious decision. Employing digital media and sophisticated advertising and marketing tactics also elicits ethical challenges both related to their manipulative potential and their differential reach: all of which may contribute to social and health disparities. In addition, the practices recommended in health and risk messages may conflict with values people cherish. For example, people could be urged to change the way they communicate with their spouses on intimate issues, relinquish the consumption of favorite traditional foods—or messages may raise issues that recipients find taboo according to their culture or religious beliefs. Health and risk messages may have unforeseen and unintended adverse effects that could affect people’s emotional and physical aspects by inadvertently contributing to people’s sense of guilt through shaming or stigmatization. Also, on the cultural and social level, such messages may contribute to an idealization of a certain lifestyle or commercialization of products and celebrities associated with the messages.
Philosophical and ethical frameworks typically used in communication ethics, bioethics, communication campaigns, and social marketing literature emphasize the central guiding principles of personal autonomy and privacy with the aim to ensure equity and fairness. The obligation to avoid “doing harm” includes concerns regarding labeling, stigmatizing, and depriving; the obligation to help; the obligation to respect people’s autonomy to make free choices, particularly concerns regarding persuasion tactics and manipulations and the use of threat tactics, provocative appeals, distressing images, framing tactics, cultural sensitivity, and moral relativism; the obligation to obtain consent; the obligation to truthfulness; the obligation to sincerity; the obligation to correctness, certitude, and reliability; the issue of personal responsibility; equity obligations including concerns regarding segmentation and “targeting”; the obligation to comprehensibility; the obligation of inclusion; utility and efficiency considerations; the “harm reduction” approach; and concerns regarding social value priorities and “distortions,” which includes prosocial values as moral appeals.