Action Media: Consultation, Collaboration and Empowerment in Health Promotion By Warren Parker Abstract Communication for health promotion is a complex process that is further problematised by limitations within communication theory. Linear models of communication give primacy to the communicator and see communication as a largely objective process. These models, which are often referred to as "communicator-message-receiver" (CMR) models, incorporate the communicator as a primary agent in determin- ing the nature of information and the mechanisms for information flow. Action media is presented as a methodology for the development of media products that integrate 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. It is not intended that the methodology 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 Warren Parker works with the Society for Family Health, Population Service International, Johannesburg, and was previously a Consultant to the Department of Health. 45 in media development, whilst also providing important insights into context-based activities that are consultative, collaborative and em- powering. Action Media as it pertains to health promotion, has the following elements: Identification of significant health challenges; identification of sufficiently homogenous groups within defined geographic areas and collaboration with individuals within each context to co-facilitate workshops. 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.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. 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 qualita- tive understandings of community contexts on the other. 46 Medias d'Action: Consultation, Collaboration et Passage du Pouvoir Dans le domaine de Promotion de la Sante Par Warren Parker Resume: La promotion de la communication dans le domaine de la SantiS est un processus complexe, qui se complique davantage lorsqu'on la considere dans les limites de la thdorie de communication. Les modeles Iin6aircs de com- munication privil6gient le communicateur et voient la communication comme un processus objectif. Ces modeles qu'on appellc communicateur-message- r6cepteur (CMR) considerent le communicateur comme un agent fondamental, dans la determination du type d'information et le m^canisme de diffusion approprte. Les mddias d'action sont pr6sent6s comme une approche qui exigent la production des materiels appropri6s, permettant d'int£grer les intents du communicateuret ceux du public visd, toujours dans le contexte de promotion de la sant£. Cette mgthodologie se base sur les me'thodes dites pardcipatives (PAR), et cherche a incorporer une recherche contextuelle qualitative, au deVeloppement des madias. Cependant il faudrait se garder de percevoircelle- ci comme un moyen exclusif et absolut, de foumir les matdriels de promotion de la sante\ Elle ne constitue que 1 'une des methodologies utili sdes par ceux qui Warren Parker travaille avec la Societe de la Sante' Familiale, Service International de la Population, Johannesburg. II fut anteneurement le Consultant du Dcpartcment de la Sante 47 s'efforcent de promouvoir les madias de la sante\ permettant de percevoir les activity's consultatives, collaboratives ainsi que de passsage du puvoir, selon les spe'cificite's du contexte. En gros, les mCdias d'action dans la promotion de la same" englobent les aspects suivants: Etablissement des de"fis majeurs dans le domaine de la santd; identification des groupes spdcifiques ainsi que d'indivindus importants, sur qui on peut compte, en ce qui concerne 1'organisation des ateliers. Les mate'riels des me'dias ainsi congus sont census dormer un apercu relativement pr6cis, du contexte social du public vise". Apres la conception des mate'riels de promotion de la sant6 approprie's au niveau des communaut6s, on essaye de les g6ne"raliser au niveau national. Cette me"thodologie se distingue des mdthodes centres sur la prodution des m6t6riels sans jamais se soucier de leur adaptability au contexte social. Son point fort demeure le fait qu'elle tient compte de la dynamique du contexte sur les m6dias. On s'efforce de soutenir les activite's du public vise", au lieu de servir tout simplement comme moyen de ve"hiculer les informations sur la sante\ La me'thodologie de 1'Action des Madias permet d'eValuer les possibility de coope'rer avec des individus et des groupes bien place's au sein de la communaute" concerned. Et tout cela sans jamais perdre de vue la complexity du contexte du deVeloppement des madias. II s'agit done d'une approche qu'on peut facilement re'-e'diter, qui permet la production des mate'riels bien adapters, tout en donnant un apercu relativement r6alistc du contexte social du public vise1. 48 Action Media: Consultation, Collaboration and Empower- ment in Health Promotion 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 deter- mining the nature of information and the mechanisms for infor- mation 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. Conven- tional CMR approaches emphasise how meaning is made, rather than how messages are understood by ordinary people. Con- ventional communication models are sometimes supplemented with text-based semiology, but neither provide for sufficient collaboration between communicators and receiver/readers. Peirceian-based semiotics, however, offers a culturally open method for understanding both the making and the interpreta- tion of messages, from an infinite variety of different class, political, language and historical contexts (Tomaselli 1996). 'Action media' is presented in this paper as a methodology for the development of media products that integrate the interests of both the communicator and representatives of target audi- ences within a health promotion context. The methodology has its roots in 'participatory action research' (PAR) approaches and incorporates qualitative contextual research with a media de- velopment processes. 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 49 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 method- ologies 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 (Fiske, J1982:7) 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 commu- nication and provide for a mechanistic analysis that seeks to scientise communication 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 re- ceiver (or reader). Semiotics allows for acknowledgement of the reader's subjective interpretations of messages (Tomaselli 1994). 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 50 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. 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. Communication Methodologies For the practice of a dialogical communication to occur, prac- titioners 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. Obvi- ously health promotion is not without it's ideological dimensions and political baggage, but in general its premise is that indi- viduals 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 inte- grated into a holistic health infrastructure and where particular emphasis is placed on making resources accessible and rel- evant. Primary health care objectives and services according to: Population Communication Services (1993) 'Reaching Young People', Packet Series 5, John Hopkins School of Public Health, Baltimore, include the following: • analysis of community needs related to health - for example, prevalence of waterbome diseases, prevalence of unplanned pregnancies? •health education and promotion - for example, HIV/AIDS awareness.lobbying against smoking ? 51 • preventative services — for example, immunisation, provi sion of condoms, ante-natal and post natal care • curative services—or example, therapeutic treatment of ill ness, surgical management of trauma • rehabilitative services - for example, physiotherapy and counselling Typical methodologies for the development of health promo- tion 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 mes- sages. 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 au- dience, 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 prod- ucts. 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. Par- ticipants in pre-testing sessions are limited in terms of choices, and responses to words and images tend to be over-elaborated 52 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 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 mate- rials 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 • Involve pre-testing • 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 devel- opment are lost. In recent years there has been a trend towards the develop- ment 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. 53 Action Media 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 audi- ence. 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 leveLThe 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-governmen- tal 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 54 townships), bars, taverns, filling stations, hair salons, com- muter sites as well as supermarkets, chain stores and pharma- cies. An allowance is made for mark-ups at wholesaler and re- tailer level to ensure sustained distribution within the commer- cial 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 under- standings 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 to- gether 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. 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 de fined geographic areas — for example, college students, youth formations in townships. • Collaboration with individuals within each context to co- facilitate workshops —for example, lecturers, teachers, ad ministrators 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 55 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 na- tionally as health promotion products. At the outset, it is intended that the products be integrated into existing infra- structures, and be utilised as a cornerstone for other commu- nity-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 Wethodology differs con- siderably 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 en- dorsement of condoms was a particular objective of the research interaction. Emphasis on the development of critical perspec- tives 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 perspec- tives 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 56 mixture of ideas and discussion between researchers and par- ticipants, as well as interpretations by the artists and designers who act on the brief. Discussion 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 processes followed with commercial sex workers in Zaire as follows: "Grounded in principles of group dynamics, experiential training begins with the principle that people al- ready 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 reality 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 inter ac- tions with respondents in tightly controlled situations. The 57 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 particu- lar 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 trans- formative 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 convention- ally 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 devel- oped. 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 58 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 environ- ment of sexist practice, whilst the separately developed —Viva Condoms— image was viewed by some as an appalling degra- dation 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 mean- ings, 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 rel- evance 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 prod- ucts 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. 59 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 'lived1 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 ex- tremely 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 perspective however, it becomes clear that media products must be viewed dynamically and that the subjectivity of readers must be clearly understood. Media prod- ucts function within contexts, and are read from diverse sub- jective perspectives. We cannot assume an objectivity within media products that makes meaning and interpretation abso- lute. 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 includ- ing, for example: What opinions are held about community radio? How often is the commercial heard? What programme 60 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 incor- porate 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 inter- ventions , 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 and 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. 61 Acknowledgement I am indebted to workshop participants and co-facilitators for important insights and contributions made during the develop- ment of the Action Media methodology. Bibliograpy Basch, C.E. (1987), "Focus Group Interview: An Underutilised Research Technique for Improving Theory and Practice in Health Eduction", Health Education Quarterly , Vol 14:4, pp 411-448. Carr, W. & Kemmis, S. 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Hojbjerg: Intervention Press. 63