Effective health communication & health promotion ethics

EFFECTIVE HEALTH COMMUNICATION
Komunikasi kesehatan?
Seni dan teknik untuk memberikan informasi, mempengaruhi dan memotivasi individu, institusional dan audiens public tentang pentingnya masalah kesehatan (US Department of Health and Human Service, Steps to Healthier US, 2004)

Pendekatan multidisiplin untuk mensasar audiense yang berbeda dan berbagi informasi yang berkaitan dengan kesehatan dengan tujuan untuk:
 mempengaruhi, melibatkan dan mendukung: individu, komunitas, profesi kesehatan, kelompok khusus, pengambil keputusan dan publik untuk memperkenalkan, mengadopsi, membertahankan perilaku, praktek dan kebijakan yang bertujuan meningkatkan kesehatan*

Karakteristik Effective Health Communication (Fertman & Allensworth. 2010)
Akurasi
Ketersediaan
Imbang
Konsisten
Peka budaya
Didasarkan bukti

Karakteristik Effective Health Communication (Fertman & Allensworth. 2010)
Mencapai sasaran
Reliabel
Repetisi
Pertimbangan waktu
Mudah dipahami

Tipe of Communication
Komunikasi verbal – non verbal
Komunikasi satu arah – dua arah
Komunikasi inter-personal dan komunikasi massa
Komunikasi internal dan eksternal
Tips untuk media cetak
Gunakan spasi dan hindari kepadatan tulisan
Pesan usahakan singkat
Gunakan judul yang jelas dan bullet –
Gunakan format tanya jawab – jawaban yang singkat
Gunakan kalimat dan kata aktif serba kata kerja yang kuat
Hindari istilah medis, dan gunakan bahasa percakapan
Gunakan desain yang akan mendorong pemahaman, termasuk gambar dan grafik yang menggambarkan hal-hal yang utama
Tambahkan materi/bahan/media tulis dengan media audiovisual atau percakapan/diskusi


Komunikasi efektif bila
Pesan yang dikirim oleh pengirim disampaikan secara lengkap seperti harapan pengirim dan diterima oleh penerima selengkap yang diinginkan pengirim, serta pengirim mendapatkan umpan balik dari si penerima bahwa pesannya telah tersampaikan lengkap
Agar pesan dapat tersampaikan dengan lengkap, harus ada dialog
Informasi
Pemasaran
Insentif
Restriksi
Indoktrinasi
Peraturan
Mengubah perilaku dengan informasi


Transtheoretical theory tahapan perubahan perilaku (Prochaska, 1988):
Prekontemplasi  (belum mau berubah/sadar, ingin)
Kontemplasi (sudah sadar/ingin/berpikir tapi belum beraksi)
Persiapan (langkah awal utk bertindak)
Tindakan
Pemeliharaan

Tahapan Perubahan Perilaku  transtheoretical theory
(Simon-Morton, Greene & Gottlieb, 1995)
Perubahan perilaku:
Komunikasi persuasif
Sumber:
Kredibilitas
Ketertarikan
Power
Pesan:
Tipe dan penampakan
Isi pesan
Diskrepansi
Saluran:
Media: tatap muka, audio visual, media interaktif
Modalitas:pandang, dengar, taktil
Penerima:
Demografis: umur, jenis kelamin, ras dsb
Psikologis: pengetahuan, kepercayaan dsb
Tujuan/hasil:
Waktu
Ruang lingkup:fakta atau perilaku
Target: perilaku, pengetahuan ???


Perubahan SIKAP : Komunikasi persuasif
Sumber:
Kredibilitas
Ketertarikan
Power
Pesan:
Tipe dan penampakan
Isi pesan
Diskrepansi
Saluran:
Media: tatap muka, audio visual, media interaktif
Modalitas:pandang, dengar, taktil
Penerima:
Demografis: umur, jenis kelamin, ras dsb
Psikologis: pengetahuan, kepercayaan dsb
Tujuan/hasil:
Waktu
Ruang lingkup:fakta atau perilaku
Target: perilaku, pengetahuan ???

Health Promotion & Communication Ethics
Dimensions of Biomedical*
 Paternalism/Autonomy
 Beneficence
 Non-maleficence
 Justice

* (Beauchamp & Childress, 1989, cited in Northhouse & Northhouse, 1992)

Biomedical ethics?*
 Biomedical ethics is concerned with the application of ethical principles and theories to the problems that occur in the fields of health care and medicine
 Etik biomedis merupakan aplikasi prinsip etik dan teori masalah yang terjadi di dalam area pelayanan kesehatan dan medis
    *(Beauchamp & Childress, 1989, cited in Northhouse & Northhouse, 1992)
The distinctive challenge of health promotion ethics
Biomedics
Individually
Patient’ autonomy
The objectives of “treatment” is curing, no harm and beneficence
Health promotion
Group, community, local or national population
Initiated by professionals, not clients
The “ends” of health promotion are innately problematic and contested
The distinctive challenge of health promotion ethics
Biomedics
Takes place in social context, but they work through physical and biological process
Health promotion
Health promotion interventions work through both physical and social processes – human being in a variety of ways and cannot be as easily isolated from their cultural, economic and social contexts as can most therapeutic interventions
‘culture’ is frequently not only a context but also a working medium of health promotion

Ethics in health promotion:
 Consider the concepts of:
 Well-being/kesejahteraan
 Integrity/integritas
 Virtues/kebaikan
 Autonomy/otonomi
 Responsibility/tanggung jawab
 Civility/keberadaban
 Caring/perhatian
 Solidarity/solidaritas

Challenges in Health Promotion Ethics
Promosi kesehatan kadang diinisiasi oleh profesional daripada “klien” atau masyarakatnya sendiri
Profesional tersebut melakukan “intervensi” pada kehidupan orang lain, yang kadang “tanpa mengundang terlebih dahulu”
Berbeda dengan intervensi terapetik “individual” à ada kontrak antara terapis dan klien/pasien sebelumnya
Challenges in Health Promotion Ethics
Promosi kesehatan ditujukan pada populasi lokal, bahkan nasional, tidak hanya individu.
   Implikasinya:
Efek utk baik atau sakit akan lebih besar
Pelaksana program promosi kesehatan “sepertinya” lebih memikirkan orang-orang secara abstrak atau statistik daripada mengidentifikasi orang
Secara rutin pelaksana program promosi harus mengukur perbedaan kebutuhan dan prioritas dari kelompok dan individu
Pelaksana promosi kesehatan berhadapan dengan hubungan dengan “banyak-banyak” orang, daripada “hubungan satu satu”

Challenges in Health Promotion Ethics
 Akhir dari promosi kesehatan kadang problematik
Ada pertanyaan tentang mentargetkan usaha dan distribusi manfaatnya (dan keadilan)
Ada juga pertanyaan tentang “apa yang dipromosikan” – issu tentang arti, dan dimensi berbeda dari kesehatan
Ada pertanyaan sulit tentang konsekuensi jangka pendek dan jangka panjang (apakah mungkin promosi kesehatan mempunyai “efek non kesehatan” sebagai indikator keberhasilan program

Challenges in Health Promotion Ethics
 Promosi kesehatan ditujukan pada  manusia yang tidak dapat diisolasikan dari konteks ekonomi, budaya dan ekonomi (seperti intervensi individual)
 Intervensi promosi kesehatan dilakukan melalui proses fisik dan sosial

Challenges in Health Promotion Ethics
 Budaya tidak hanya konteks, tetapi juga medium kerja promosi kesehatan
Bagaimana caranya menilai penerimaan secara etis tentang sesuatu yang disebut rekayasa sosial atau budaya
Seberapa jauh kemungkinan untuk melakukan evaluasi intervensi promosi kesehatan lepas dari pertimbangan kontribusi untuk iklim sosial secara luas

Issues in health promotion:
 Does a particular approach respect autonomy?
 Does it bring about some benefit?
 Does it avoid harm?
 What combinations of benefit and harm does it produce?
 Dangerous to our own health à there is far less agreement on what can or should be done to make people less foolish
Where does personal choice and collective responsibility begin
How we reconcile two of our most prized social values, personal freedom and good health?
Issues in health promotion ethics:
What are the appropriate limits of the country/province/district in liberal society in regulating, restricting or prohibiting behaviors that lead to premature morbidity and mortality in shaping, molding or influencing the preferences and desires of its citizens, in protecting citizen from commercial influences that may encourage or sustain patterns of behavior that are an-ethical to the goals of public health?

A case
Pikirkan bahwa sebuah tim promosi kesehatan diminta untuk mempromosikan kesehatan pada kelompok remaja umur 16-18 tahun yang sudah tidak sekolah lagi, pengangguran, dan menggunakan sebagian besar waktunya untuk menonton televisi, pergi rame-rame, merokok, minum-minuman keras dan melakukan aktivitas seksual secara bebas.
 Apa aktivitas prioritas yang akan dilakukan?

Harm principle
What about  an injury that is threatened, on that is possible, or only remotely so, one that is merely statistical, smoking in an open-air café, for example?
What if the potential harm involves an annoyance, for example the smell of smoke in open-air?
What if act that is self-regarding in terms of injury is other-regarding in terms of economic cost, for example smoking alone?

Paternalism
We do not leave it to the discretion of  consumers, however well informed, whether or not to drink grossly polluted water, ingest grossly contaminated foods, or inject grossly dangerous drugs
We simply prohibit such things on grounds of public … to a very large extent … the justification of public health measures, in general, must be baldly paternalistic
Their fundamental point is to promote the well-being of people who might otherwise be inclined cavalierly to certain sorts of diseases
Health Communication campaigns and the censorship of advertising
Health communication campaigns that discourage certain activities or encourage the adoption of others are the most common form of intervention designed to promote healthy behavior.
They would at first appear to pose no ethical challenges.
Messages targeted at those most at risk may open the way to stigmatization and hence to the imposition of inequitable burdens.

Health Communication campaigns and the censorship of advertising
Two examples illustrate this point. In the context of the AIDS epidemic efforts to counter the tendency toward marginalization of those most at risk led to the creation of campaigns that suggested that everyone was at risk for HIV infection.
The second case involved decision made by the New York State Health Department to require the posting of warning at bar about the potential hazards of alcohol consumption during pregnancy.
The ethics of social marketing :
Is not surprising that public health officials have come to recognize that they had much to learn from the advertising industry
If, for example, advertising could convince adolescents around the world that they wanted and needed nike running shoes could they not be convinced that cigarette smoking was bad? Could not the manipulative capacity of advertising be mobilized for public health goals?
Whatever the answer to those questions will be-and the challenges of using advertising for public health goals may be substantial-social marketing raises critical ethical issues.

The ethics of social marketing :
Is the subversion of autonomy implicit in the manipulation of desire and preference ever justifiable? Can the protection of individuals from the manipulative activity of commercial advertisers justify counter-manipulation in the name of public health? Does such manipulation simply attempt to level the playing field? And does such an effort at balancing provided the ethical warrant for what otherwise might be considered morally troubling?
In testimony before Congress the American Public Health Association stated, “Advertisements should be to promote good health products and not products that kill.”


References:
American Cancer Society. 2006 Smoke Free Track – Advocacy and Media Advocacy for Smoke free policies. San Fransisco: ACSU
Blundel, R. 2004 Effective Organizational Communication. Essex, England: Pearson Education Limited
Dignan, M.B., & Carr, P.A.(1992) Program Planing for Health Education and Promotion, Pennysylvania : Lea & Febiger
Fertman, CL., Allensworth, DD. 2010 Health Promotion Program – From Theory to Practice. USA: Society for Public Health Education
Galea, S., & Hadley, C. 2006 Disaster Preparadness. In: Gorin, SS., & Arnold, J. Health Promotion in Practice. San Fransisco, US: Jossey-Bass – A Wiley Imprint.
Keleher, H., MacDougall, C., & Murphy, B. 2007 Understanding Health Promotion. Victoria, Australia: Oxford University Press

The minimum standards

1. Water supply, sanitation and hygiene promotion (WASH)  Water supply, sanitation and hygiene promotion (WASH)

Water supply, sanitation and hygiene promotion (WASH)

The aim of any WASH programme is to promote good personal and environmental hygiene in order to protect health, as shown in the diagram below. An effective WASH programme relies on an exchange of information between the agency and the disaster-affected population in order to identify key hygiene problems and culturally appropriate solutions. Ensuring the optimal use of all water supply and sanitation facilities and practising safe hygiene will result in the greatest impact on public health.
Hygiene promotion is vital to a successful WASH intervention. The focus on hygiene promotion is general and specific. In general terms, hygiene promotion is integral to all of the sections and is reflected in the indicators for water supply, excreta disposal, vector control, solid waste management and drainage. 
More specifically, the focus narrows on two hygiene promotion standards in this chapter and relates to particular hygiene promotion activities.

WASH
Disease prevention
Hygiene improvement in emergencies
Enabling environment
Hygiene promotion
WASH standard 1: WASH programme design and implementation
WASH needs of the affected population are met and users are involved in the design, management and maintenance of the facilities where appropriate.
Key actions (to be read in conjunction with the guidance note) Identify key risks of public health importance in consultation with the affected population.  Provide and address the public health needs of the affected population according to their priority needs (see guidance note 1).
 Systematically seek feedback on the design and acceptability of both facilities and promotional methods from all different user groups on all WASH programme activities (see Core Standards 1, 3–4 on pages 55–65).
Key indicators (to be read in conjunction with the guidance note)
 All groups within the population have safe and equitable access to WASH resources and facilities, use the facilities provided and take action to reduce the public health risk (see Hygiene promotion standard 2 on page 94).
 All WASH staff communicate clearly and respectfully with those affected and share project information openly with them, including knowing how to answer questions from community members about the project. 
 There is a system in place for the management and maintenance of facilities as appropriate, and different groups contribute equitably (see guidance note 1).
 All users are satisfied that the design and implementation of the WASH programme have led to increased security and restoration of dignity.
Guidance note
1. Assessing needs: An assessment is needed to identify risky practices that might increase vulnerability and to predict the likely success of both the provision of WASH facilities and hygiene promotion activities. The key risks are likely to centre on physical safety in accessing facilities, discrimination of marginalised groups that affects access, use and maintenance of toilets, the lack of hand-washing with soap or an alternative, the unhygienic collection and storage of water, and unhygienic food storage and preparation. 
The assessment should look at resources available to the population, as well as local knowledge and practices, so that promotional activities are effective, relevant and practical. Social and cultural norms that might facilitate and/or compromise adherence to safe hygiene practices should be identified as part of the initial and ongoing assessment. The assessment should pay special attention to the needs of vulnerable people. If consultation with any group of vulnerable people is not possible, this should be clearly stated in 
the assessment report and addressed as quickly as possible 

2.Hygiene promotion

Hygiene promotion is a planned, systematic approach to enable people to take action to prevent and/or mitigate water, sanitation and hygiene-related diseases. It can also provide a practical way to facilitate community participation, accountability and monitoring in WASH programmes. Hygiene promotion should aim to draw on the affected population’s knowledge, practices and resources, as well as on the current WASH evidence base to determine how public health can best be protected. Hygiene promotion involves ensuring that people make the best use of the water, sanitation and hygiene-enabling facilities and services provided and includes the effective operation and maintenance of the facilities. The three key factors are:
1. a mutual sharing of information and knowledge 
2. the mobilisation of affected communities
3. the provision of essential materials and facilities. 
Community mobilisation is especially appropriate during disasters as the emphasis must be on encouraging people to take action to protect their health. Promotional activities should include, where possible, interactive methods, rather than focusing exclusively on the mass dissemination of messages. Hygiene promotion standard 1: Hygiene promotion implementation. Affected men, women and children of all ages are aware of key public health risks and are mobilised to adopt measures to prevent  the deterioration in hygienic conditions and to use and maintain the facilities provided.Key actions (to be read in conjunction with the guidance notes)  Systematically provide information on hygiene-related risks and preventive actions using appropriate channels of mass communication 

 Identify specific social, cultural or religious factors that will motivate different social groups in the community and use them as the basis for a hygiene promotion communication strategy
 Use interactive hygiene communication methods wherever feasible in order to ensure ongoing dialogue and discussions with those affected 
 In partnership with the affected community, regularly monitor key hygiene practices and the use of facilities provided.  Negotiate with the population and key stakeholders to define the terms and 
conditions for community mobilisers 
Key indicators (to be read in conjunction with the guidance notes)
 All user groups can describe and demonstrate what they have done to 
prevent the deterioration of hygiene conditions (see guidance note 1). All facilities provided are appropriately used and regularly maintained.  All people wash their hands after defecation, after cleaning a child’s bottom, before eating and preparing food 
 All hygiene promotion activities and messages address key behaviours and 
misconceptions and are targeted at all user groups.. Representatives from all user groups are involved in planning, training, implementation, monitoring and evaluation of the hygiene promotion work 
 Care-takers of young children and infants are provided with the means for safe disposal of children’s faeces (see Excreta disposal standard 1 on page 105 and guidance note 6). 
Guidance notes
1. Targeting priority hygiene risks and behaviours: The understanding 
gained through assessing hygiene risks, tasks and responsibilities of different 
groups should be used to plan and prioritise assistance, so that the information flow between humanitarian actors and the affected population is appropriately targeted and misconceptions, where found, are addressed. 
2. Reaching all sections of the population: In the early stages of a disaster, it may be necessary to rely on the mass media to ensure that as many people as possible receive important information about reducing health risks. Different groups should be targeted with different information, education and communication materials through relevant communication channels, so that information reaches all members of the population. This is especially important for those who are non-literate, have communication difficulties and/or do not have access to radio or television. Popular media (drama, songs, street theatre, dance, etc.) might also be effective in this instance. Coordination with the education cluster will be important to determine the opportunities for carrying out hygiene activities in schools. 

3. Interactive methods: Participatory materials and methods that are culturally appropriate offer useful opportunities for affected people to plan and monitor their own hygiene improvements. It also gives them the opportunity to make suggestions or complaints about the programme, where necessary. 
The planning of hygiene promotion must be culturally appropriate. Hygiene promotion activities need to be carried out by facilitators who have the characteristics and skills to work with groups that might share beliefs and practices different from their own (for example, in some cultures it is not acceptable for women to speak to unknown men). 
4. Overburdening: It is important to ensure that no one group (e.g. women) 
within the affected population is overburdened with the responsibility for 
hygiene promotion activities or the management of activities that promote 
hygiene. Benefits, such as training and employment opportunities, should be offered to women, men and marginalised groups.
5. Terms and conditions for community mobilisers: The use of outreach workers or home visitors provides a potentially more interactive way to access large numbers of people, but these workers will need support to develop facilitation skills. As a rough guide in a camp scenario, there should be two hygiene promoters/community mobilisers per 1,000 members of the affected population. Community mobilisers may also be employed as daily workers, on a contract or on a voluntary basis, and in accordance with national legislation. Whether workers have paid or volunteer status must be discussed with the affected population, implementing organisations and across clusters to avoid creating tension and disrupting the long-term sustainability of systems already in place. 
6. Motivating different groups to take action: It is important to realise that health may not be the most important motivator for changes in behaviour. 
The need for privacy, safety, convenience, observation of religious and 
cultural norms, social status and esteem may be stronger driving forces 
than the promise of better health. These triggering factors need to be taken into account when designing promotional activities and must be effectively incorporated into the design and siting of facilities in conjunction with the d s engineering team. The emphasis should not be solely on individual behavioural change but also on social mobilisation and working with groups. The disaster-affected population has access to and is involved in identifying and promoting the use of hygiene items to ensure personal hygiene, health, dignity and well-being. Key actions (to be read in conjunction with the guidance notes) .Consult all men, women and children of all ages on the priority hygiene items they require (see guidance notes 1, 3–4). Undertake a timely distribution of hygiene items to meet the immediate needs of the community (see guidance notes 2–3).
 Carry out post-distribution monitoring to assess use of and beneficiary satisfaction with distributed hygiene items (see guidance notes 3 and 5).  Investigate and assess the use of alternatives to the distribution of hygiene items, e.g. provision of cash, vouchers and/or non-food items (NFIs) (see Food security – cash and voucher transfers standard 1 on page 200). Key indicators (to be read in conjunction with the guidance notes) Women, men and children have access to hygiene items and these are used effectively to maintain health, dignity and well-being  All women and girls of menstruating age are provided with appropriate 
materials for menstrual hygiene following consultation with the affected opulation (see guidance notes 5 and 8). All women, men and children have access to information and training on the safe use of hygiene items that are unfamiliar to them (see guidance note 5). Infor mation on the timing, location, content and tar get groups for an NFI distr ibution is made available to the affected population (see guidance notes 3–5).

Guidance notes
1. Basic hygiene items: A basic minimum hygiene items pack consists of water containers (buckets), bathing and laundry soaps, and menstrual hygiene materials. List of basic hygiene items 10–20 litre capacity water container for transportation 
One per household 10–20 litre capacity water container for storage 
One per household 250g bathing soap One per person per month
200g laundry soap One per person per month
Acceptable material for menstrual hygiene, e.g. washable cotton cloth 
One per person 
2. Coordination: Discuss with the shelter cluster and the affected population 
whether additional non-food items, such as blankets, which are not included 
in the basic hygiene items are required (see Non-food items standard 1 on 
page 269). 
3. Timeliness of hygiene items distribution: In order to ensure a timely distribution of hygiene items, it may be necessary to distribute some key generic 
items (soap, jerrycans, etc.) without the agreement of the affected population and come to an agreement concerning future distributions following 
consultation. 
4. Priority needs: People may choose to sell the items provided if their priority 
needs are not appropriately met and so people’s livelihoods need to be 
considered when planning distributions.
5. Appropriateness: Care should be taken to avoid specifying products that 
would not be used due to lack of familiarity or that could be misused (e.g. 
items that might be mistaken for food). Where culturally appropriate or 
preferred, washing powder can be specified instead of laundry soap.
6. Replacement: Consideration should be given for consumables to be 
replaced where necessary.
7. Special needs: Some people with specific needs (e.g. incontinence or 
severe diarrhoea) may require increased quantities of personal hygiene items 
such as soap. Persons with disabilities or those who are confined to bed may need additional items, such as bed pans. Some items may require adaptation for sanitary use (such as a stool with a hole or commode chair).
8. Menstrual hygiene: Provision must be made for discreet laundering or 
disposal of menstrual hygiene materials. 
9. Additional items: Existing social and cultural practices may require access 
to additional personal hygiene items. Subject to availability, such items (per 
person per month) could include:
- 75ml/100g toothpaste 
- one toothbrush
- 250ml shampoo
- 250ml lotion for infants and children up to 2 years of age
- one disposable razor
- underwear for women and girls of menstrual age
- one hairbrush and/or comb
- nail clippers 
- nappies (diapers) and potties (dependent on household need).

School Sanitation and Hygiene

Schools can provide an arena where sanitation can be shown at its best

Schools provide excellent opportunities to support sanitation and hygiene promotion programs. The curriculum naturally offers opportunities to teach about dirt and disease and what can practically be done to improve health through better sanitation and hygiene. Construction and use of appropriate child friendly sanitary facilities (handwashing stations, soap and toilets) can be especially effective in reducing the incidence of diarrhea.

Schools may be better locations in which to enforce certain behaviors in children than the home. Schools can also provide an arena where sanitation can be shown at its best, and certain positive hygienic behaviors (hand washing with soap before eating and after going to the toilet) can become an engrained habit at a young age.

Nevertheless, hygiene promotion in school cannot rely solely on teaching and enforcing certain habits. Research has shown that children will more willingly change behavior if they are having fun and if they are following their peers. Imitation is one of the most successful forms of learning; hence young children will look to their older brothers and sisters or to older school friends to adopt new behaviors and life skills.

When developing and implementing school sanitation and hygiene programs several key issues need to be kept in mind:

1) School sanitation facilities: The main users of the facilities are children and designs need to be appropriate. This is particularly critical for young children around the age of 4 to 5 who are just starting to use the toilet and will be put off if toilets are too large, dirty or dark.

2) Getting the message right: Schools provide an arena within which to influence children’s behavior. Direct hygiene education may have limited effect in triggering behavior change; investigations focused on children’s behaviors, attitudes and interests are needed to develop the right hygiene promotion strategy.

3) Coordination: The Ministry of Education sets educational policy and regulates schools, while water and sanitation may be the responsibility of a different ministry. It is important to facilitate collaboration between these ministries, so that resources can be effectively directed at sound and consistent approaches.

4) Linking home with school: Schools are part of the larger community and must be supported by its members. A school water, sanitation and hygiene program will only be effective if it is reinforced and supported within the community, and the homes of the students. Hence, a school sanitation and hygiene program needs to be embedded within the context of a larger community water, sanitation and hygiene program if it is to re is ach its full potential.

Friskila Damaris Silitonga SKep. NS.  MPH