Introductory Chapter: Global Health Communication - Focused Issues and Challenges

1.1. Adoption of products and services

It has long been recognized that simply having great products or services was insufficient, if people were unwilling to use them. This is the classic problem of “building a better mousetrap.” The product can only be successful if people recognize the problem, are aware of the solution, find the solution beneficial, know where to obtain the product, find the outlets to be convenient, have the means and willingness to pay, and the list goes on. The public health equivalent is the myriad services and products that have been proven to improve health if only they are adopted. For example, in the earliest years of international development, the USAID and other donors provided family planning and child health technologies, such as contraceptives, oral rehydration solution, and vaccines, to countries with very high rates of child and maternal mortality. They quickly realized that, in order for these new technologies to be successful, they would need to be paired with behavioral interventions to promote adoption, proper use, and adherence. Later, similar strategies were used to increase demand for services, such as skilled delivery and antenatal care visits among pregnant women. It was the behavioral response—adoption of the technological innovation—no less than the innovation itself, that proved crucial to achieve the health outcome. “Better” technologies, like better mousetraps, cannot be effective when communities do not use them or do not use them correctly. Today, we have even more amazing technologies, such as ARVs, rapid diagnostic tests for malaria, PrEP for prevention of HIV, and GeneXpert machines that can distinguish drug-sensitive from drug-resistant TB, with new innovations appearing every day. Optimizing the life-saving potential of these technologies means using the full suite of available behavior change tools and approaches to connect these new technologies with the audience segments that can most benefit from their adoption and use. It also requires effective partnerships and close coordination to ensure that behavioral interventions are well synchronized and coordinated with supply-side sectors such as R&D, service delivery, product distribution, and information systems.

1.2. Prioritize customer experience

Numerous public health strategies, for example, WHO’s End TB Strategy, remind us to develop “patient-centered” approaches [5]. Nevertheless, public sector approaches, especially those in resource-poor settings, often struggle with issues of adequate supplies, staffing, and properly functioning equipment and supplies. Historically, public health has tended to prioritize biomedical over behavioral interventions and adherence to clinical protocols over consumer experience. After all, patients tend to be poor judges of the real quality of clinical care. As every marketer and retailer knows, consumers tend to prioritize subjective qualities such as convenience, friendliness, and appearance. Marketers naturally understand that it is important to be attentive to consumer experience and generally do this better than the public sector. Despite the advantages, this also has its drawbacks, for example, patients can be attracted to substandard care in the private sector, both formal and informal, avoiding more effective alternatives available in a public system fraught with long lines, limited hours, staffing problems, and poor customer service. However, increasingly, public health practitioners realize that, in order to achieve the ambitious health goals that have been set, such as SDG 2030 Goal 3, new tools will be needed and the consumer perspective will need to be featured more prominently [6]. In recent years, in order to bridge this gap, new tools, such as human-centered design (HCD) and nudging, are being adapted from the commercial sector and quickly taken up. Such approaches—that place the customers’ experience at the center of their strategy—are being increasingly adopted and evaluated, in order to increase uptake of priority practices, reduce the gap between clinical and consumer perceptions of quality, and lead to better health outcomes [7, 8].

1.3. Identify behavioral bottlenecks

There are a class of diseases, often termed as “lifestyle diseases,” which include atherosclerosis, heart disease, stroke, obesity, and type 2 diabetes and diseases associated with smoking, alcohol, and drug abuse. Most people are well aware that lifestyle changes—such as regular physical exercise combined with a healthy diet—can help reduce the risk of such serious diseases and lead to a longer better quality life, yet they do not act on what they know so well. Research has shown that these diseases can often be prevented by “simple” modifications in lifestyle behaviors such as eating a healthy diet, regular exercise, avoiding tobacco, and getting proper sleep. This begs the often asked question “why don’t people do what is good for them,” or why do not people act (more) rationally? If people acted rationally, we would not see these diseases at the levels we do. Nevertheless, changing such lifestyle behaviors has proven challenging, involving the full spectrum of SBC approaches to affect all of the factors that can influence decision-making. These include (1) internal factors such as knowledge, attitudes, and beliefs; (2) social factors such as social norms, traditional practices, and the influence of important others; and (3) structural factors such as policies, regulations, and changes in the physical environment that determine access, convenience, and availability.

“Why won’t people do what is best for them?” is a question that has challenged the field of behavior change since its origins and has led us to go beyond addressing individual factors (such as awareness, knowledge, and beliefs) to address the social and structural factors that can have such a powerful influence on individual behaviors. This fight has recently been joined by behavioral economists (BE) who have developed a new field that bridges economics and behavioral sciences to provide a fresh perspective on the seemingly irrational human decision-making and behavior. The field of behavior change has expanded and benefited significantly from the emergence and broad acceptance of this new field and the fresh perspective and tools it provides. Brought into the public spotlight in the past several years, through several best-selling books, as well as numerous podcasts, TED talks, and other popular media, behavioral economics has been able to shed new light on human behavior and what shapes behavioral choice. The BE practitioners have been rewarded not only with popular acceptance but have also been awarded the Nobel Prize in economics three times between 1992 and 2017. BE’s contributions to SBC are relatively recent, so another of our key challenges will be to fully document how significant its contributions can be.

1.4. Negotiate behavior change

For the past 60 years or more, social causes and public health programs have adopted all manners of media to inform and persuade, often to good effect, especially when media channels were combined and paired with interpersonal means of community engagement. Disease outbreaks in recent years have offered an opportunity to examine the role that various forms of communication play as communities and outside experts work and struggle to negotiate local solutions. The West African Ebola outbreak 2014–2015 clearly showed that media was able to quickly and broadly convey information about the risk to audiences near and far. However, suspicion and rumors could also spread quickly through social media and social networks and just as quickly lead to detrimental results. We also saw that medical solutions could be stalled or ineffective without community dialog and effective, negotiated community engagement [9]. Disease outbreaks such as Ebola have clearly shown that communities need to be engaged from the outset, and, if their concerns are ignored, they can mobilize to thwart the efforts of public health workers. In outbreak situations, decisions must be made quickly, so it is not uncommon to find a small village besieged by technical experts from the outside—whether from the district, the capital, or other countries. It should not be surprising that communities that have become accustomed to receiving few services from the outside may be suspicious of the sudden attention, and it is not unusual for rumors to spring up questioning the motives of the outsiders. “Community engagement” has become the broadly accepted term to describe the strategy for creating dialog with communities to gain or regain their trust and cooperation in the face of an outbreak or other unusual health event. An important aspect of community engagement is the recognition that behaviors are not determined solely by individuals. The “social” in social and behavior change is important because individual choice has its limits and behaviors often involve social norms, traditions, and taboos. In order to successfully influence individuals to make better choices, we need to engage social networks effectively, for example, by building on the important roles played by respected leaders in the community and elders within the family [10]. For example, during the Ebola crisis, traditional burial practices and customs were found to be a major conduit of disease transmission. However, the solution was not to end traditional practices. Community leaders and technical experts worked with experts in SBC, including anthropologists, to find out ways to accommodate traditional beliefs and practices in behaviors that were also effective in stopping transmission.