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Communication for Social Change: Successes and Challenges in Addressing the Social Determinants of Health

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I.    Introduction

When asked how to address the social determinants of health, many health promoters cite the need to ensure universal access to social programs -- such as safe and accessible playgrounds for children, stay-in-school programs for kids at risk of gang involvement, affordable housing, etc. Unfortunately, even when social programs are available individuals are often not empowered to do what it takes to bring themselves out of poverty and be able to access health services. Communication efforts to address the social determinants often fail because they ignore underlying social influences. This article focuses on this dilemma and offers a solution. Health promoters in the developing world have seen much success in addressing the social determinants of health by combining the interest-grabbing techniques of communication with the participatory skills of community development -- an approach referred to by those who practice it as Communication for Social Change (CFSC).

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II.    What is Communication for Social Change?

Communication for Social Change (CFSC) is an approach that uses communication media such as radio, television, and theatre to raise awareness about social issues in a community. With CFSC, however, the target audience must be the owner of both the message and the medium. So rather than promoting healthy behaviour through an emotional drama or television soap opera developed by an international non-governmental organization, CFSC would ensure that the audience being addressed controls the development of the drama and dictates.

Although it has been applied to development efforts inside and outside the field of health, CFSC provides a specific approach to addressing the social determinants of health. As such, it is of tremendous value to health promoters. It is a relatively new approach and has really been developed conceptually by the work of the Rockefeller Foundation, which held two conferences on the topic -- one in Lake Como, Italy in 1997 and the other in  Cape Town, South Africa in 1998. The original conference participants have since established a consortium of organizations committed to its development and practice called the Communication for Social Change Consortium: http://www.communicationforsocialchange.org/

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III.    The Bangladesh Example: A Success Story

In 2002, a non-governmental organization in Bangladesh, the Bangladesh Rural Advancement Committee (BRAC), undertook a new program to address the social determinants of health affecting extremely poor women in single-parent households. In August of that year, I travelled to Bangladesh to study BRAC's CFSC program. The program was attempting to change the reality that poor single women are excluded from their rural village communities in Bangladesh. Without a husband to support them or any financial stability for themselves and their children, they were seen as a burden on the village. They tended to be uneducated and unemployed, or employed by prostitution or begging.

BRAC's programs had faced major obstacles. Efforts to provide the women with livestock so they can start their own business of selling at the local market were stalled when other villagers stole their livestock, leaving them feeling defeated and worthlessness. BRAC realized that something was needed to empower these women through improved relationships and increased understanding of their situation by their communities. BRAC saw CFSC as a means of accomplishing this.

The program director, a long-time employee of UNICEF Bangladesh, was very familiar with the approach of CFSC and eager to see it put into practice with the program design. Theatre was the medium selected to raise the issue of these poor excluded women within villages across the country. Local community members (an equal representation of men and women, primarily poor, living in local villages) were the heart of the program. Employed by BRAC, these community members first interviewed the extremely poor women living in their villages and then created a play based on their local stories. The play was then mounted in each of the surrounding villages to raise the issue for discussion among village members.       

To encourage this discussion, the actors were expected to hold three community meetings following the evening of theatre where all levels of the community were invited to participate in identifying community issues and brainstorming solutions. A BRAC representative (also a local community member) facilitated this process and ensured that women and poorer villagers were included in the discussion, but did not direct the conversation beyond asking a few relevant questions.           

In many of the villages where this program was first implemented (in the summer of 2001), the three community meetings led to a more permanent event. The groups did not want to stop meeting, but saw an opportunity to improve their villages through collective effort. BRAC quickly recognized this, and offered support to those communities that did want to continue meeting in the form of a small sum of money and ongoing facilitation to assist them in putting their ideas for community improvement into practice. By August of 2002, there were over 700 of these community groups in existence across Bangladesh - all a result of a play they themselves created.

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IV.    Successes - Why Does it Work?

For BRAC's CFSC program to work and be sustainable, the research showed that the community needed to take the responsibility for change. At no point in the process did BRAC employees dictate the message or attempt to control the outcome of the community's discussion. This approach is hardly new to community development practitioners, who recognize the value of allowing communities to direct change. But for communications, which relies heavily on the development and dissemination of a message, it can be challenging. What communications offers are techniques to mobilize the community by invoking emotion. With the BRAC example, holding community meetings without the play would not have had nearly the same intrigue for community members. Therefore, the true success of the CFSC approach is the combination of communication media with community development.

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V.    Challenges

With many of the communities targeted by BRAC's CFSC program, once the evening of the play had passed, the community discussion no longer centred around the theme of the extremely poor. This was a major conundrum for the program. To what extent should the BRAC representative be responsible for reminding the community of the original issues raised through the play: the exclusion of the extremely poor women from their community? BRAC's approach was to stay entirely out of the village discussion and let the participants choose their own focus. This is the underlying principle of CFSC, however much it is a challenge for health promoters and their funders. Those who practice the approach say that the solution is to simply ask the right questions at the right time rather than interfering in the discussion and decision-making. BRAC's perspective was that any movement towards community-led change was positive for the community as a whole.

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VI.    Adapting CFSC for the Developed World

Although the example outlined in this article is from a developing country, there are many potential applications for CFSC in Canada and other parts of the developed world. Aboriginal reserve communities are one of the closest Canadian examples to the tight and community-oriented villages of Bangladesh, but the approach can certainly be used by health promoters in a range of situations. For example, the approach is particularly appropriate for youth culture because of its comfort level with media in general as well as new media technology.

A further step towards a true CFSC approach would be to involve youth in the initial design of the media itself. A potential example would be a project whereby a group of street kids are engaged in developing a film about life on the streets and then facilitate a discussion about the issues raised in the film with students at inner-city high schools. The impact is clear: not only are those receiving the message gaining value from talking through the issue with their peers, but the ‘real' target of the project - the street kids themselves - are learning how to address their own issues through self-reflection and discussion. This of course is only one example, but CFSC is a powerful approach simply because it combines the strength of communications to inspire with the ability of community development to address the interests and needs of the community. The potential of the approach in the developing world is only beginning to be realized. It provides a rich area for exploration for health promoters both abroad and here in Canada.