This chapter draws upon key components of the theory of communicative action (Habermas 1984, 1987) as a complement to the application of dominant theories of health communication on the ground. That perspective is grounded in symmetri- cal, egalitarian—not hierarchical—relationships between health-care providers and their patients. Such relationships will be accomplished through responsibility-shar- ing—that is, reasoned dialogue and negotiation, both of which are critical to patient care. Habermas’s (1984, 1987) theory of communicative action (TCA), which has been applied to health-care settings (e.g., Brown 2008) will emphasize patient or patient’s caregiver participation, dialogue, consensus, cooperation, and negotiation, all geared toward understandings that are rationally negotiated by all parties in the care of the patient. Such outcomes are outside the bailiwick of those current prac- tices that are grounded in extant health-communication theories.
One of the health scourges in Africa’s urban communities is malnutrition. In some African countries, such as Kenya, higher urban than rural child mortality re- sults from, among other things, extreme poverty, low nutritional status, and family disintegration (Garenne 2010).
The application of a Habermasian analysis to reducing child malnutrition is one in which parents or caregivers engage in reasoning, “not merely for reasoning in general, but for reasons in a form of argumentation” (Habermas 1984, p. 249) geared toward facilitating their cooperative, rationalistic efforts and shared under- standing of the menacing outcome of such malnutrition and the importance of its prevention. Its key feature, therefore, is that it engages participants in “the argu- mentative redemption of validity claims” (Habermas) in every stage of the process, including the argumentative rationalization of the very essence of a child-malnu- trition-reduction program. It enables health-care providers to conduct specifically effective, tailored interventions that resonate with specific audiences (that is, the urban poor at risk for child malnutrition). It would aim to engage the lifeworld of patient populations—that is, moving beyond the medical realm per se and integrat- ing parents’ or caregivers’ taken-for-granted convictions into a negotiation process for preventing child malnutrition. The rationale for this theoretical proposal is borne out by the characteristics of TCA (e.g., emphasis on the pragmatics of language, a linguistic expression) as a medium for transmitting culture and building consensus
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on criticizable validity claims) and by its relevance to the sensitivity of health man- agement in an urban environment.
Current health campaigns, hewn to theoretical guidelines, are essentially strate- gic actions. The argument here is that the antithetical properties of strategic action justify the significance of communicative action as a complement to the dominant health-communication theories that provide much of the framework for Africa’s health campaigns. This implies that health-care providers are at liberty to engage in practices that are contingent on either of those two forms of actions. Nutrition field agents can act either strategically or communicatively. Strategic action, which can be either open (read: symmetrical) or concealed, focuses on, say, program effective- ness. Concealed strategic action has two forms. The first is unconscious decep- tion, by which communication is systematically distorted; and conscious deception, which is full-scale manipulation. The second is communicative action, framed by mutual understanding and acceptability of public accountability and commitments.
It is action oriented toward reaching an understanding and a consensus, both pos- sible outcomes consistent with African discursive norms. This is the crux of this chapter, namely, that campaigns for urban health not only engage in symmetrical communication but also in one that fosters (a) expert patients who have better ac- cess to knowledge, make necessary changes in lifestyle and repeated visits to health services, and adhere to drug regimens; (b) creative agents as patients who operate within the constraints of the health-care environment; (c) informed, involved pa- tients who have a positive effect and a noncontentious approach to communication;
and (d) better opportunities for participation by patients in, and negotiation of, the health care they receive (Schneider et al. 2010).
It must be pointedly acknowledged here that “Habermas does not reject the in- strumental conception of rationality and replace it with an alternative, ‘communica- tive’ conception…. his claim is simply that instrumental models do not provide a sufficient basis for a general theory of rational action” (Heath 2001, p. 13). Haber- mas (1984) writes: “A communicatively achieved agreement has a rational basis; it cannot be imposed by either party, whether instrumentally through intervention in the situation directly or strategically through influencing the decision of opponents”
(p. 287).
Consequently, Habermas describes a symmetry condition in which there is un- constrained dialogue to which all speakers have access, and in which they have the prevailing force of better judgment. It is devoid of domination or sheer influ- ence and bereft of all coercive distortion. Ideal speech is defined in relation to a number of symmetry conditions which, if obtained, can be used to identify speech approximating ideal conditions: (a) there must be a symmetrical distribution of op- portunities to contribute to discussions, i.e., all can speak; (b) there must be oppor- tunities for participants to raise any and all subjects they wish to see addressed, i.e., nothing is “off the table”; and (c) there must be an inviting environment to discuss every topic fully and to the satisfaction of those who raised the topic (Habermas 1990). All of those conditions are consistent with argumentation, negotiation, and consensus that are fundamental to the cultural underpinning of decision making in
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Africa. Health-care providers, therefore, seek through speech acts an orientation toward understanding, consensus and agreement, rather than toward fulfilling their own specific agendas or personal goals. Such a theoretical perspective emphasizes planning through widespread participation by the community, dialogue, consensus, cooperation, and negotiation, not necessarily through strategic action.
Habermas identifies as a speech act that which is being engaged by both senders and receivers of linguistic acts geared toward understandings that are rationally ne- gotiated by all parties. But there are limits to such negotiations. While, say, parties to a speech act can understand the conditions under which a message recipient can understand, accept and endorse the speech act and be persuaded by its claims (e.g.,
“Keeping your child healthy by having a sanitary environment,” or “Ensuring up- to-date vaccination records means having healthy children”), neither the recipient nor the sender can know the conditions of the acceptability of the speech act relative to the actual attitudes and beliefs of the individual other.
TCA has both strategic and communicative relevance to community or national development initiatives. As noted in a preceding paragraph, TCA has been applied to a variety of investigations in disparate disciplines such as community develop- ment, social movements, politics, education, theology, organizational processes, and the performing arts. Its key theoretical elements—e.g., ideal speech situation and the cultural tradition—can lead health-care providers to manage effectively childhood malnutrition and its consequences by encouraging parents and caregiv- ers to (a) question or introduce any counterproposals (the ideal speech in symmetry conditions); (b) discuss malnutrition issues within the contexts of a community’s life world (the cultural tradition); (c) ensure that message themes are subject to va- lidity challenges (“scope for freedom”), even as communicative action is oriented toward reaching an understanding, yet not requiring an agreement, but welcoming an agreement to disagree; and (d) analyze cultural change and cultural plurality. If undertaken in proper settings, the likelihood of attitude and behavior change oc- casioned by effective campaigns (instrumental action) will be more likely. Because of the cultural sensitivity that childhood malnutrition issues particularly engender in sub-Saharan Africa, for example, it is important that field workers and interven- tionists apply Habermas’s notion of the ideal speech situation to analyze at multiple scales the interactions between them and parents and caregivers, the targets of cam- paigns. Such communicative interactions are relevant to nutrition management for at least four reasons.
First, the participation inherent in communicative interactions can be an addi- tional opportunity to increase the chances for the messages to be accepted politi- cally by the government and socially by the community, even as it offers a forum to parents and their children to collaborate in the process of crafting campaign mes- sages generally perceived as culturally and endogenously sensitive.
Second, the interactions can be used as a means to improve nutrition-manage- ment objectives, goals, and protocols through presuppositions of argumentation and negotiation, for which Africans have a growing penchant (e.g., Schneider et al.
2010; Scholtz et al. 2008).
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Third, the interactions can provide opportunities for participants to ground com- municative action within a lifeworld; that will help them reach a reasoned consensus centered in a local agency. Current practices tend to undermine such rationalization.
Fourth, the interactions are a basis for evaluating patient involvement; that will ensure that communicative action is inherently measurable and campaign outcomes scientifically determined. Did parents of malnourished children, for example, report that they had ample opportunities to raise issues in dialogues or negotiations? Such evaluations of communicative action can be combined with overall campaign eval- uations to determine audience exposure to mass media plans (who were exposed to the campaigns and at what frequency and what do they now know?); and outcomes (did the communicative experience engender reason and persuasion, leading in the long run to the desired behavior change?).
Granted, certain realities in Africa, for example, the minuscule presence of lib- eral democracies, do not bode well for an application of TCA. Quite apart from the continent’s massive economic struggles, it has been estimated that “In sub-Saharan Africa, the number of malnourished children is projected to grow from 33 million in 1997 to 49 million in 2020, representing 10 million more malnourished children than in the baseline” (Rosegrant and Meijer 2002, p. 3439S).
It bears noting here that a communicative model of action is not synonymous with mere speaking; it is not mere argumentation. And it is also important to note that conversations must be held in the dominant local language—the linguistic me- dium—enabled by participants’ performative attitude and skills in “language mix- ing.” That means code-switching and borrowing justified by the disparate languages and dialects over even small geographic areas and by the geographic mobility oc- casioned in an age of growing cosmopolitanism—even in Africa’s rural areas. This calls for the participation of initiating actors versed in using different languages in the same conversation to coordinate action.