While IEC was aimed at giving people information and awareness about health is- sues, BCC campaigns seek to help people change behavior relating to health. BCC campaigns on reproductive health of women focused on behavior such as: delaying sexual initiation and age at marriage, encouraging using of condoms, spacing births, supporting others trying to change, supporting people living with HIV/AIDS, and seeking and adhering to health services/treatment. But BCC also could not always bring desired results because the decision to change one’s behavior rests with an in- dividual. Health educators in BCC initiatives act as facilitators and do not exert any control over an individuals’ behavior change because usually only the individual
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understands the implication of behavior change on his/her life; the individual knows about his/her prior experience with behavior change; and the individual is better aware of his/her own abilities, strengths, and weaknesses. The Andhra Pradesh Urban Slum Health Care Project (APUSHCP) was a successful BCC initiative in improving the health status of urban slum women in India (Family Welfare Depart- ment 2001).
Andhra Pradesh Urban Slum Health Care Project
The APUSHCP was initiated and implemented in 2001, with the World Bank’s as- sistance, in Andhra Pradesh State of India. It is the largest and most populous state in south India. The total population of Andhra Pradesh stands at 75,727,541 of which around 36 % of the population lives in slums (Census of India 2001). In spite of avail- ability of government hospitals in the municipal towns, they are primarily curative ser- vice centers and do not render preventive health-care services to the slum population.
The Post Partum Units and Urban Family Welfare Centers provide health extension services to a small proportion of urban slum population. Inability to provide neigh- borhood health extension such as antenatal care for pregnant women, immunization services for children, sensitization about preventive health care aspects, and regular advice on temporary or permanent methods of contraception was a major limitation of the institutions catering to the needs of the urban poor women living in the slums.
The APUSHCP was aimed to achieve the goal of improved maternal and child health among the slum community. The project used BCC to respond to the needs of the target audiences, provide a supportive environment to encourage and reinforce behavior change, and provide linkages with services using a coordinated multi- pronged approach. The following focus areas were identified for undertaking BCC:
age at marriage, safe and institutional delivery, nutrition for mother and child, small family norms with male responsibility, spacing, immunization and Vitamin A ad- ministration, home-based care for diarrhea, early treatment for Acute Respiratory Infection (ARI), and prevention and treatment for Reproductive Tract Infections (RTI) and HIV/AIDS. BCC led to community mobilization and increased demand for services, while satisfactory services provided at the Urban Health Centers re- inforced behavioral change. BCC through Women’s Health Groups, Self-Help Women’s Groups, Integrated Child Development Services (ICDS) workers, and community volunteers succeeded in enabling positive behavior change among the slum women beneficiaries to seek health care and demand quality services from the Urban Health Centers (Somayajulu 2004).
Strategic Health Communication
Strategic communication goes beyond IEC and BCC even though it incorpo- rates elements form the two approaches. It has become central to combating the world’s major complex development problems. This approach recognizes that ef-
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fective communication is grounded in a particular socioecological context, includ- ing enabling environments, service delivery systems, communities, husbands and wives, family members, and individuals. Strategic communication involves iden- tifying and understanding pathways to change within these complex systems and developing bold strategies that address these behavioral pathways. It mobilizes a comprehensive array of communication approaches including digital media, broad- cast media, community mobilization, interpersonal communication, advocacy, and capacity building to catalyze change.
Strategic health communication can bring about considerable change in the health-seeking behavior of the target population. It creates an environment for in- troduction and adoption of a health intervention. It is assumed that once the envi- ronment is created and the intervention is launched, it would have relatively better acceptability. Strategic health communication aims at creating awareness as well as creating an environment perceptive to change. Strategic health communication takes an integrated approach to maternal and childcare in the areas of nutrition, clean environment, hygiene, and family interaction and support. While health is a common concern of all age groups and gender, it became imperative for health communication experts to be conscious of gender-based perceptions about health, gender differentials in health information needs, the credibility of sources of infor- mation, and the preferred sources of information of women.
India’s fight to lower MMR is failing due to growing social inequalities and shortages in primary health-care facilities. Maternal deaths can be avoided with the help of strategic health communication involving skilled health personnel, access to adequate nutrition, better medical facilities, and family planning. India has begun to implement strategic health communication to initiate positive behavior change among slum women to step up the knowledge and utilization of health services. The following section analyzes the benefits of successful strategic health communica- tion initiatives for slum women in India and their implications for the health status of their sisters who live in urban slums of Asia and Africa.
Rights of the Girl Child
Despite women’s biological advantages, the higher mortality rates in several coun- tries of south and east Asia reveals the persistence of “missing women” who have died due to infanticide, gender-based abortion, systematic neglect, and discrimina- tion in access to health and nutrition. Women in India constitute a population of 495.74 million with 360.52 million in the rural areas and 135.22 million in the urban areas. The human development status of women shows wide interstate and intrastate variations. In the Indian context, gender relations are determined by the complex interplay of power relations based on class, caste, ethnicity, and religion (Desai and Thakkar 2001). There is considerable variation in the social construction of gender in different parts of India, especially between the northern and southern regions (Prasad 2004).
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The high preference for sons in South Asia including India has led to many girl children being annihilated even before they are born. The adverse sex ratio in India, which stands at 940 females per 1,000 males, is a reflection of this reality (Census of India 2011). Women in the developing world including India generally neglect health problems and tend to go without medical attention for a prolonged period of time. Health care for women is often regarded as a luxury rather than a necessity.
Women face complicated pregnancies and related poor reproductive health, abor- tion, and chronic iron deficiency. They have the primary responsibility of bearing children and shouldering the household burden with little time, energy, or resources for personal health care. Women tend to neglect their health and direct their concern and attention toward the care of families. Since women are by and large silent about their health problems, the decisions regarding their health care rests with family members, particularly male members. According to the NFHS (2007), around half of the women in India are not involved in decisions about seeking health care for themselves.
The Meena Communication Initiative in South Asia developed by UNICEF (2002) and supported by the governments of Bangladesh, India, Pakistan, and Nepal is an important strategic communication initiative aimed at changing the percep- tions and behavior that hamper the survival, protection, and development of female children in the region. This strategic communication initiative involves production of multimedia packages to put across gender, child rights, and educational messages using the medium of popular entertainment, which is aimed at altering the targeted persons from mere recipients of information to seekers of information to protect the health of girls and women. The Meena Communication Initiative is based on a shared need for content creation in the region to promote women’s health, gender equality, and empowerment of women, which are important MDGs to be achieved in South Asia to improve the human development status in the region.
Reproductive Health Care
Reproductive health care forms an important and permanent agenda in women’s health. Annually, huge investments area made in terms of money, resources, and materials to create health infrastructure and awareness among women. As in many other developing countries, unequal power relations and the low status of women, as expressed by limited access to human, financial, and economic assets, weak- ens the ability of women to seek health care for themselves (Prasad 2008b). The National Rural Health Mission launched by the government in 2005 was aimed at increasing the outreach of the health system to village and rural households through the provision of voluntary trained female community health activists called ASHA.
It also recommends strengthening the primary or community health centers as a key step to empowering public health infrastructure.
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The National Mission for Empowerment of Women (NMEW) announced on March 8, 2010 works with all the states and union territory governments and has 14 ministries and departments of Government of India as its partners with the Ministry of Women and Child Development as the Nodal Ministry. The mandate of the Mis- sion is to bring in convergence and facilitate the processes of ensuring economic and social empowerment of women with emphasis on health and education, reduc- tion in violence against women, generating awareness about various schemes and programs meant for women, empowerment of vulnerable women, and women in difficult circumstances (http://www.nmew.gov.in). The Mission aims to engage in strategic communication for interministerial convergence of gender mainstream- ing of programs, policies, institutional arrangements, and processes of participating ministries, which have largely hitherto operated independently and in a stand-alone manner.
The child sex ratio in India has been sliding gradually over the decades from 962 to 1,000 boys in 1981, to 945 in 1991, 927 in 2001, and 914 in 2011. To address this complex issue, which lacked a national action plan, the NMEW has launched The- matic Convergence Projects in 2012 using strategic communication to tackle the declining child sex ratio in 12 gender-critical districts spread over seven states of In- dia. It has developed a Communication Charter based on BCC through community social organizations to chalk out strategic communication action plans to address the problem of sex-selective elimination of girls in India (http://www.nmew.gov.in).
In a study of the influence of strategic health communication on health behavior change of urban slum women in two slums of Hyderabad City in Andhra Pradesh with intensive and nonintensive health communication campaigns, it was found that there is a gap between health services and the users’ end in terms of infor- mation, knowledge, availability, and utilization of services (Haripriya and Prasad 2009). The intensive strategic reproductive health communication program used a variety of print media to target slum women including posters, charts, newspapers, pamphlets/leaflets and magazines. Electronic media such as TV, radio, film shows/
videos and audio cassettes were also used to expose women to intensive strategic reproductive health communication. Street plays, puppet shows and Harikathas or mythological/traditional stories were also used to create widespread exposure to all health messages among slum women in the intensive program area. Interpersonal/
group media were also employed to expose slum women to health messages in the intensive area through group meetings, women’s clubs, child service center ( bal- wadi) teachers, health officers/personnel and relatives/friends.
Haripriya and Prasad (2009) observed that slum women in the program-intensive area had better levels of awareness of reproductive health than slum women in the nonintensive area. More than two-thirds of the slum women in the intensive area had live births whereas only half of the slum women in the nonintensive area had live births. While three-fourth of pregnant women were visited by health workers and advised for regular antenatal checkup by a health worker in the intensive area, only half of the women reported such visits in the nonintensive area. Majority of the slum women (91 %) had undergone three or more antenatal checkups in the in- tensive area against half of the women in the nonintensive area. A great majority of
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slum women (94 %) utilized the free distribution of Iron or folic acid tablets in the intensive area women against less than half of the women in the nonintensive area.
More than three-fourth of the women in the intensive area had their delivery in a medical institution while more than 10 % of the slum women in the nonintensive area had their delivery at home. Most of the women in the nonintensive area were assisted by relatives/friends/others in their delivery at home, whereas a negligible number of women in the intensive area who had delivery at home were assisted by Trained Birth Attendants (TBAs). The awareness and utilization of monetary benefits from the government during first and second pregnancies and sterilization is significantly higher among women of intensive area than among women of the nonintensive area (Haripriya and Prasad 2009).
It is found that women who reside in the slums with intensive strategic reproduc- tive health communication have better levels of exposure and awareness of repro- ductive health and have greater levels of utilization of health services than women who reside in the slums with nonintensive health communication programmes.
Slum women exposed to intensive strategic reproductive health communication had better knowledge of antenatal, delivery and postnatal care, family planning, mater- nity benefits, and monetary benefit for sterilization. Slum women exposed to inten- sive strategic reproductive health communication expressed greater improvement in health behavior in terms of nutrition, environmental cleanliness, personal hygiene, and reproductive health. Strategic communication to increase the awareness and knowledge levels of reproductive health had positive effects on the utilization of health services and health behavior of slum women (Haripriya and Prasad 2009).
Women with HIV/AIDS
There is a growing feminization of the HIV/AIDS epidemic in India with 38.4 % of those living with the virus being women (http://www.unaids.org). The fact that more than 2 million women in India are living with HIV/AIDS has set off alarm bells in the Indian medical fraternity—especially since more than 90 % of these are married women in monogamous relationships: more married women in India are at risk of getting AIDS than sex workers. The virus is also increasingly moving toward the rural areas and slums with 57 % of the virus load being shared by the women who live in villages and slums. Several factors combine to increase the vulnerability of women to HIV/AIDS and they must also be understood in the context of the poverty and inequalities that define the daily lives of both women and men in South Asia.
Knowledge of AIDS among women has been increasing over time, but many women have still not heard of AIDS. Knowledge of AIDS is universal among men and women with 10 or more years of schooling but majority of women with no education have not heard of AIDS (Gupta et al. 2006). As part of the AIDS preven- tion program, the Government of India has been using mass media, television in particular, extensively to create awareness among the general public about AIDS and its prevention. In India Breakthrough, a human rights organization has launched
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a strategic media campaign titled What Kind of Man Are You? This strategic com- munication campaign highlights the rising incidence of married women infected by the AIDS virus by their husbands. Apart from this, Breakthrough has been organiz- ing various workshops to provide sex education to the general public. It also has an SMS facility through which people’s queries are answered, informing them about the treatment and care for the infected.
The organization has also launched an intensive multimedia campaign to focus public attention on the growing problem of HIV/AIDS. Sameer Soni and Man- dira Bedi, popular television stars, who feature in a music video, Maati, sung by Shubha Mudgal, which talks about a pregnant woman who discovers that she is HIV-positive because of her husband’s promiscuity, feel that the responsibility and the guilt that a man feels on infecting his innocent wife is brought out beautifully in the video, directed by Arjun Bali. “The fact that television and music are so popular with the masses will help spread the message much faster in a populated country like India, than workshops and prevention measures targeting small groups of peo- ple,” says Soni (Khosla 2005). The message is being conveyed through music vid- eos, eye catching advertisements in newspapers, radio, and television. The different visuals have the same theme—a woman asking her husband to protect her by using a condom. This strategic campaign aims to empower women in an exceedingly pa- triarchal society, enabling them to discuss sexuality freely with their husbands and encouraging the use of condoms among men with their wives.
Women living with HIV/AIDS have started strategic initiatives that would ex- press and improve their situations. They have called for recognition of their fun- damental human rights and for decision-making power and consultation at all levels of policy and programs affecting them. They have urged economic support for women living with HIV/AIDS in developing countries, support for self-help groups and networks, realistic portrayals of people living with HIV/AIDS by the media, and accessible and affordable health care. They also want their reproduc- tive rights to be respected, including the right to choose whether or not to have children (http://www.icw.org).
Strategic communication involves many community efforts mobilized to protect women’s health. A young widow who lost her husband from AIDS started a support group specifically for women to break the cultural taboo of silence among women with HIV/AIDS. She decided to fight AIDS by educating young girls and began ap- pearing in public, speaking at schools and gatherings, and eventually on television when the media picked up on her efforts. She also began visiting other HIV-positive women, trying to get them to go public and called the first meeting of the Positive Women’s Network of South India. Positive Women’s Network is an organization formed by women living with HIV/AIDS (WLHA) in 1998 to address the need for a support system and to improve the quality of life of women living with HIV and their children in India (http://www.pwnplus.org/who.htm—Positive) Women’s Net- work The network began with 18 women who showed up to talk about their lives and the impact HIV had had on them. Now the group has more than 1,000 members most of whom are housewives and meetings feature doctors, dieticians, and social workers. Members of the network can take advantage of counseling and social ser- vices as well (Warrior 2003).