Let me start by explaining why public health communication is important for Pakistan since I am involved in the subject matter. Unlike developed countries, where citizens expect to have their healthcare needs taken care of after paying taxes, Pakistan spends a minuscule portion of its GDP on healthcare. The burden of providing quality healthcare to the citizens of Pakistan was systematically privatised in the eighties. This has put a heavy burden on the people, especially on the poor.
The cost is high in monetary terms on the majority of people as they have to mostly pay for healthcare out of their pockets and that is not the whole cost they bear. The sad insight, after studying healthcare data, is that many poor families consciously choose to live, and often die, with a high ‘disease burden’ without getting the proper treatment required. The situation is especially bad when it comes to medicines as their prices, including lifesaving drugs, have risen to 400% over the past three years. A sad situation indeed.
According to the World Health Organization (WHO), disease burden in a country indicates the impact of health problems leading to mortality or loss of health due to disability, injury and risk factors. Disease burden is estimated by adding together the number of years of life lost because of early death due to a disease and the number of years of life lived with disability due to the disease. Together, this is termed as Disability Adjusted Life Year (DALY) or, the disease burden.
In Pakistan, the disease burden is 21,004 DALYs lost per 100,000 people (according to a report published by the Ministry of National Health Services) which is high, although it has improved since the year 2000. The solution to this problem is a combination of behaviour change on the part of the people and access to quality healthcare facilities on the part of the government and other philanthropic organisations. Although there is little behaviour change communications can do for non-communicable diseases such as diabetes and heart disease, it can massively contribute to improving the situation for 49.9% of the disease burden in Pakistan.
A lot can be achieved to improve this situation through behaviour change, obesity, malnutrition and pollution-related diseases which contribute heavily to the DALYs. Not surprisingly, people who are more affluent and well-educated have greater access to gyms, quality nutrition and dieticians. Others lack the education and behaviours to prevent such issues, especially those related to hygiene (diarrhoea, Covid-19, others) which fill up to half the hospital beds in the country.
It, therefore, becomes the government’s responsibility to provide the general public with access to facilities such as clean drinking water and sanitation; however, simply providing the facilities is not enough. They also need to drive behaviour change within the general public to avoid the suffering caused by preventable issues.
For example, Public Health England executed the world’s largest anti-obesity campaign known as Change4Life to help citizens overcome the burden of preventable obesity. The campaign removed some of the guilt and shame associated with obesity and shifted the blame to modern life. It educated the public about how they could take simple and practical steps to improve health outcomes. The integrated campaign involved broadcast media as well as private sector and grassroots engagement, resulting in the fastest-building campaign in UK Government history. It won an Award for Excellence from the Marketing Society, with 85% of mothers agreeing the campaign “made me think about my children’s health in the long term” and penetration of healthier foods increasing by 20% in families with children exposed to the campaign.
In Pakistan, an example of a behaviour change campaign is the communication undertaken for the prevention of Covid-19 focusing on the WHO prescribed behaviours of washing hands with soap and water, wearing a face mask and ensuring effective social distancing. It is important to note that while there was a lot of communication and awareness (consistently above 85% according to Ipsos surveys), the adoption of preventative behaviours dropped during some campaign periods while the campaign was on the air. The massive repetition of the same advice again and again without emotional engagement and contextualisation fatigued audiences causing them to deliberately ignore the advice!
The Critical Role of Behaviour Change Communications for Public Health
The first thing I must highlight is the difference between the regular stock of health-related communication that comes from the government and effective behaviour change communication. Changing behaviours is much more than making people aware of issues and sharing the official government narrative. The typical stock of government communication focuses on broadcasting official directions to people and informing them about official actions the government has taken to provide them with facilities. Effective behaviour change communications emphasise ‘role modelling’ simple and highly specific behaviours, rather than giving general advice and information. According to Brian Jeffrey Fogg (a research associate at Stanford University), Motivation, Ability and Prompts must work simultaneously and together for behaviour to change.
1 Motivation is the main driver to persuade people to make an effort, which can be driven by a desire for a better life for themselves and their families, or by a desire to avoid suffering. It is important to clearly understand peoples’ motivators and to hone in on them through communications.
2 Ability is the realistic ease of access people will have to the requisite facilities required for the behaviour change. For example, access to soap and running water is critical for behaviour change linked to hygiene. If access is physically difficult or perceived to be difficult, then action will be unlikely. Conversely, a high sense of ease and convenience increase perceived ability and accelerate behaviour change.
3 Prompts are nudges given to the audience to convert the motivation into tangible results at the right moments in time. For example, a nudge to eat healthy food at the right time, or to wear a mask in public places for corona, or a Facebook ping to respond to a new notification. Prompts can be given through advertising, signage, leaflets or by word of mouth. Effective prompts should be simple and focused on the tangible behaviours to emphasise (for example, wash hands, call a certain number, consciously restrict sugar intake) rather than on generic feel-good messaging.
The people who are most in need of health-related behaviour change communication tend to be at the bottom half of the pyramid; the people in the top half tend to be better educated and have access to better facilities. Most agencies working with consumer brands are good at engaging the top half but can struggle to connect and contextualise with the bottom half.
The easier we make it for our audiences to adopt new behaviours (or stop certain behaviours), the more successful the behaviour change process will be. People like to start with baby steps and will be turned off if the change process is perceived to be difficult or cumbersome.
I sincerely believe that better public health behaviour change communications by the government and by philanthropic institutions will make life better for millions of Pakistanis. A lot of suffering can be avoided if the behaviour change communication is effective. Quality healthcare treatment is expensive and hard to access for millions in Pakistan and prevention is always better than the cure.
Afzal Hussain is Chief Strategy Officer & General Manager, M&C Saatchi World Services Pakistan.