Communicating for Social and Behavioral Change: Reflections and Highlights on the IUPHE Global Conference in Brazil

“Authentic thinking, thinking that is concerned about reality, does not take place in ivory tower isolation, but only in communication¹ .” (Paulo Freire, 1968)

Brazil has a long-standing and rich tradition in communication. A tradition that is also exemplified by the work of 20^th century educator and leading advocate of critical pedagogy, Paulo Freire (1921–1997).

Freire is considered a key influencer on the theory and practice of participatory communication for health and social change. In fact, “during the 1950s, experiences with participatory communication first appeared” when Freire “worked with adult literacy campaigns among the poor peasants in North-eastern Brazil. Freire's original literacy work empowered landless peasants to formulate their own demands” for a better and healthier life. “From this experience, he grew into one of the most influential proponents for participatory communication theory and practice. Central to this line of thinking was the emphasis on letting the stakeholders get involved in the development process and determine the outcome, rather than imposing a pre-established (i.e. already decided by external actors) outcome².”

Brazil was also the venue of the recent 22^nd IUPHE World Conference on Health Promotion (Curitiba, Brazil, May 22–26, 2016)³, which I was pleased to attend to share some of my own work. Organized by the International Union for Health Promotion and Education (IUPHE), this triennial conference attracts an average of 2,000+ participants from different regions of the world. The theme this year, promoting health and equity, resonates with Freire's teachings and reminds us all of his sharp emphasis on including underserved and vulnerable populations in equity-driven processes.

These ideas were also reflected in a few of the communication sessions at the conference. For example, the concepts of equity, inclusiveness, and community engagement were central to the UNICEF-led sub-plenary session, Health promotion and communication responses to disease outbreaks – lessons from “Getting to Zero Ebola” and polio eradication⁴, in which I had the honor to participate alongside UNICEF colleagues. All case studies, lessons learned, and data discussed as part of this session strongly pointed to the importance of a participatory and community-driven approach to communication and development to make sure communities are ready to respond and can successfully address the kinds of health and social threats posed by epidemics and disease outbreaks. There is no shortage of planning models for social and behavior change communication and development supporting the integration of community engagement in risk communication^5–8. Of equal importance, a community-centered approach, which supports community ownership of the communication process, is associated with community resilience^9,10. This approach is also likely to improve the sustainability of all interventions and related outcomes (e.g., the flow of goods and services that may be needed at the time of an epidemic or behavioral and social gains toward improved outcomes, etc.) by addressing key barriers to outbreak control and disease mitigation as identified by community members and other stakeholders^11,12. A session on listening to the people¹³ as an approach to encourage participation in community health interventions also reinforced the idea of community ownership as related to other health and disease areas.

The importance of stakeholder engagement was also a key theme that emerged from some of the IUPHE sessions on health literacy. Presentations on this topic described health literacy as a cross-cutting platform to improve health outcomes and empower different groups and communities to participate in health and social processes, by for example, proposing that health literacy is included in all policies; or exploring the role of health literacy in the promotion of health equity; or looking at recent experiences and lessons learned across cultures^14–16.

Other sessions focused on the potential role of different media on promoting health equity, with a major focus on visual media, the Internet, and new media. Of interest, one of the sessions focused on the use of the Internet and Internet-based interactive tools to find and adapt evidence-based interventions to fit the needs of new settings and populations¹⁷ or to assess and present effective elements of best practices in order to increase access to evidence-based methods among practitioners and policymakers¹⁸. Finally, many poster sessions focused on the need for capacity building and training to improve patient-provider communication in Brazil and other countries in the region. Overall, the conference highlighted several important emerging topics, experiences, and data at the intersection of health promotion, health communication and development.

Perhaps what I personally felt missing is a broader discussion of the role communication can play in promoting behavioral, social, and systems-level change and ultimately advancing health equity. Given the legacy Freire has bestowed on Brazil, any plenary discussion and celebration of his work and/or the role of public and community engagement in the management and planning of intersecting communication systems,¹⁹ a key mantra of Freire's writings and experience, would have been especially suitable given the conference's location.

The work of Freire has been receiving a lot of attention in recent times^2,20. However, the implementation of participatory communication models seems to vary in Brazil and other countries within Latin America. As other authors mention, “the practice of health communication in the region has reflected some sort of co-existence of different models and approaches –IEC [information-education-communication], CBC [communication for behavior change], participatory approaches–, and there is certainly a long way to be covered with regards to the role of participation and culture in health communication²⁰.” Similarly, while the Internet is projected to reach an audience of 378.3 million users by the year 2018 in Latin America²¹, the use of information and communication technologies (ICT) to address the health needs of underserved populations in the region, still appears to consist primarily of “small, short-term pilot interventions with limited engagement with the formal health sector”, which do not “include health equity as an explicit component²².”

Strategies to continue to advance the theory and practice of health communication in Latin America, as well as to make sure that all interventions are inclusive of “equity” as a core organizing principle, and to fully harness the lessons from the region's rich history and commitment to the field, include some of the “usual suspects” – building evidence; identifying champions; building capacity; encouraging a sharp focus on behavioral and social results; and establishing suitable professional networks. A focus on increasing the number of academic health communication programs offered by schools of public health, communication, nonprofit management, business, medicine, and many other intersecting fields is also crucial to this effort.

As someone who worked and lived in Brazil for a few years and traveled extensively in the region, I know that the creativity, commitment, and resourcefulness of its professionals have the potential to surprise us again with new models that may impact generations to come, just as Freire's work. The ongoing Zika epidemic may provide an opportunity to further the integration of community engagement and participatory planning strategies as a core component of risk communication interventions, and hopefully institutionalize participatory methods across different health and social areas. As a Journal, we stand interested in receiving submissions on health communication research and interventions from authors who work in Latin America, so that we can help increase the visibility of the work that takes place in the region and share best practices with our global professional community.

Saudades do Brasil…

In This Issue…

This issue of the Journal reflects a variety of current topics, many of them also discussed at the IUPHE conference. First, the role of the Media in healthcare advocacy and education is expertly discussed by editorial board member and great colleague Dr. Isabel Estrada-Portales. In her Inside Commentary, Dr. Estrada-Portales focus on mental health issues as an example to discuss ways researchers and advocates may effectively work with the media to make health issues relevant to them and secure the kind of coverage that will increase public concern. Again on mental health, one of the papers in this issue explores African American and African perspectives on the influence and implications of major historical events, such as slavery and colonialism, on mental health issues. Other papers focus on health literacy, including the role of narrative and metaphor or the use of visual communication to overcome health literacy barriers; or explore the role of systematic reviews and (perceived) conflict of interest in generating evidence-informed policy, among other topics. Whether referring to at-risk groups, journalists or other media, or policymakers, many of the research studies and interventions in this issue are concerned with engaging different groups and stakeholders and addressing the need for behavioral, social, and policy change on a variety of topics. With best wishes for a wonderful summer!