THE USES OF MASS MEDIA AND HEALTH CAMPAIGNS FOR ETHNIC MINORITY GROUPS: A CASE STUDY

Dissertation submitted in accordance with the requirements of Manchester Metropolitan University for the degree of Master of Science in Practitioner Research by

YUMIKO DOI Department of Health Care Studies Manchester Metropolitan University

June 2003

CONTENTS
List of Tables List of Figures List of Acronyms Used in Text Abstract 1. Ethnic minority health in the UK: its history and recent problems 1-1 Ethnic minority health in the UK: its history and recent problems 1-2 Structure of chapters Health promotion and mass media use: its adaptability to ethnic minority health 2-1 Health promotion: what is its purpose? 2-2 Use of concepts of health promotion in ethnic minority health promotion 2-3 Mass media and health promotion: an example in health promotion 2-4 Use of mass media in ethnic minority health promotion 2-5 Conclusion and further questions Mass media health promotion campaigns for ethnic minority groups: a discussion in relation to real-world research 3-1 Review process and methodology 3-2 Results 3-2-1 General observation 3-2-2 Conceptual/theoretical backgrounds 3-2-3 Use of mass media: reasons and usage within campaigns 3-2-4 Evaluation methods 3-2-5 Effectiveness of campaigns 3-3 Implication of the study results for designing mass media health promotion campaigns for ethnic minority groups 3-4 Conclusion The Malaria Radio Campaign within Asian Population in the UK: a case study 4-1 Case study: the Malaria Radio Campaign within Asian Population in the UK 4-1-1 Background 4-1-2 Design and planning of the Malaria Radio Campaign 4-1-3 Conducting the campaign 4-1-4 Evaluation 1 post survey 4-1-5 Evaluation 2 qualitative research 4-2 Discussion: analysis for the reasons of the campaigns failure 4-2-1 Finding 1 The impact of missing information concerning peoples accessibility to health information and use of mass media on the campaign effect 4-2-2 Finding 2 The impact of missing theories/concept upon the campaign effect 4-2-3 Finding 3 Misunderstanding of the suitable campaign period 4-2-4 Finding 4 - The importance of the qualitative evaluation study within the campaign 4-3 Conclusion Conclusion 5-1 Summary of the study 5-2 Issues of recent ethnic health promotion campaigns and implication for future Page iii iii iv v 1 1 6 9 9 15 19 26 29 31 32 34 36 41 45 52 56 62 68 70 71 71 72 74 74 77 83 86 89 97 98 100 105 105 107 113

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LIST OF TABLES
2-3-1: The conflicting priorities of mass media vs. public health institutions 3-2-1: Articles for review 3-2-2: Campaign topics for ethnic media health promotion 3-2-3: Targeted ethnic minority groups and sex 3-2-4: Aims and goals for campaigns 3-2-5: Adaptation of concepts and theories 3-2-6: Ways of use of mass media within campaigns 3-2-7: Commonly used mass media tools 3-2-8: Evaluation methods 3-2-9: Summary of effects of campaigns on their goals 4-1-1: Listening habits of Asian radio programmes 4-1-2: Listening time bands of Asian radio programmes 4-1-3: Recognitions of the malaria radio advertisement 4-1-4: Results of statistical test (chi-square) of value, recognition of the radio advertisement 4-1-5: Travel dates and behaviours towards taking prophylaxis 4-1-6: Commonly mentioned words concerning impressions of the radio advertisement 4-1-7: Commonly mentioned words concerning music 4-1-8: Commonly mentioned words concerning the quality of information 4-2-1: Summary of the designing and conducting process of the Malaria Radio Campaign 4-3-1: Suggesting process of the designing and conducting the Malaria Radio Campaign Page 23 35 37 37 39 42 49 50 53 58 76 76 76 77 77 80 80 81 85 101

LIST OF FIGURES
2-1-1: The Tannahill model of health promotion Page 12

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LIST OF ACRONYMS USED IN TEXT

AIDS acquired immune deficiency syndrome CVD cardio vascular disease(s) DFID Department for International Development DOH Department of Health FoCaS the Forsyth County Cancer Screening Project HIV human immunodeficiency virus NHS National Health Service WCTU the Womens Christian Temperance Union WHO World Health Organisation

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Abstract
Ethnic minority health is a new topic in the United Kingdom health service sector, this in spite of a long history of multiculturalism. According to previous studies, the major negative features associated with ethnic minority health are related to cultural background, e.g. the problem of the language barrier in accessing appropriate health information and the associated difficulty in adequate communications with health workers. Health promotion for ethnic minority groups has been developed to try to solve such issues by taking into account these kinds of cultural barrier. One of the most popular methods of health promotion for ethnic minority groups is the mass media campaign. Health promoters, because of the easy application of a variety of appropriate languages and the supposed direct access to the target populations prefer this. However, the problem of the mass media campaign directed specifically at ethnic minority groups is the lack of accumulative information concerning both their design and conduct. The fact is that many previous projects of mass media health promotion for ethnic minority groups were planned and conducted in relation to theories and concepts developed through health promotion projects for white populations. It is questioned as to whether these existing health promotion methodologies are truly appropriate for ethnic minority groups. This study discusses this point in relation to a specific case: The Malaria Awareness Project within Asian Populations in the UK. This project was designed and conducted using existing health promotion theories and methodology whist also attempting to apply some aspects of target populations cultural background. The projects purpose was, via the use of a radio advertisement, to encourage target populations to take anti-malaria prophylaxis prior to travelling to their home countries (that are malaria epidemic/endemic areas). The results reveal however, that the project had little or no impact in changing the target populations behaviours. An evaluation study showed that: (1) the target populations felt insulted by the style of the advertisement; (2) that the content of the advertisement was inappropriate. The case study reveals that adopting existing theories and methodologies of health promotion for ethnic minorities still contains some significant problems and requires further study.

Chapter 1 Ethnic minority health in the UK: its history and recent problems

1-1 Ethnic minority health in the UK: its history and recent problems

Britain is a multi-ethnic and multicultural society1. The major ethnic group is white-British; recent ethnic populations migrating from South Asia, Caribbean countries and Ireland supplement this majority. In addition to these groups, there are significant numbers of other ethnic groups living in the UK; e.g. Chinese, African and Eastern European people (Kings Fund, 2000). According to the population census of England and Wales, the minority ethnic population was almost 2.9 million; this represents 6% of the total UK population (Balarajan and Raleigh, 1992). The Kings Fund reports that approximately one person in sixteen in the UK population is now from a minority ethnic group (Kings Fund, 2000). However, the history of ethnic minority groups in the UK is recent; beginning in the 1950s and 1960s when populations from former British colonies, such as the Indian sub-continent or Caribbean countries, migrated to the UK as non-skilled or semi-skilled workers (Brah, 1992). This short history has caused a somewhat rushed development and application of social policies affecting those ethnic minority populations (Chen, 1999).
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The definition of ethnic groups has been in a long-term debate. Sometimes it is confused as race which is more related to biological or genetic state (Spencer, 1971; Jones, 1991; 1994; Papadopoulos and Alleyne, 1998). While this study would not attempt to discuss the debate of ethnicity, the definition of ethnic group in this study adopt Hilliers concept of ethnic group: a social group that shares certain distinctive features, such as language, culture, physical appearance, religious affiliation, customs and values (Hiller, 1991: adopted Henley and Schott, 1999, p. 7). In general, all people are belonging to one of ethnic groups. However, most of society has a major ethnic group in terms of the numbers of population, strengthen of cultural or political power. In the UK, especially in England, the major ethnic groups is white English, and other ethnic groups, e.g. AfroCaribbeans, Indians, Pakistanis or Chinese, are all called ethnic minority groups (Henley and Schott, 1999). In this study, the concept of ethnic minority groups is following this explanation.

In academia, many researchers have focused on the fact that there are significant health issues observable among those ethnic minority groups that have developed since the beginning of the 1980s. For example, a group of dentists studied the high prevalence of some oral health issues among those groups, such as dental structure (Poynton and Davey, 1968), oral hygiene (Walsh et al., 1989; Williams et al., 1989); dental care (Williams et al., 1989; Bedi, 1989); and oral malignancy (McMichael, 1984; Donaldson and Clayton, 1984). Other scientists have been interested in the high prevalence of other health problems, such as breast and cervical cancer (McAvoy and Raza, 1988; Donaldson and Clayton, 1984), as well as health service usage (Donaldson and Taylor, 1983). The Kings Fund recently reported that more than 60 percent of Asian people in England and Wales are likely to have heart disease. In addition to this, they showed that black African-Caribbean people have five times more likelihood to develop high blood pressure, under the age of 65, than those of the majority population. Furthermore, newborn babies from Pakistani mothers are likely to show a higher mortality rate than those of British-born mothers (Kings Fund, 2000). In spite of the accumulation of ethnic minority health studies in academia, and their subsequent dissemination to government officials, the reactions by agents to those reports have been very slow. In 1994, the UK Government initiated the Ethnic Health Unit within the National Health Services. However, more active official initiatives focusing on ethnic minority health started roughly in 1999 when the Green Paper, the so-called Our Healthier Nation was published. In this paper, numerous relationships between populations opportunities for a long and healthy life and their ethnic backgrounds are brought into focus. In the narrative developed by this paper, many indirect issues concerning ethnic minority health are emphasised, such as health inequalities, social exclusion, poverty and access to

health care. Thus, it can be concluded that tackling these issues, in order to improve ethnic minority health, has now become a government priority (Aspinall, 1999). It is fair to say that the green paper can be considered a turning point in developing ethnic minority health issues in practical ways. For example, many local NHS organisations and councils are involved in ethnic minority health concerns, e.g. the Health Improvement Programme, Health Action Zone and Healthy Living Centre (Aspinall, 1999). The issue is, however, that these actions, aimed towards improving ethnic minority health in the UK, have only just started. And therefore, an understanding of their character, methodologies and influences remains somewhat obscure. The most problematic point when tackling ethnic minority health issues is a lack of understanding and considerations of the impact of cultural diversity upon ethnic minority health among professional health practitioners. Bartlett (1984) noted that many diverse aspects relate to the health of human beings, such as individual factors (knowledge, attitude, or skills), social factors (family, peers, employers and so on), and environmental factors (income, housing etc.), these factors directly and indirectly affect the formation of health behaviours, and those health behaviours directly influence the individuals health status. In short, individual, social, and environmental factors can be directly related to peoples health status. Bartletts explanation of the related factors affecting health behaviours and status is adaptable as an explanation for ethnic minority health status in a multicultural society. In a multicultural society such as the UK, differences associated with social and cultural determinants (individual and social factors in the Bartlett model) affect different viewpoints in regard to the causes and treatments of ill/health (health behaviours) among different ethnic minority groups (Nazroo, 1997; Papadopoulos and Alleyne, 1998; Henley and Schott, 1999; Arora et al., 2000). Moreover, those cultural differences affect perceptions about the timing of

seeking treatment, whom to consult and the appropriate treatment regimes to be undertake (Henley and Schott, 1999). As a result, ethnic minority health issues are likely to differ from those of the major population group. Indeed, there are many ethnic minority health issues, associated with social cultural bases, reported by researchers2. Health services in a multicultural society are, however, likely to be understood through the lens of medical attitudes based on a Western medical sensibility with small or no consideration of patients ethnic cultural backgrounds3. This is particularly observable in new areas of the health service. Health promotion/education, for example, is itself a recently developed area within the field of health studies. Its effectiveness and methodology is, in general, still controversial (Klapper, 1960; Gatherer et al, 1979; Tones, 1993; Naidoo and Wills, 1999; Swinehart, 1997). Notwithstanding this, because of the increasing demands to improve health conditions among ethnic minority groups, demands to conduct effective health promotion/education projects for those groups have increased. The major issue for UK health promotion for ethnic minority groups is, however, that of a well funded comprehensive promotion strategy that takes into account ethnic diversity. a comprehensive promotion strategy for ethnic minority health in Britain is confined and limited

For example, Bedi and Elton (1991) discussed that Asian schoolchildren were more likely to have a problem of dental caries than other ethnic groups because of their diet, e.g. intake of sugar, and oral hygiene habits, e.g. uncommon use of tooth brush (Bedi and Elton, 1991). Similarly, Williams and co-workers (1991) reported that the prevalence of oral cancer was especially significant among migrants from male Indian subcontinent because of the relation with their cultural habits such as use of chewing tobacco called Pan, poor oral hygiene and their diet. Apart from oral health, Pierce and Armstrong (1996) showed how Afro-Caribbeans belief concerning diet and body image was inconsistent with medical ideas for preventing diabetes, and concluded that this inconsistency of cultural belief could be one of the causes of diabetes among this ethnic population. 3 Western medicine is likely to be part of a medical knowledge among ethnic minority groups as well. It is because health services are now likely to be based on western medicine even in their original countries. It could be called dual medical categorisation (Doi, 2001, p. 61), which is a mixture of traditional and cultural medical knowledge and western medical knowledge. Some researches in developing countries provide more detailed discussion for this (See Agyepong and Manderson, 1994: Nabiswa et al., 1994:Winch et al., 1996)

by the availability of resources, a situation reflected in the other fields of the health service sector. Bhopal and Donaldson (1988) assert that the strategic priorities of health education/promotion for ethnic minority groups are very narrow, directing attention to limited issues such as birth control, pregnancy and childcare. More than a decade later, one of the leading organisations in health promotion, the Health Development Agency (formerly the Health Promotion England), focused on health promotion for ethnic minority groups, and came to the same conclusion. That is that the priorities of health promotion for ethnic minority groups are still narrowly selected. In this case, being confined to issues such as alcohol, children and families, drugs, immunisation and sexual health, these target areas do not make any allowance for cultural difference associated with ethnic minority groups. Thus, there is still no real differentiation made between these ethnic groups and the majority white population (Health Promotion England, 2002). This indicates that the objectives of health promotions are still very much based on the established paradigms of the major population in spite of the diversity of cultural, religious and social backgrounds prevalent among ethnic minority groups, with their associated differences in health issue focus. In addition, the numbers of health promotion campaigns for ethnic minority groups are still relatively small, especially at the national level. As a consequence of these limitations, health promotion campaigns for ethnic minority groups are still likely to be designed and conducted without purpose-built guidelines, the references used being directed towards existing health promotion methods developed from experiences with major populations.

One question to be addressed in regard to this usage is whether these health promotion methods which have been developed through health promotion campaigns for major populations are appropriate for the ethnic minority groups.

1-2 Structure of chapters

The main purpose of this dissertation is to contribute to the debate on the appropriate methodology of health promotion campaign for ethnic minority groups. This is achieved by analysing and evaluating existing health promotion discussions, data from previous health promotion projects for ethnic minority groups, and a case study. This in order to answer the question indicated above, i.e. whether recent health promotion debates and methodologies are appropriate for the field of ethnic minority health improvement. The discussion will be carried out by focusing on one of the most common types of health promotion campaign, i.e. mass media health promotion (for both a major population and ethnic minority groups). This is because this type of health promotion method provides rich resources for discussions whilst excluding any biases associated with differences in campaign tools. The second purpose of this study is to underline how social scientific debates can contribute to the development of an understanding of the nature and necessity of the field of health promotion and ethnic minority health study. As previously discussed, scholars associated with ethnic minority health study seem to appreciate the necessity of the application of social scientific debates. Here one can isolate Sociology and Anthropology which help to

explain the cause of ill/health among ethnic minority groups. A question the discussion seeks to answer is this: how are health promoters able to apply and incorporate these discussions into their work? Answering this question is achieved by describing and examining both the level of intention, and the application of understanding in terms of the social and cultural aspects of ethnic target populations in regard to their previous experiences of health promotion campaigns, and in relation to a case study. This dissertation is divided into three sections: the first section addresses conceptual issues focusing around two areas, i.e. health promotion and ethnic minority health study (analysis and synthesis); the second section considers whether the synthesis of first discussion is related to real world experiences, namely actual health promotion campaigns for ethnic minority health. Finally, using a case study, the synthesis suggests some points for improving health promotion campaigns in the future. Chapter 2 discusses the consistency/inconsistency of concepts of health promotion and ethnic minority health study. In this chapter, the core concept of health promotion is defined and clarified. The chapter also considers how the perspectives of health promotion can share the approaches and methods associated with the ethnic minority health study. Chapter 3 explores the notion of real world experiences. This chapter considers how health promoters might cope with designing and conducting health promotion projects, and how they might integrate methodologies of health promotion into campaign projects for ethnic minority groups. The data collected and discussed in this chapter contributes to the creation of a brief guideline for designing and conducting health promotion campaigns for ethnic minority groups. The guideline suggests how an awareness concerning the ethnic target populations socio-cultural background can be an important factor for ethnic minority health promotion

projects. Chapter 4 discusses elements contained in the conclusion of Chapter 3 in light of evidence coming from the case study. Through a discussion concerning the failure of the Malaria Awareness Project, the dissertation examines why health promoters need to understand the social and cultural backgrounds of ethnic minority groups. Chapter 5 offers a conclusion centring around the attitudinal and methodological requirements for health promoters working for ethnic minority health promotion projects. The possible contribution of this dissertation to future health promotion debates is that of clarifying the issues of recent health promotion campaigns for ethnic minority groups combined with a provision of clues for developing an official guideline for health promotion campaigns design for ethnic minority groups in regard to policy makers.

Chapter 2: Health promotion and mass media use: its adaptability to ethnic minority health

The previous chapter discussed the brief history of ethnic minority health issues and recent policy and problems associated with their improvement. This discussion focused on the necessity for health promotion/education for those groups in order to improve their health situation. However, health promotion/education is, itself, a new term in the UK health service sector. As a consequence, there are no certain guideline for health promotion/education in relation to these groups. The present chapter discusses the consistence/inconsistency of recent concepts and approaches towards health promotion/education for ethnic minority groups. Initially, in the chapter, we discus the basic concepts to health promotion. Then, the discussion moves on to the adaptability of those concepts to the specific case of ethnic minority health promotion/education. Thirdly, the chapter develops and explores a methodological discussion with the associated use of mass media health promotion cases. The purpose being to discover whether the general practices of health promotion are adaptable to the field of ethnic minority health.

2-1 Health promotion: what is its purpose?

This study has repeatedly used the phrase health promotion and education. Some health practitioners confuse these terms and mix their meanings with little consideration. One should

note that health promotion and health education are slightly different. Downie and co-workers write that, health promotion comprises efforts to enhance positive health and reduce the risk of ill-health, though the overlapping spheres of health education, prevention, and health promotion (Downie et al., 1996, p.2). What is the difference between health education, prevention, and health promotion? And how do these concepts act to improve human health? The concepts behind these words are closely related, and have been developed within the history of public health. Among these, the concept of health promotion is a recent term. It has its origin in the public health movement, when the devastating social effects of outbreaks of epidemic diseases applied social pressure for sanitary reform in the new industrial towns4, such as London. Those outbreaks also made people aware of the necessity for health education in order to prevent diseases. This could be achieved by improvements in lifestyles and behaviours (Naidoo and Wills, 1994). However, ideas coming from the field of health education became controversial by the mid 1980s. The point made by critiques is that health education approaches are narrowly focusing on improving individual lifestyles without consideration of community education (Ewles and Simnett, 1999). In 1985, the World Health Organisation (WHO) declared a strategy of Health for All by the Year 2000,5 based on the Declaration of Alma Ata in 1978. In this strategy, the WHO put forward 38 target fields as prerequisites for health, and also declared the necessity for fruitful intersectional collaboration in order to approach those target areas. Although this strategy did not specifically mention the phrase, health promotion, the notion is implied.

A report by Edwin Chadwick, who administered the Poor Law, is considered the first official report to mention the relationship between poverty and ill-health associated poor sanitation and hygiene. In 1854, John Snow, one of the first epidemiologists proved this relationship from the incidence of cholera epidemic in Broad Street, London. 5 The title of strategy was changed to Health for All when the end of the 20th century approached.

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Indeed, the WHO continuously published numerous statements concerning the above strategy. These statements, the so-called Ottawa Charter of 1986, are considered the turning point from health education to health promotion (Dawnie et al, 1996). The movement from health education to health promotion in the UK occurred after the Ottawa Charter. In 1988, the Department of Health (DoH) published Public Health in England (so-called Acheson Report). In this report, the committee defined public health as the science and art of preventing disease, prolonging life and promoting health thorough organised efforts of society (quoted by Downie et al, 1996, p. 69). This means that health promotion is recognised, as a substantial and vital factor of public health which requires institutional collaboration. During 1990s, the idea of health promotion becomes a health policy in the UK. For example, the health of the nation strategy in England, accelerated the setting up of working groups and task forces to clarify the key concepts of health promotion, and led to variety of activities and resources. More recently, health promotion has been placed at the top of agenda of the National Health Service (NHS), requiring the active co-operation of national and local government, statutory and voluntary groups, and the wider community. The history of health promotion shows that the idea of health promotion was combined with other ideas related health, such as education and prevention, and requires multiple institutional and individual participation in order to approach its aims. This is because, as the history of health promotion reveals, improving health is impossible through the application of individual efforts alone, e.g. change of lifestyle and diet. It also requires institutional supports, e.g. improving sanitation, maintaining houses, social facilities and services. Because of its complexity for individuals and institutions, there have been

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developed a number of health promotion models, e.g. the Caplan and Holland model, the Beatitie model, the Frence and Adams model, the Tannahill model and the Tones model. These models attempt to clarify how health promotion should be understood within society (Naidoo and Wills, 1994). Among these, the Tannahill model is the most popular. This model clearly explained the relationship between health promotion, education, prevention and protection. According to Tannahill, health promotion is the combination of three factors, health education, health prevention and health protection (See Figure 2-1-1).

Figure 2-1-1: The Tannahill model of health promotion

Health education
5 4 3 2 6

2 Health 1 preventio n

7
Health protection

Source: Downie et al.(1996), Fig. 4.1, p.59

In the above figure, each circle is considered the position of the health promotion provider. Health prevention is based on the medical model, and therefore the provider of this health promotion is a clinician. Approaches to health promotion in the health prevention environment are mainly associated with clinical methods, e.g. immunisation, screening etc., which tackle health issues directly. Health education is promoted by health educators in order to improve peoples knowledge and practical attitudes. For this purpose, the provision of

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information concerning health issues is crucial. Facilitators of health protection are mainly policy makers. In this approach, health promotion is conducted through the setting of regulations or policies, e.g. setting environmental regulations. The approaches to health promotion are various in terms of the combinations of above three objectives6. One thing that is cleared from these discussions of concepts, and Tannahills model of health promotion, is that the whole idea and practice of health promotion is not directly related to the treatment of illness/diseases. It is, rather, indirect action towards reducing the risks of the causes of illness/diseases through individual and community improvements. Downie and co-workers (1996) explain that the aim of health promotion is to create a powerful force for change, and for this reason, health promotion stresses the importance of acquiring life skills (Downie et al., 1996, p.3). Peersman (2001) also notes that the role of health promotion professionals is only to facilitate the strengthening or building of such communities(Peersman, 2001, p. 6). Both authors agree that the most important aim of health promotion is, therefore, the empowerment of individuals and the community. Empowerment is a word which has been used by people who are involved in social development, at both the national and international level for a long time (DFID, 2000; Mayo, 2000). According to the Department for International Development (DFID), empowerment is defined as the power to think and act freely, exercise choice, and to fulfil their potential as full and equal members of society (DFID, 2000, p. 11). In order to enhance peoples

The combination of each factor of health promotion is as follows: 1: Preventive services, e.g. immunisatization, cervical screening, hypertension case finding, developmental surveillance, use of nicotine chewing gum to aid smoking cessation; 2: Preventive health education, e.g. smoking cessation advice and information; 3: Preventive health protection, e.g. fluoridation of water; 4: Health education for preventive health protection, e.g. lobbying for seat-belt legislation; 5: Positive health education, e.g. life skills work with young people; 6: Positive health protection, e.g. workplace smoking policy; 7. health education aimed at positive health protection, e.g. lobbying for a ban on tobacco advertising (quoted from Naidoo and Wills (1994), Figure 5.5, p. 98).

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empowerment, authorities and aid workers are required to provide and maintain appropriate services and systems, e.g. education, training etc., to people. These systems for empowerment reminds one of the Tannahills model of the field of health promotion. In light of this, one is able to suggest that services and education provided within health promotion is aimed at improving, enhancing and strengthening the potential power of communities (including individuals), this in order to cope with illness/diseases, and this avoid many of the risks of illness. This is not only a matter of changing attitudes and behaviours, but also changing perceptions and knowledge towards a specific health issues. Within the conceptual framework of health promotion, health promoters are required to understand not only the target populations health issues, but also many other elements, e.g. the social situation, cultural perspectives and so on, this in order to design an effective campaign programme, enhancing individual/community empowerment. Downie et al. (1996) explain the importance of understanding the target populations cultural and social situation with a discussion of values7. According to these writers, value is the foundation of ones way of thinking. As a member of society, human being refer to two sets of values in order to establish their attitudes and place within in a community: these are (1) personal values, i.e. self-determination, self-government, a sense of responsibility, self-development, and (2) social value, e.g. do not harm persons, help if you can, and act justly, also maximise utility. Health promotion is concerned with changing the target populations attitudes that are based on those values, this enables the empowerment of peoples coping skills in regard to health. The important point in the present discussion is that those values have been created

Their terminology, value, is almost same meaning of ethics. However, they prefer to use value to ethics because ethics is likely to suggest the unchangeable principles of hallowed tradition in medicine (see Dawnie et al., 1996, Chapter 9).

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through the relationship between a person and his/her community/society. As a consequence, health promoters need to know the target populations cultural and social situations in order to understand the source of their values, and thus, provide effective methods of enhancing empowerment for coping with health issues.

2-2 Use of concepts of health promotion in ethnic minority health promotion

The general concepts and aims of health promotion are consistent with the fundamental ways of approach to ethnic minority health issues. As noted in the previous chapter, many health issues in multicultural society are related to peoples social and cultural foundations. For example, Kwan and Bedi (2000) reported that the rate of tooth loss in old age among British Chinese was extremely high. This is partly because Chinese traditional belief says that having teeth in old age will eat away their childrens fortune, and bringing bad luck to the family; therefore, elderly Chinese are less careful about their oral health (Kwan and Bedi, 2000). This health belief and the consequences on this groups health can be explained within the value discussion outlined in the previous section. In terms of the perceptions of Chinese elders, their traditional idea concerning family fortunes are considered more valuable than their oral health (sense of responsibility in personal values), and therefore, their attitudes to oral health care is consequently poor. As this example shows, one needs to somehow approach and appeal to the social and cultural foundations of ethnic groups (namely values), this in order to (1) encourage ethnic minority groups to expose and take on board different perspectives on health, (2) to provide

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information on how to cope with health issues, and (3) to take actions in order to improve them. This is exactly the same meaning as that of empowerment. Empowerment is, indeed, recognised as a key issue and emblem among the UK and US officials in order to improve ethnic minority health (Chen, 1999). Through this discussion, one is able to say that the basic concepts and approaches of health promotion are consistent with the fundamental approach of ethnic minority health studies. The question to be addressed is, however, whether general health promotion theories and methodology based on concepts and approaches that seem to be consistent with a core discussion of ethnic minority health studies, can also apply to these ethnic populations. Leviton (1989) categorised the numerous theories, which have been developed and used in the health promotion field into five categories, these are as follows:

1: Cognitive and decision-making theories: the common idea associated with these theories is that heath behaviour can be changed by an enhancement of a specific health issue. Therefore, this approach should provide information and behavioural skills in order to recognise and to tackle the issue in question, e.g. the health belief model (Resenstock, 1974). 2: Learning theories: the idea behind these theories is based on the relationship between a person and the persons environment. It starts from the individuals action which contributes to creating the environment, and both the persons action and the created environment effect a change in the persons cognition, e.g. social leaning theory (Frankish et al., 2000). Health promoters provide the first step of the action and environmental setting in order to influence the individuals final cognition.

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3: Theories of motivation and emotional arousal: the idea behind such theories is that health behavioural change is expected to occur through a persons experience as they cope with a variety of tasks. In order to deal with these tasks (associated with internal/external demands), the individual is expected to exceed his/her resources, one such resource is the recognition and knowledge of a specific health issue. Health promoters set those tasks in order to provide a sequence of experiences, e.g. coping theory (Lazarus and Folkman, 1984). 4: Theories of interpersonal relations: these theories propose that health behavioural change will occur through a congress with institutional norms. An institution, by various means, pressurises its members to share in the institutional norms. As a consequence, the members are expected to be behaviourally consistent with those institutional norms. Health promoters set an institution (community, group etc.) as the first step of the promotion, e.g. reference group-based social influence theory (Fisher, 1988; Krohn and Thornberry, 1993). 5. Theories of communication and persuasion: the basic idea concerning these theories is focused on the methods of communication with target populations in order to change their behaviours. The final aim of this theoretical approach is to persuade audiences (target population) to take targeted action through the use of the most effective appeals, such as positive appeals to audience (McGuire, 1988).

These theories tend to be appropriated from other fields of knowledge, such as psychology, and have been tested as to their effectiveness in real world health promotion programmes. This empirical background indicates that, as long as psychological aspects are shared by all human beings, those theories related to human behaviours can be considered to be adaptable to any human beings regardless of ethnic differences. Indeed, many scholars adopt those theories into

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their health promotion projects. St. Lawrence et al. (1995), for example, used a cognitivebehavioural approach to an HIV/AIDS campaign for African-Americans in the USA. After the provision of an educational programme aimed at enhancing the recognition of HIV and its preventive methods to African American youth populations, their knowledge and attitude towards safer-sex was dramatically improved. Alcalay et al. (1999) also conducted their health promotion project in the USA by using a combination of theories in the field of health promotion, e.g. social learning theory, self-efficacy theory and social marketing theory etc., in order to improve Mexican-American populations awareness of cardiovascular disease (CVD), as well as changing their health behaviours (the SALUD PARA SU CORAZN Project). Because of carefully designed campaign methods, such as media advertisements based on marketing theory and community educational sessions based on social learning theory, the awareness of CVD risk factors and its preventive methods are improved. Through an appreciation of these examples, one overriding principle becomes clear, that the important point for the adaptation of those theories into ethnic minority health promotions is the choice of the most appropriate theory (or theories) for ones target population. For example, Alcalay and her co-workers conducted a feasibility literature research prior to planning the SALUD PARA SU CORAZN project, and found the necessity of close communication with Latino populations in the USA in order to facilitate a successful health promotion project. As a result, they chose appropriate theories and methods that would appeal/align with to the target populations sensibilities. In consideration of the above, it is possible to conclude that there are no specific health promotion concepts that are adaptable for all ethnic minority health promotions. However, it is possible to apply developed health promotion theories and concepts within ethnic minority

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health promotions. This is a recent coping strategy used by health promoters who are currently involved in ethnic health promotion.

2-3 Mass media and health promotion: an example in health promotion

If the conceptual backgrounds and approaches of ethnic minority health studies are reasonably consistent, how do methods for health promotion apply to ethnic minority health promotions? Methods of health promotion are not exhaustive because of the continuous growth and development of health promotion, as the history of health promotion shows. (Ewles and Simnett, 1999). However, Ewles and Simnett (1999) suggest six core competencies in health promotion: (1) managing (e.g. money), planning (e.g. effective and efficient health promotion campaigns), and evaluating (e.g. methods and approaches); (2) communicating; (3) educating; (4) marketing and publicising about a health promotion campaign or a core health issue; (5) facilitating and networking; and (6) influencing policy and practice. Among these competencies, the process of communicating and educating requires health promoters to have direct contact with promotion targets, and the choice of effective tools in this process. Methods of health promotion, especially communicating and educating vary greatly. However, one of the most popular communication tools among health promoters for these purposes is mass media (Naidoo and Wills, 1999). The relationship between mass media and health promotion (education) has been a long one. For example, Wallack (1981) described how the Womens Christian Temperance Union (WCTU) in the USA showed their commitment to the use of media in order to warn against the risks of drinking in the early

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1870s, media campaigns concerning drug use and smoking started at the beginning of the twentieth century (Wallack, 1981). In the UK, Naidoo and Wills (1999) write that the powerful effects of propaganda during the Second World War were influential in persuading health promoters to adopt a similar strategy (Naidoo and Wills, 1999, p. 241). There is no doubt that the increasingly sophisticated technologies of the mass media have become powerful tools in providing both information to the general public and keeping health issues on the public policy agenda. The most significant advantage of the mass media is its capacity to quickly establish channels of communication to large numbers of people (Ewles and Simnett, 1999). In the case of health promotion, this characteristic is particularly beneficial because the target populations in health campaigns are often likely to be both ill defined demographically and geographically scattered. For example, on the national level anti-smoking health campaign, it is difficult to estimate how many people are indeed smokers and how many smokers actually hope to quit smoking. On the other hand, there are some distinct disadvantages associated with media health campaigns. Such campaigns are less likely to provide immediate feedback from a mass audience when compared to other media programmes (Naidoo and Wills, 1999; Atkin, 2001). Because of the ambiguous feedback coming from media health campaigns, their effectiveness has been controversial despite its long history and popularity. Health promoters have used the mass media accepting its contradiction and suppressing scepticism about its effect because of its attraction in terms of communication. The study of the effectiveness of media health campaigns has been an important topic among health promoters ever since mass media began to be used for health promotion, but by the 1950s its effectiveness was already in question (Tones, 1993). In terms of the classical

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literature, Klapper (1960) noted that the conversion of public opinion through media communication was rare, although the media did contribute to the firming up of ones existing opinion. Liebert and Schwartzenbergs (1977) extensive literature review, which studied publications between 1970-1975, supported this. According to them, television might be effective in terms of attracting ones attention, but was not effective in terms of promoting behavioural change. Griffiths and Knutson (1960) also discussed the effectiveness of mass media in public health field, and agreed to its effectiveness in the provision of information, but were sceptical about any associated long-term behavioural change. Gatherer (et al. 1979) evaluated 49 studies of mass media health campaigns and detected evidence of their effectiveness in terms of health promotion. This effectiveness was likely to be observed in the specific target objectives. For example, they noted that small short-term effects (increasing levels) could be observed in the cases where the objective of the media health campaign was to improve knowledge among the target population. In the case of changes in attitude, some modifications were observable but not necessarily in the desired directions. Finally, if the campaigns aim was to change the target populations behaviour, the outcomes were very variable, ranging from no change to long-term change (Gatherer et al, 1979; Naidoo and Wills, 1994). In regard to the present case study, the effects of media health campaigns are also shown to be dependent on their campaign objectives. Because of the mixed results of media health campaigns, there is no strong conclusion to be drawn as to their effectiveness. Swinehart (1997) also considered the reasons behind this absence of any strong conclusion. According to Swinehart, thousands of media health campaigns have been conducted whose aims, costs, duration, access to media, themes or

21

appeals used, as well as target populations, are all highly variable. Each of these factors differs within each campaign. As a result, campaign functions also differ greatly. Naidoo and Wills (1994) tried to define the effectiveness of mass media in relation to health topics. They write, today we are further down the road of identify in what the mass media can and cannot achieve in health promotion (Naidoo and Wills, 1994, p. 269). According to the writers, it is generally agreed that:

1: mass media campaigns whose aim is the improvement of knowledge/recognition for health issues are likely to succeed; 2: a mass media campaign whose aim is to change attitudes towards health issue is likely to fail; 3: a mass media campaign whose aim is to change behaviours towards a health issue is unlikely to approach any satisfactory level of success.

The above definitions are almost coincident with the results of the previously discussed literature research. One could question why mass media health campaigns seem not to be significantly effective, especially in relation to attitude and behavioural change. One of the reasons might be found in the fundamental difference between mass media and health promotion in terms of notions of public health. Atkin and Atkin (1990) described those differences as the conflicts among the functions and goals of the mass communication and public health sectors (Atkin and Atkin, 1990, p. 15).

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Table 2-3-1 shows these conflicts between mass communication and public health. The most significant difference between the two sectors is their aims: mass communication aims to entertain audiences in order to make profits. On the other hand, health campaigns in the public health field aim to educate the audience in order to improve health conditions, profit is not a consideration.

Table 2-3-1: The conflicting priorities of mass media vs. public health institutions Mass media objectives Public health objectives To entertain, persuade, or inform To educate To make a profit To improve public health To Reflect society To change society To address personal concerns To address societal concerns To cover short-term events To conduct long-term campaigns To deliver salient pieces of material To create understanding of complex information
Source: Atkin and Atkin (1990), p. 16.

With reference to those diversities, mass media audiences are more likely to seek entertainment rather than education (unless they spontaneously seek educational information), and therefore they tend not to pay attention to serious heath messages2. As a result, the health message would tend not to have a strong impact upon the audiences health behavioural change. Indeed, Flay and his co-workers noted that regular television viewers to a specific programme were not motivated to change their behaviour (in this case, quitting smoking) through a special health promotion programme included within the regular show. Additionally, they confirmed that those regular television viewers who were actually motivated to quite smoking were not interested in seeking out health promotion programmes on their regular media channel (Flay et al., 1993). As we have seen the relationship between mass media and audiences is less likely to fit in with the aims of the public health field, it is

23

therefore difficult to produce a strong impact in order to change the target populations health behaviour through the use of mass media communication. Wallack (1981) suggested that there are two major components of a media health campaign whose aim is behavioural change; a theory or theoretical models for approaching their campaigns goal (i.e. behavioural change) and a method to achieve ones goal such as the message or the delivery of a message. He insisted that a point of failure of media health campaign might be the faulty relationship between these two components. His discussion contributes to an awareness of the necessity to apply mixed theories and methods from both the fields of mass media communication and public health education. For example, there are many theoretical models developed by behavioural scientists, e.g. the health belief model (Becker, 1974), Fishbein and Ajzens theory of reasoned action (Fishbein and Ajzen, 1975) and PRECEDE (Green et al., 1980). These models are very useful in designing campaigns that achieve the goal of behavioural change. At the same time, theories developed within mass media communication, e.g. the social marketing approach, are adaptable in order to consider the message delivery system within health campaigns (Wallack, 1990). However, there is still ambiguity in terms of designing an effective media health campaign due to the variety of theories and models available. Atkin (2001) also agreed with the two combined approaches in relation to media-based health campaigns, such a strategy development entails a sensitive application of mass communication theories and best practice campaign principles. Based on such ideas, he tried to develop strategies and guidelines for designing effective mass media health campaigns using a variety of theories concerning human behaviours. He pointed out the following six

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main factors which health promoters should consider in order to create an effective media health campaign:

1. Audience characteristics of target populations, e.g. accessibility to mass media; 2. Responses expected responses to a campaign from audience; 3 . Campaign messages the approach to expected responses, the most appropriate message context should be designed, e.g. containing awareness of the risks of the health issue, and persuading the audience to use precautions; 4. Channels - the approach the expected responses the most appropriate channels and types, e.g. radio advertisement, TV programme, newspaper articles, should be chosen; 5. Quantitative dissemination - to approach to expecting responses, the most appropriate quantity of message should be delivered, e.g. a 30 second radio commercial. 6. Message design - to approach the expecting responses, the most appropriate message delivery styles, e.g. one-side content, two-sides content8, and fear appeal, should be delivered.

Atkin introduced possible theoretical and methodological approaches to each of these factors in order to design an effective media health campaign. Atkinss contribution to the field of health promotion is that he showed how to use theoretical/conceptual models in the process of designing a health promotion campaign. Many scholars have already studied the impact of each of these factors upon health behaviour and

The style of one-side content is that a message will be delivered from a health promoter to target populations unilateral way through mass media, e.g. radio and TV commercial, newspaper advertisement. Two-side content is that a message and a response exchange between a health promoter and target populations through mass media, e.g. debate programmes.

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have created numerous strategies and frameworks to comprehend them. But these factors have not been systematically discussed in terms of the process of designing media health campaigns until the Atkins guideline. If, for a moment, we glance at the factors of message design, we can isolate various strategies, i.e. fear appeals which are effective in changing behaviours, but also contain the risk of the boomerang effect or the null effect produced by peoples defensive responses. On the other hand, positive appeals may effect people who have already imaged their desired behaviours, but will not effect those have not. Atkin developed these models which have been further advanced by the scholars mentioned in each section. This detailed guideline has been the most helpful in considering systematic campaign design so far9.

2-4 Use of mass media in ethnic minority health promotion

In spite of many issues of the use of mass media for major population health promotion campaigns, mass media is also a popular health promotion tool for ethnic minority health campaigns. Here one brings to mind the statement of Ewles and Simnett (1999). They note that the most significant advantage of the mass media for health promotion is its capacity to quickly establish channels of communication to large numbers of people who are often likely to be both ill defined demographically, and geographically scattered. In terms of the situation of ethnic minority groups, this is a huge advantage for conducting health promotion. Although the access rate of health services among ethnic minorities in the UK is higher than white

However, Atkin concluded that there still were no guaranteed methods to conduct a successful mass media health campaign.

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population, the patterns of use of those services are very partial in terms of ethnicity, age and gender (Nazroo, 1997). In addition to this, Nazroo (1997) noted that ethnic minority groups use a much reduced variety of health services than white populations. This means that ethnic minority groups are more likely to have potential numbers of people who have not received direct health information from the health service sectors, and that even those who access health sectors receive limited health information in regard to the specific service areas. Another advantage of mass media for health promotion is its variety: visual/verbal communication, such as TV and radio, are especially important in communicating with both the general population and specific communities which might have some difficulties in communication, the obvious example being illiteracy. This is why mass media have been commonly used for health promotion/education in developing countries where the illiteracy rate is normally very high. Withington and Samsujjoha (2000) gave their reason for choosing mass media (in this case, radio) for their health promotion in Bangladeshi as use of the mass media is limited by access but does not require literacy and possible increases authenticity of the message received (Withington and Samsujjoha, 2000, p.83). This statement indicates that the ideal usage of mass media for ethnic minority health promotion, even in multi-cultural industrialised countries. Communication barriers associated with language differences (mainly non-English speaking) among ethnic minority groups are often isolated as one of the major concerns for health services provision (Health Education Authority, 1994; Kwan, and Williams, 1998; Ewles and Simnett, 1999; Henley and Schott, 1999). This causes several problems among ethnic minorities in relation to accessing health services. The Health Education Authority (1994) revealed that ethnic minority groups, especially women, had a high requirement for

27

formal/informal interpreters at their GPs practice. Kwan and Williams (1998) also reported that Chinese communities in the UK were anxious about health practitioners (in this case, dentists) understanding of patients needs arising from poor communication, this situation causes poor accessibility to dental practices. These communication barriers are an important issue for ethnic health management. According to King et al., culturally appropriate and specifically targeted campaigns in community languages have been found to be effective in reaching their target groups (King et al., 1999, p. 104). At the same time, some health promoters have revealed that non-English ethnic minority groups in multi-cultural society are likely to use multi-cultural mass media as their major information sources especially the terrestrial tools (Alcalay et al., 1993: Bass and Kane-Williams, 1993; Ziga de Nacio et al., 1999; King et al., 1999). This is because of difficulties in understanding information in English, but also because of straight (an immediate) understanding of information both verbally and visually in their own languages. Alcalay and co-workers noted that multi-cultural messages provide ethnic groups with a crisper and more to-the-point feeling than the English translation (Alcalay et al, 1993, p. 361). These evidences are possibly suggesting that ethnic minority groups, especially among the first generation, are more comfortable in communicating with their own languages when it came to health issues. For the above reasons, health promoters focus on mass media as a preferable tool to deal with communication barriers because of its easy adaptability to various languages. Through this discussion, we can see that characteristics of mass media are, at least, useful in solving some concerns of ethnic minority health promotion. Further, generally developed health promotion methods are considered to be usable for ethnic minority health

28

promotion. However, mass media use for ethnic health promotion campaigns has not been developed with the support of those with theoretical backgrounds, but by empirical data in relation to ethnic minority groups.

2-5 Conclusion and further questions

This cross-border discussion between health promotion theory, concepts and method for general population and ethnic minority communities revealed that there are no specific theory, concept or methodology applicable to ethnic minority health promotion. Recently theories and methodologies for ethnic minority health promotion campaigns have been adopted from the field of health promotion. The concept of health promotion and an approach to ethnic minority health study are consistent, and the most popular health promotion method, mass media use, is also suitable for solving communication problems with ethnic minority groups. Are these facts, however, enough to resolve our question? Through this discussion, it was indicated that ethnic minority health promotion methods have been developed through the adaptation of selected objectives, e.g. communication problems from the existing theories and methodology. In other words, those styles of campaign design and delivery seem to be only temporary solutions for ethnic minority health campaigns, and they do not contribute to the development of guidelines for future ethnic minority health promotions. Further, there is no critique adaptable to the general health promotion methods for ethnic minority health promotion. Is it reasonable to conclude

29

that general health promotion guidelines, especially mass media use, are suitable to ethnic minority populations? In the next section, we will examine this question, and discuss the problems of the adaptation of general health promotion methods into ethnic minority health problems.

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Chapter 3 Mass media health promotion campaigns for ethnic minority groups: a discussion in relation to real-world research

The previous chapter discussed the consistency/inconsistency of existing health promotion concepts and methodologies in relation to ethnic minority health promotion. This chapter develops this discussion in a more practical way through the analysis of data from a mass media health promotion campaign for ethnic minority groups. Because of the absence of an actual text/paradigms for designing and conducting mass media health promotion campaigns (especially in regard to ethnic minority groups), many researchers have planned and developed their campaigns with reference to previous similar campaigns. As a result, there has been no exemplar study that is based on these campaign results. Consequently, references used for feasibility studies in each campaign vary, and have not contributed to develop the general accumulation of data concerning mass media health promotion campaigns. When trying to consider health promotion campaigns that use the mass media in relation to the UK, one is confronted by the fact that the numbers of references are very limited. In terms of a database search and intensive manual literature research between 1983 to 2002, only a few articles concerning ethnic minority health promotion were available. Added to this, the actual numbers of ethnic minority health promotions have been quite scant, this can, perhaps, be associated with its short history (as discussed in Chapter 1). All in all, at this time it is very difficult to discover specific guidelines concerning ethnic minority health promotion using mass media in the UK. However, there are numerous ethnic health media campaign reported in other multicultural societies in other parts of the world, for example, in

31

the United States of America, Australia and Canada. These countries all share similar historical backgrounds and recent migratory developments in ethnic minority groups. It is beneficial to consider the experiences of these countries. The aim of this chapter is to review published studies, not only in the UK, but also throughout the world, and to examine how actual ethnic minority media health promotion campaigns were planned, conducted and executed. Further, this chapter aims to develop the missing guideline for the design and implementation of health promotion for ethnic minority groups.

3-1 Review process and methodology Review objectives

Objectives of this literature review are:

To develop a process of designing and conducting mass media health promotion campaign for ethnic minority groups;

To clarify conceptual backgrounds of actual ethnic media health campaigns; To identify way of use of mass media within a health promotion campaign; To examine the effectiveness of those campaigns.

The end of this discussion will draw a brief guideline for a media ethnic health promotion campaign.

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Materials for this review

Adopting a part of systematic literature review technique, an initial data base search was conducted. MEDLINE, Cambridge Scientific Abstracts (CSA), J-STOR and Elsvier Science Direct were the main sources of this search. After several key word search (e.g. ethnicity and health promotion, ethnicity and media health promotion), it was revealed that the total numbers of materials were very limited. Therefore, a manual search was added on the data base resource.

Inclusion/exclusion criteria

Only the following types of study were included: Studies that were based on an actual ethnic health promotion campaigns (e.g. exclusion of review articles); Studies which used mass media as an information source to ethnic target populations; Studies that were conducted in a multicultural society whose major population is white.

Data extraction

First data extraction was conducted in abstraction form, data was sought that fulfilled the above criteria, and a full text was used for data collection and analysis. Further the following 8 categories of data were extracted:

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1: Campaign date and place; 2: Campaign or promotion aim; 3: Campaign target ethnic minority group(s) and where possible, their sociogeographical backgrounds; 4: Type of media used and its usage within the campaign; 5: Other campaign methods in use; 6: Whether the used media is a main tool of the campaign; 7: Evaluation methods for the campaign; 8: Results of the campaign.

3-2 Results

A total of 47 possible literatures were selected. In terms of the check up, and the data extraction criteria above, the following 12 articles were examined.

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Table 3-2-1: Articles for review Title of article and published date (Chronological order) Cost-effectiveness of a community antismoking campaign targeted at a high risk group in London (2002) Promoting early detection of breast cancer among Vietnamese-American women (2001) SALUD PARA SU CORAZN: A communitybased Latino cardiovascular disease prevention and outreach model (1999) Effect of a media-led education campaign on breast and cervical cancer screening among Vietnamese-American Women (1999) First Aid for Scalds campaign: reaching Sydneys Chinese, Vietnamese, and Arabic speaking communities (1999) Community-based interventions to improve breast and cervical cancer screening: results of the Forsyth County Cancer Screening (FoCaS) Project (1999) Promoting health in African American populations (1999) Pretesting Spanish-language educational radio messages to promote timely and complete infant immunization in California (1999) Recruitment Strategies in the womens health trial: feasibility study in minority populations (1998) Evaluation of a pilot study for breast and cervical cancer screening with Bradfords minority ethnic women; a community development approach, 1991-93 (1996) Can health education increase uptake of cervical smear testing among Asian women? (1991) Promotion of breast-feeding in a Chinese community in Montreal (1983)
Source: Author

Author(s) Stevens, W. et al. Nguyen, T. et al. Alcalay, R. et al. Jenkins, C. N. H., et al.

Campaign or promotion place Camden and Islington (London), UK Alamada County control) Los Angels, Orange County, USA Washington D.C., USA Santa Clara and Alameda (intervention), Orange country (control), CA, USA Sydney, Australia Winston-Salem and Greensboro, NC, USA

King et al. Paskett, E. D. et al.

Wingood, G. M. Ziga de Nacio, M. L et al. Lewis, C. E. et al.

The Bayview-Hunters Point, San Francisco, USA California, USA Atlanta, Georgia, Birmingham, Alabama and Miami, the USA Bradford, UK

Kernohan, E. E. M.

McAvoy, B. R. and Raza, R. Chan-Yip, A. M. and Kramer, M. S.

Leicester, UK Montreal, Canada

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3-2-1 General observation

The majority of promotion programmes were conducted in the USA followed by UK (3 out of 12), Australia and Canada. Those countries are well-known multi-cultural societies. Moreover, the numbers of new migrant have been increasing in recent years. Although campaign topics vary, cancer, especially cervical and breast cancer, and related campaign programmes were the most active (See Table 3-2-2). The choices of those topics was based on the results of numerous medical reports. In many cases, the targeted health issue is more significantly observable among the targeted ethnic minority groups than the major white populations. For example, Paskett et al. (1999) cited that:

Breast and cervical cancer account for one-third of new cancer cases and 18% of cancer deaths among women in the United States. The impact of these cancersis greater among older, low-income, and minority women. (Paskett et al., 1999, p. 453)

Similarly, Kings and co-workers showed the high admission rate for emergency services among ethnic minority groups in comparison with major white populations as follows:

In 1996, Nguyen found that, between 1991 and 1995, 33% of children admitted to Sydneys Royal Alexandra Hospital for Children came from families of a non-English speaking background. This supports 1990-91 data from the NSW Childsafe surveillance system that showed at least 37% of children admitted to emergency services in participation paediatric hospital came from homes where a language other than English was spoken. The highest numbers were form families speaking Vietnamese, Chinese, and Arabic language. (King et al., 1999, p. 104).

Almost all other reviewed work showed a similar comparison between migration groups and major minority groups.

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Table 3-2-2: Campaign topics for ethnic media health promotion Campaign topics Number of articles Cancer (breast or/and cervical cancer) 6 Smoking 1 Scalds (First aid) 1 Cardio vascular diseases (CVD) (dietary) 1 Breast feeding 1 HIV 1 Infant immunisation 1 Total 12
Source: Author

Ethnic groups as target populations were also different: black (African) was the most targeted group, followed by Chinese (See Table 3-2-3). In terms of the sex of the target populations, females were more targeted (8 campaigns out of 12) than males (none). Only 4 campaigns targeted both sexes. The result is understandable because of the speciality of campaign topic, e.g. breast and cervical cancer screening or breast-feeding.

Table 3-2-3: Targeted ethnic minority groups and sex* Ethnic groups Male Black African - ** Caribbean Chinese Hispanic (including all Spanish speaking groups) Vietnamese Bangladeshi Pakistani Turkish Arabic Non-Hispanic white Eastern European Others -

Female 4 1 2 1 2 1 1 1 1 1

Both 1 1 2 1 1 1 -

* Some campaign programmes targeted multiple ethnic groups. In this case, all targeted ethnic groups were counted. ** N/A Source: Author

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The objectives of the campaigns showed several similar patterns. As well as many other health promotion campaigns, the majority of reviewed campaigns aimed to raise the awareness of the campaign topics or related objects (Pattern 1), e.g. knowledge of immunisation (Ziga de Nuncio, 1998); knowledge of first aid treatment for scalds (King et al., 1999); recognition of clinical breast examination (CBA), mammography and breast cancer (Nguyen et al., 2001). Another common campaign aim is to change the target populations attitudes (Pattern 2). As attitude change needs to be supported by peoples recognition towards a campaign topic, some campaigns aimed to improve peoples recognition towards a targeted health issue as well as to change peoples attitudes towards the targeted health issue. For example, Alcalay and co-workers aimed to increase Latinos awareness of heart diseases, and then, they expected to lead the target population towards having healthy lifestyles (Alcalay et al., 1999). Further, some of the campaigns aimed at encouraging the target populations to take a specific action (Pattern 3), e.g. to improve the cervical smear attendance rate among Asians (McAvoy and Raza, 1991); to encourage female African-Americans to go to take cancer screening tests (Paskett et al., 1999); to improve breast-feeding rate (Chan-Yip and Kramer, 1983). This pattern is also combined with another campaign aim, namely to increase knowledge or recognition concerning a specific topic (Pattern 1+3), e.g. improving knowledge of cervical cancer and attendance at screening (Kernohan, 1996); to raise awareness of cancer screening and to improve rate of annual checkups and cancer screening attendance (Jenkins et al., 1999). Additionally, these objectives were sometimes conflated in one campaign (Pattern 1+2+3), e.g. to improve knowledge of HIV and safe use with a condom, to change attitude to female domination in the relationship, and finally to encourage condoms usage (Wingood,

38

1999); to raise awareness of risk factors of smoking, to enhance individual concern to smoking, and finally to reduce the prevalence of smoking (Stevens et al., 2002). Lastly, campaign programmes are sometimes used for recruiting participants for medical/health research, or for future health promotion campaign (Pattern 4), e.g. recruiting strategies (Lewis et al, 1998). This aim is similar to Pattern 3 in the sense of encouraging people to take some action. However, it was separated in this study because the content of information in the campaign were slightly different10 (See Table 3-2-4).

Table 3-2-4: Aims and goals for campaigns Campaign aims Pattern 1: to improve knowledge/to raise awareness Pattern 2: to change peoples attitude Pattern 3: to encourage people to take an action Pattern 1 and 2 Pattern 1 and 3 Pattern 1, 2 and 3 Pattern 4: to recruit Total
Source: Author

Number of articles 3 0 3 1 2 2 1 12

The results show that the aims of health promotion campaigns for ethnic minority groups are not particularly different from those of general health promotion campaigns for the major population. Specific topics in health promotion campaigns are repeated because of the high prevalence of those health issues among ethnic minority groups, e.g. the high prevalence of cardio vascular disease (CVD)11, and breast and cervical cancer.
12

Many of the campaigns

were launched because of higher prevalence rate of a specific health topic, or lower awareness

10

For example, the campaign in the Pattern 3, information for target populations are more related to risks of illness/disease although the participant recruiting campaign is likely to emphasise the importance of the study and participants contribution for this. 11 In the UK, high prevalence of CVD is observed among Asians rather than Latinos (Nazroo, 1997). 12 This is equally a severe problem among white populations in either the USA or UK.

39

rate of risk factors than those of the major white populations. For example, Alcalay et al. explained the background of their project;

Epidemiological studies show that Latinos over 64 years of age, particularly older Latino women, are much more likely to die of heart disease than Latinos between the ages of 45 and 64Latinos are at high risk for many factors associated with CVD. Cigarette smoking, excessive alcohol use, obesity and diabetes are among Latinos most prevalent risk factors (Alcalay et al., 1999, P. 360).

Kernohan (1996) also noted the reason for launching his project;

There was local concern in Bradford amongst health professionals that, as elsewhere, the response rates for cervical and breast cancer screening were significantly lower than in the white population (Kernohan, 1996, P.S42).

These examples indicate that the topics of ethnic health promotion campaigns are likely to be chosen after a comparison with the prevalence rate of the relevant issue among the major white populations. One significant point revealed by the summary of campaign aims is that the majority of campaigns contained the central aim of improving the populations knowledge, awareness or recognition of a specific topic. Many of the campaigns blamed language barriers for the lack of topic penetration. For example, Chan-Yip and Kramer write that because of social isolation and language barriers, many Chinese women are not even aware of community resources such as prenatal classes and groups that promote breast-feeding (Chan-Yip and Kramer, 1983, p. 957). The same type of lack of awareness among Asian women in Leicester was pointed out by McAvoy and Raza (1991). King and his co-workers (1999) also discussed the high prevalence of child scalds among ethnic minority in Sydney. This was associated with poor negotiation skills with English-speaking landlords regarding the improvement of hot

40

water facilities. Additionally, they write that Arabic groups indicated that information adjusting the temperature of hot water systems was not easily understood or relevant (King et al., 1999, p. 105). In terms of the lack of primary information, the majority of designs for ethnic health promotion campaign started by providing sufficient information to the target populations. This is strongly related to the next step of campaign design, the

conceptual/theatrical background of health promotion for ethnic minority groups.

3-2-2 Conceptual/theoretical backgrounds

There are very few articles that clearly mention the conceptual/theatrical backgrounds of the campaigns (Kernohan, 1996; Alcalay et al., 1999; Paskett et al., 1999; Wingood, 1999) (Table 3-2-5). It is difficult to prove whether other campaigns referred to any concepts or theories of health promotion. However, many of them seem to design and to plan campaigns based on previous research or other health promotion programmes. This point will be more clearly shown in the next discussion which concerns mass media use.

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Table 3-2-5: Adaptation of concepts and theories Campaigns Adopted concept and theory Breast and cervical cancer screening study A community development approach (Kernohan, 1996) SALUD PARA SU CORAZN (Alcalay et SALUD PARA SU CORAZN Model (an original al, 1999) model specially developed for the Latino target population based on social leaning theory, selfefficacy, planned behaviour ) The Forsyth County Cancer Screening -PRECEDE/PROCEED model13: for planning (FoCaS) Project (Paskett et al., 1999) -the health belief model: for identifying and addressing barriers -social learning theory: for using lay health educators to enhance a sense of self-efficacy of target populations -the PENIII model14: for incorporating cultural appropriateness an sensitivity The HIV Prevention Programe (Wingood, -Social cognitive theory: for developing and refining 1999) target populations skills in self-motivation (e.g. condom use during sexual intercourse) - the theory of gender and power: for understanding of the social factors that increase womens vulnerability to HIV.
Source: Author

Alcalays SALUD PARA SU CORAZN model was developed using a variety of concepts and theories in the field of health promotion including communication and health behaviours models, such as social marketing theory. The most significant point gathered from this summary is that the three projects use multiple theories and concepts for their campaigns, the exception being Kernohans work. He developed his educational strategy based on a community development approach. In the process of developing a community, participants for this project, including women from ethnic
13

The PRECEDE/PROCEDE model is a health education /promotion framework. The PRECEDE model requires health promotion planners to plan the desired final outcomes of the planning, and to identify the possible cause of the outcomes. The five-stem framework requires the health promotion planner to systematically check all of the important factors in prior to the campaign. The PROCEDE stand for Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development. This model suggests four more steps to diagnose a process of a campaign design in addition to the PRECEDE model (for more detailed explanation, see Kline, 1999). 14 The PENIII model is a health education/promotion planning model. PEN stands for Person, Extended family, Neighbourhood. This model requires to planners to be more aware the cultural sensitivity on the health education/promotion planning (for more detailed explanation, see Kline, 1999).

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minority communities, community leaders and health professionals, identified their community priorities for improvement. To this list of the community priorities, the campaign team added breast and cervical cancers, and set up discussion meetings concerning how to improve awareness of those diseases. Through this activity, he tried to approach his campaign objectives, i.e. raising the awareness of the risks of those cancers, and the value of cancer screening, and to improve attendance rates for screenings. Although he described only one approach, his adoption of a community development method into his project includes the social learning process. In addition to this, the face-to-face contact with health practitioners within community development work provided non-professional ethnic women opportunities to ease their fears of health practitioners. This type of fear is commonly observable phenomenon among ethnic minority groups. In three other projects, concepts/theories were used for each different objective within the campaigns. These were carefully designed in order to achieve their final aim. For example, the Forsyth County Cancer Screening (FoCaS) Project (Paskett et al., 1999) aimed to encourage people to undergo cancer screening tests. In order to achieve this aim, the project team tried to identify barriers in accessing screening tests using the health belief model; then, the team involved lay health educators in order to enhance the target populations sense of self-efficacy. This was done as a preparation for behavioural change based on the self-learning theory. Finally, they set up suitable service environments associated with the PEN III model in order to accept those recruited populations. Wingwood (1999) also used social cognitive theory in order to raise target populations knowledge and attitudes in relation to HIV and its prevention. Additionally, he used social theory in order to raise the womens perception of

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responsibility in sexual relationship in order to support their behavioural change, in this case, condom use. These examples indicate that a design for a health promotion programme is not a simple process, and requires a variety of considerations in regard to each campaign objective. For example, Wingwood studied the nature of sexual relationship among African-Americans prior to this campaign, and found that the target populations were likely to be passive in regard to use of contraception methods because of poor knowledge and self-motivation within maledominated cultural background. Because of this, he decided to adopt social cognitive theory in order to enhance their knowledge and self-motivation as well as to encourage their selfefficacy based on the theory of gender and power. The common point which emerges in these four projects is that the project team studied the target population in detail prior to the design of the campaign, and chose theoretical/conceptual model very carefully in terms of each object that was needed in order to clear the process of the health promotion project (as the Wingwood example above shows). The advantage of this detailed design and planning based on concepts/theories is that it is easy to define the effect of the selected concept/theory upon the target object. For example, Paskett et al. (1999) reported a significant increase in both mammography and Pap smear screening attendance rate associated with positive change of beliefs, barriers and knowledge concerning those screenings. This result indicates that the health belief model and the social learning theory provided an effective direction for this project. In the case of the HIV Prevention Programme by Wingood, the programme had two separated phase: the first phase was so-called the HIV education programme whose aim was improving participants knowledge of HIV/AIDS; the other was so-called the HIV intervention programme which

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teach and improve survival skills in various fields to prevent HIV infection, e.g. how to use condoms, how to be involved in healthy relationship without any risks of infections etc.15 According to Wingwoods report, the participants for the whole programme were twice as much as use condoms than those who joined merely the first education programme. The first programme was designed with reference of the social cognitive theory; and the HIV intervention programme was planned in terms of the theory of gender and power. Although it indicates the weakness of the theory of gender and power for encouraging an action, it does suggest to re-think an application of different theory/concept in order to improve his campaign. Through this discussion, it can be seen that use of multiple conceptual/theoretical backgrounds provides several components within a campaign, and provide a simple procedure that can be applied in order to alter unsuccessful components of the campaign.

3-2-3 Use of mass media: reasons and usage within campaigns

In Chapter 2, we discussed the major reason for mass media use for ethnic minority health promotion, this can be defined as breaking communication barriers which are commonly observed among ethnic minority groups. Indeed, many of reviewed studies described their reasons for choosing mass media, as a tool for their promotion campaigns, was the high success rate in achieving the target populations attention. For example, Kings et al. noted that:

15

It is also called the skilled education.

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 English language mass media campaigns have been found to have limited reach and recall in groups with a non-English speaking backgrounds, who comprise almost one third of the populations of Sydney. However, culturally appropriate and specifically targeted campaigns in community language have been found to be effective in reaching their target groups (Kings et al., 1999, p. 104)

Alcalay et al. (1999) also writes that a key stumbling block to informing Latinos about heart healthwas the absence of appropriate bilingual materials (Alcalay et al., 1999, p. 367). Minority groups are likely to have difficulties in fully understanding the contents of information given in English. Moreover, even if they do understand the English contents, the impact of information in English is less forceful than in their mother tongue (Alcalay et al., 1993). Therefore, minority communities seem to be more likely to reach for ethnic language media sources for information. For example, Zinga de Nuncio et al. showed that the access rate towards ethnic language mass media among Spanish-speaking communities was high. They reported that 99% of persons who listened to Spanish-language format stations were Hispanic, (and) 58% of listeners who preferred Spanish-language stations were women (Zinga de Nuncio et al., 1999, p. 270). Moreover, the same research result reported that those who listen Spanish-language radio stations listened Spanish-language radio sessions 17 minutes longer than for the overall average listening sessions for any other radio format. These evidences introduced sufficient support evidences for choosing mass media as a campaign tool. In addition to this major reason, some of the campaigners reviewed simply focused on the positive characteristic of mass media for health promotion campaigns, namely its impact upon larger populations. For example, Zinga de Nuncio et al. noted that:

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One widely used approach to public health education is mass media, which has the potential to reach a large target audience. When coupled with other community immunization activities, mass media is a potentially useful tool in promoting immunization. (Zinga de Nuncio et al., 1999, pp. 269-270).

Jenkins et al. (1999) also mention the high success rate of media-led interventions in the previously mentioned promotion campaign for breast and cervical cancer screening, this is because of the wider penetration into target populations by mass media. From this discussion, one is able to put forward the following: that the majority of mass media health promotion campaigns for ethnic minority groups chose mass media as a campaign tool because of: (1) enhancing understanding of health message for ethnic target populations; and (2) reaching target populations more widely and effectively. Once health promoters choose mass media as a campaign tool, the next phase of designing and planning a health promotion campaign for ethnic minority groups is the choice of implementation of those tools. There are a several patterns of use of mass media: (1) the use of single mass media tool; (2) the use a few mass media within a campaign; and (3) the use of several methods, including mass media, within a campaign. Among the reviewed campaigns, only one campaign used a single mass media tool (Ziga de Nacio, 1996). The most common usage is several mass media tools at the same time, e.g. TV, radio, booklets and video (Alcalay et al., 1999), or a combination of mass media and other methods, e.g. newspaper, TV and radio advertisement and community education sessions (Ngyen et al., 2001) (See Table 3-2-6 for other patterns). Table 3-2-7 shows the summary of the commonly used mass media tools. Electronic mass media (e.g. radio, TV, video) is a very popular tool. Among these electronic mass media, radio is more popular than other two. The popularity of electronic media is understandable because of the high rate of illiteracy among ethnic minority groups, especially the older generation and women (McAvoy and Raza, 1991).

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There were two ways of using electronic tools: one is through advertisement; and the other is referral. Referral indicates both news coverage and references within a broadcast programme, including interviews. Referrals are a more indirect approach than advertisements when considering the target populations. This is because this type of use of mass media normally relies on the media companies preference for campaign target topics. It includes the risk of failure of a campaign. For example, Stevens et al. (2002) used newspaper coverage for their main campaign tool, in this case, a Turkish play. Fortunately, for the research team, newspaper articles repeatedly gave positive comments and reviews concerning this play (31 articles were published during the campaign period), and therefore, many people came out to see it. If those comments had of been negative, it could have been very difficult to encourage people to see this play. Obviously this would have adversely influenced the positive campaign result. Moreover, occasional radio talk shows by a paediatrician in the Chan-Yip and Kramers project pushed her target population to attend the parental counselling organised by health practitioners (Chan-Yip and Kramer, 1983).

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Table 3-2-6: Ways of use of mass media within campaigns Brief campaign name and authors Used media and methods Community anti-smoking Campaign in Radio advertisement, London (Stevens et al., 2002) Newspaper articles, Posters Breast Cancer campaign among VietnameseNewspaper articles, TV American women (Ngyen et al.,2001) and radio advertisements.

Other method A play ()* Community education sessions, Vietnamese physician education, Distribution of written materials - ** -

SALUD PARA SU CORAZN campaign (Alcalay et al., 1999) Breast and cervical cancer screening campaign among Vietnamese-American Women (Jenkins et al. 1999) First Aid for Scalds campaign (King et al., 1999)

The Forsyth County Cancer Screening (FoCaS) Project (Paskett et al., 1999) Promoting health (HIV) in African American populations (Wingood, 1999) Infant immunization Campaign (Ziga de Nacio et al., 1999) Recruitment Strategies in the womens health trial (the WHT:FSMP) (Lewis et al., 1998) Breast and cervical cancer screening project within Bradfords minority ethnic women (Kernohan, 1996) Cervical smear testing campaign among Asian women (McAvoy and Raza, 1991) Promotion of breast-feeding in a Chinese community in Montreal (Chan-Yip and Kramer, 1983)
* (): the main campaign tool. ** Not mentioned. Source: Author

TV advertisement, Radio programme, video, booklets Booklets, newspaper articles and advertisements, billboard, brochures, posters, TV, video Radio advertisement and programmes (community representatives interviews), newspaper advertisement and articles in health section, posters, newspaper articles Brochures, public bus advertisement, newspaper and radio advertisements Public street advertisement, video Radio advertisement TV, radio, magazines and newspaper advertisements (both paid and unpaid), brochures Posters, leaflets, newspapers articles and radio referrals Video, leaflet and fact sheets Occasional radio talk shows by a paediatrician

Free party, church meeting programmes, community and individual educational sessions, birthday cards Five sexual risk reduction group sessions () Mass mailing, presentation at churches, referrals from physicians Workshop () Home visit () Parental counselling, discussion groups in church and community meeting

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Table 3-2-7: Media tool Radio TV Newspaper

Commonly used mass media tools Numbers of campaign used this tool Advertisement Referral (programme, news coverage) Advertisement Referral (programme, news coverage) Advertisement Referral (programme, news coverage) Advertisement 6 3 4 0 4 4 1 4 4 3 4

Magazine Video Printed advertisement (e.g. posters) Street advertisement (e.g. billboard, public bus ad. Etc) Printed materials (e.g. brochures, booklet, leaflets, fact sheet)
Source: Author

The media advertisement as a campaign tool can be divided into two types: the first provides direct information concerning a target health topic; the second providing information concerning the main campaign tool, e.g. information about a Turkish play (Stevens et al., 2002); or the availability of screening tests (Kernohan, 1996). In the first type of media use, information content is more likely to contain information about the risks of the targeted health issues, or information on prevention against these issues, e.g. the availability of health services. As this is part of the main tool for the campaign, campaigners carefully designed the style of information delivery in order to fulfil purposes; namely to attract the target populations attention, and also to educate them (or sometimes, to encourage people to take action). For example, Ziga de Nuncio et al. (1999) made a Spanish radio advertisement (jingle) to provide information concerning periods of child vaccination. In order to attract peoples attention, and to make the information more memorable, they adopted a familiar Latin American nursery rhyme. The contents of the rhyme are as follows:

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Spokesperson: Tiene un beb recin nacido? Vacune a su beb el 2, 4, 6, y a los 12 y 15 meses Musical lyrics: Cos y dos son cuatro, cuatro y dos on seis, seis y seis son doce, y quince meses son (translation to English: (Spokesperson) Do you have a newborn baby? Immunize your baby at 2, 4, 6, 12 and 15 months (Musical lyrics) Two plus two is four, four plus tow is six, six plus six is twelve, and fifteen months are all) (Ziga de Nuncio et al., 1999, p. 272)

As this example shows, this type of use of mass media requires careful consideration of both quality, and information delivery style. This is because many campaigners demand for the efficacy of mass media16. The second type of media message is, in some sense, the same as the first. This type of message also expects to raise peoples awareness of the campaign and its campaign tool, e.g. community meeting, screening monitor discussions, and encourage them to take action, e.g. attending a meeting. The difference between this type of message from the first one is that the former emphasises the rewards for participants rather than the risks of the targeted health issue. This is more a commercial marketing technical than a pure health promotion campaign technique. For example, Paskett et al. (1999) included a community meeting, the so-called Womens Fest, within their campaign. This is a free party, including food and prizes, as well as other diabetes educational classes and the examination of blood pressure. Naturally, their media message included the information for these events in order to raise attendance. In a similar case, the campaign conducted by Wingood (1999) promised to provide a 10 reward for those participants who completed educational sessions in relation to HIV. Another important point that emerged from this review is that many campaigns introduced both the ethnic language of the target population and English (the main language in

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the country in which the campaign was conducted). This finding seems to be in contradiction with the reasons for the use of mass media, i.e. language barriers among ethnic minority groups for English communication. Indeed, McAvoy and Raza (1991) reported that the majority of their target populations reported that the campaign materials translated into their own language, e.g. Gujarati, Punjabi, Urdu, Hindi and Bengali, were easier to understand. However, 34% of their ethnic minority target populations preferred English written materials rather than ethnic language written sources. This finding suggests that campaigners should consider the diversity of social, economic situation or generations within the same ethnic group, and therefore their communicable language. For example, South Asian ethnic groups are now reaching the third or fourth generation who were born and educated in the UK. Their language skills are quite different from either older generations or the newly migrated. The result of McAvoy and Razas work suggests the necessity for providing bilingual language materials for a health promotion campaign in multicultural industrialised countries, such as USA, UK and so on.

3-2-4 Evaluation methods

The evaluation process is one of the most important parts of a campaign. However, as some scholars have noted, it is common that many campaigns do not include evaluation studies within health promotion strategy. As a result, it is difficult to accumulate data concerning the effectiveness of health promotion (Swineheart, 1997). In spite of general criticism concerning

16

There are many conceptual support for designing the content of media advertisement for health promotion campaign. For example, Fear appeal, entertainment approach (See Atkin and Atkin, 1990).

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lack of evaluation, reviewed campaigns in this study showed that quite many campaigns conducted the campaign evaluation. The types of evaluation methods vary, but many of them use a single evaluation method (Table 3-2-8). Only a few campaigns used multiple methods of evaluation. Alcalay et al. (1999), for example, used formative methods during programme planning for identifying community needs, messages and communication strategies. Summative evaluation was used for detecting changes in awareness in regard to cardio vascular diseases (CVD) risk factors, knowledge of CVD prevention and so on. In addition to these methods, surveys were conducted to introduce measurements in terms of evaluation effects of the campaign. Kernohan (1996) also used qualitative methods (discussion and focus groups) in order to examine the result of main quantitative evaluation result.

Table 3-2-8: Evaluation methods Evaluation method Pre/post survey Pre/mid/post survey Pre/post interview Post survey (comparative study) Formative evaluation Summative evaluation Discussion and focus group
Source: Author

Numbers of campaign used this method 7 1 1 2 1 1 1

The most popular evaluation method is the pre/post survey method. In this case, there are some patterns of choice for sampling numbers: the first is using the same sample population for both pre/post surveys; the second is using different sample populations between pre and post surveys. The second sampling method seems to be less accurate statistically. However, there are a few obvious reasons for campaigners using this sampling method. For

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example, Stevens et al. (2002) described the difficulties in tracing the participants of the presurvey after the end of the campaign because of the high mobility rate within the Turkish communities in the UK. Indeed, they could only trace 47% of the formally interviewed people, and therefore had to recruit new participants post campaign. To avoid missing sampling numbers between pre and post surveys, Chan-Yip and Kramer (1983), McAvoy and Raza (1991) and Ziga de Nuncio et al. (1999) used a comparative study, only using the postsurvey method. Chan-Yip and Kramer divided their sampling into controlled and uncontrolled groups, namely counselled and un-counselled groups, and compared the effect of the campaign with the use of the chi-square test. Similarly, McAvoy and Raza compared the effect of their campaign with the use of two different groups in terms of used campaign methods, e.g. leaflet group and video groups. The results were analysed by the same statistical test as Chan-Yip and Kramers. In the case of Ziga de Nuncio et al., they compared two radio advertisements after their pilot campaign, rather than human groups. This is because their campaign aim is to develop an effective radio message concerning child immunisation. These comparative studies may not accurately prove the effectiveness of a campaign itself, but would contribute to show how the campaign tool would be effective in its public reception. Some of the campaigns did not clearly describe the type of sampling populations, i.e. whether they interviewed the same individuals between the pre/post survey (Kenohan, 1996; Jenkins et al.; Paskett et al., 1999; Nguyen et al., 2001). However, generally speaking, sampling numbers between the pre and post survey were relatively close, and this would not cause sampling bias. These three cases also applied a comparative study between controlled and un-controlled groups in addition to pre and post survey. In terms of showing the effectiveness of a campaign, the latter cases, i.e. Kenohans, Jenkinss and Pasketts, are more

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appropriate than cases of a single comparative study, i.e. Chan-Yip and Kramers, McAvoy and Razas and Ziga de Nuncios. The combination of pre/post survey within two different groups show clearer results of both the effectiveness of the campaign and the effective campaign tool. Some campaigns using pre/post survey methods clearly showed their hypothesis prior to their campaigns (Ziga de Nuncio et al., 1999: Nguyen et al., 2001). In terms of a general tendency among the reviewed literatures, research hypothesis tend to be vague in regard to campaign aims and objectives, and therefore there are no specific definitions for their hypothesis. The advantage of defining hypothesis within campaigns is that they provide a clear direction for evaluation planning. For example, Nguyen et al. (1999) cited that:

primary hypothesis (is) rates of ever having had a clinical breast examination (CBE) and mammogram would be significantly greater among consumers in the intervention community than consumers in the control community the reports of health promotion campaigns clear definitionSecondly hypothesis (is) testing differences among the two groups of consumers in screening knowledge, attitudes and intentions. (Nguyen et al., 2001, p. 268)

As previously discussed, the provision of those hypothesis clearly reflects their sampling and evaluation methods. It provides both a clearer idea of designing mass media health promotion, and the process and results of this specific campaign. The overall impression of evaluation methods of mass media health promotion campaigns for ethnic minority groups are vague. It completely depends on the campaigners choice associated with campaign aims. The most confusing point is that of sampling choices for pre/post survey tests. As Stevens et al. (2002) points out, some ethnic minorities are difficult to trace after a campaign because of their frequent mobility. Furthermore, because of the characteristics of mass media, whose access choice depends on individual preference, target populations who were approached prior to the campaign may not have access to the

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campaign itself. Although it is possible to force them to access the campaign, the result would not be appropriate for generalisation if the campaigns aim is to examine the effectiveness of mass media campaign upon ethnic minority groups in general. In terms of these difficulties, the most frequently used evaluation methods among recent media health promotion campaigns for ethnic minority groups are as follows: (1) pre/post survey; and (2) post survey. The sampling populations are not strictly consistent between the pre and post survey, but the basic sampling numbers between the pre and post survey are likely to be same. The most important point is the use of the comparative study, which seems to provide clearer and powerful results of a campaign.

3-2-5 Effectiveness of campaigns

Since the target health issue and the populations of each reviewed campaign are different, it is difficult to generalise in terms of the effectiveness of campaigns. Peersman and Orkley (2001) describe the difficulties of this type of review study: what is known about what works in health promotion is heavily dependent on what questions have been asked and how they have been addressed (Peersman and Orkley, 2001, p. p.39). In the following examination, we will see the effectiveness of campaigns in terms of campaign aims as outlined and clarified in the previous section (see Table 3-4 in the section 1). Again, as each study set up its own level of achievement, it is difficult to compare the effectiveness of their interventions numerically (some campaign did not show the result with use of numerical report). Therefore, in this study, if authors reported positive results either

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numerically or literally, it is understood as a positive effect of the campaign intervention. Table 3-2-9 shows the effectiveness of campaigns in terms of the two most common goals of campaigns, i.e. improving peoples knowledge or raising awareness concerning a target health issue and encouraging people to take action, such as taking a screening test. Before discussing the effectiveness of intervention, perhaps the recognition of the campaign itself should be discussed. In general, the recognition of campaigns is reasonably high. Jenkins et al. (1999) reported that:

78% of respondents in the intervention area could recall at least one element of the media intervention. Respondents recalled a mean of 3.3/6 media elements promoting checkups, 3.3/8 elements promoting Pap test, 4.0/8 elements promoting clinical breast examinations, and 2.9/7 elements promoting mammography (Jenkins et al., 1999)

Similarly, Stevens et al. (2002) reported that almost 40% of respondents were aware of the play, which was used as a main campaign tool. King et al. (1999) and Nguyen et al. (2001) also showed a high awareness rate of their campaign among their respondents. In particular, King et al. reported that mass media was especially effective in raising peoples recognition of the campaign: 44% of Arabic and 67% of Vietnamese respondents heard of the campaign through radio; and half of the Chinese respondents received the campaign information through a Chinese newspaper. As these results show, the media effect upon peoples recognition of campaigns is high.

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Table 3-2-9: Summary of effects of campaigns on their goals Brief campaign name and authors Knowledge/ awareness* Community anti-smoking Campaign in London (Stevens et al., X 2002) Breast Cancer campaign among Vietnamese-American women X (Ngyen et al.,2001) SALUD PARA SU CORAZN campaign (Alcalay et al., 1999) Breast and cervical cancer screening campaign among X Vietnamese-American Women (Jenkins et al. 1999) First Aid for Scalds campaign (King et al., 1999) The Forsyth County Cancer Screening (FoCaS) Project (Paskett et al., 1999) Promoting health (HIV) in African American populations (Wingood, 1999) Infant immunization Campaign (Ziga de Nuncio et al., 1999) Recruitment Strategies in the womens health trial (the WHT:FSMP) (Lewis et al., 1998) & Breast and cervical cancer screening project within Bradfords minority ethnic women (Kernohan, 1996) Cervical smear testing campaign among Asian women (McAvoy and Raza, 1991) Promotion of breast-feeding in a Chinese community in Montreal (Chan-Yip and Kramer, 1983)
&

Action** 6 X X X X 6

6 -

The work of Lewis et al. (1998) was not purely aiming any medical reasons, i.e. recruiting people for a medical research. But their campaign was considerable to encourage people take an action, and therefore it was included in this list. *Effectiveness on improving knowledge/raising awareness ** Effectiveness on encouraging people to take an action X: No effect / :Effective / 6: A little effect / -: N/A Source: Author

In terms of achieving their campaign aim(s), however, the results vary. Many campaigns whose aim was improving peoples knowledge concerning the risks of targeted health issues, or raising peoples awareness of the health issues, are likely to show high level of effectiveness. For example, King et al. (1999) reported over 21% of improvement concerning knowledge of first aid treatment of scalds in total. Among their target ethnic

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minority groups, Vietnamese showed the greatest improvement (64% increase). Wingood (1999) also reported that people who attended an HIV educational session showed nearly twice as likely to have greater sexual self-control, four times as likely to engage in sexual communication, nearly twice as likely to be sexually assertive, and twice as likely to have sex partners whose norms were supportive of consistent condom use17 (Wingood, 1999, p. 232). On the other hand, the campaigns effect upon peoples actions was less likely to be observable. In this case, interestingly, the campaigns aimed only to encourage people to take action, e.g. Chan-Yip and Kramer, 1983: McAvoy and Raza, 1991: Lewis et al., 1999, are more likely to approach their campaign aims than campaigns that aimed to increase knowledge and to encourage actions, e.g. Kernohan, 1996; King et al. 1999; Jenkins et al., 1999; Wingood, 1999; Alcaraly et al., 1999; Ngyen et al., 2001). Among the campaigns that aimed to change both knowledge level and behaviours, only two campaigns were successfully in encouraging people to take actions. Their aim to improve peoples knowledge either failed or showed only minor success (e.g. Paskett et al., 1999; Stevens et al., 2002). King et al. (1999) cited that:

.a high proportion of those recalling the campaign acquired the knowledge of first aid, showing that once exposed to the campaign, the message was effectively conveyed. The Arabic speaking group had a high initial level of knowledge, roughly the same as found in the English speaking populations, suggesting there was not much room for improvement (King et al., 1999, p. 107)

This type of result was also reported by other researchers (Wingwood, 1999). From the preceding discussion, one can suggest that:

17

Their intervention also achieved the change of target populations attitude towards prevention of HIV transmission.

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(1) a single campaign target, e.g. only aiming to improve peoples knowledge, or only aiming to encourage people to take action, are likely to show their campaign effectiveness; (2) double aimed campaigns are more likely to fail to achieve one of their campaign aims. Interestingly, it is difficult to define any specific tendency in the use of mass media for effective campaigns. Although many analysed campaigns used plural mass media tools within a campaign as well as other methods, such as seminars or classes, their results were not always satisfactory. On the other hand, a single media tool for a campaign, such as the case by Ziga de Nuncio et al. (1999), can achieve their campaign aim. Through the development of this discussion, two points have emerged and have been clarified: first, mass media is an effective tool for raising peoples recognition concerning a campaign; however, secondly, the effectiveness of campaigns vary. The double (or triple) aimed campaign were especially likely to fail to achieve their full campaign aims. What do these results suggest? There is a possible explanation. The most important point for effective health promotion campaigns for ethnic minority groups is the content and delivery of the health message rather than the use of numerous types of campaign tools. Of course, as Jenkins et al. (1999) points out, it may be that media-led education alone is insufficient to produce behaviour change (Jenkins et al., 1999, p. 402). However, as this discussion has already shown, numerous uses of mass media are not necessarily effective to change either knowledge and behaviour. This is not consistent with Naidoos discussion in the previous chapter. The content of the health message, according to the researchers, should be more socially and culturally sensitive. This is particularly required if campaigns aim to raise peoples attention

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towards the campaign, and to change their behaviours positively. For example, Wingwood (1999) described his success in achieving one of his campaign aims as follows:

..in general, interventions that are theory driven, emphasize interpersonal and interpersonal factors, provide skills training, and attempt to modify social norms have been more effective at promoting the use of HIV preventive behaviors (Wingwood, 1999, p. 255).

Indeed, as we have previously discussed, he carefully adopted several theories, e.g. the social cognitive theory and the theory of gender and power, in order to proceed with his campaign. This approach gave more cultural and social considerations in relation to African-Americans backgrounds. Consequently, his strategy was effective in proving the populations knowledge of contraception and HIV, and encouraging them to have more appropriate sexual relations. Interestingly, the campaigns discussed in the previous section concerning application of theories and principles are more likely to achieve their campaign targets than those campaigns which did not refer theories/principles. This outcome strongly support our discussion: it is necessary to know target populations social and cultural situation on the process of planning and designing a health promotion campaign for ethnic minority health. After the disappointing results of the campaign for Vietnamese in the USA, Nguyen and colleagues (1999) concluded that this finding reinforces the need for more culturally sensitive early breast cancer screening programmes and more intense outreach to increase screening rates among minority, low-income, and immigrant populations such as the Vietnamese (Nguyen et al., 1999). The application of theories and principles seem to be a key factor for designing socially and culturally sensitive health intervention. This strategy develops an effective mass media health promotion campaign for ethnic minority groups.

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3-3 Implication of the study results for designing mass media health promotion campaigns for ethnic minority groups

In this study, it is not an issue of which revised campaign project was the most effective or the least effective. Both the successful projects and the failed projects provide many sources for a consideration of the process of designing, conducting and proceeding mass media health promotion campaigns for ethnic minority groups. In general, the process of designing and conducting a health promotion campaign for ethnic minority groups can be conducted as follows:

(1) Setting a campaign question; (2) Feasibility research concerning a target heath issue; (3) Choice of campaign objectives/aims; (4) Choice of theory/concepts in terms of campaign objectives/aims and results of feasibility research; (5) Choice of mass media and their usage within a campaign; (6) Conducting a campaign; (7) Evaluation

The process, at a glance, is not significantly different from Atkins guidelines for mass media health promotion (See Chapter 2). For example, the factors that Atkin suggests in relation to the process of a campaign design, i.e. audience and campaign channels are all included in the design and proceeding ethnic minority health promotion campaign. One of major differences

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between the Atkins guideline and a guideline developed in this study is, however, that ethnic minority health promotion campaigns focuses more on an understanding of the characteristics of target populations than the Atkins guideline. The Atkins guideline focuses more on designing a campaign message and its delivery style. Consequently, many health promotion campaigns for ethnic minority groups are likely to spend more time on feasibility research in order to identify the reasons behind the high prevalence of target health issue with relation to target populations lifestyle, diet or economic situations and so on. For this purpose, searching numerous databases might be very useful, e.g. MEDLINE, EMBASE, ERIC etc. (Harden, 2001), as well as hand searching. Additionally, interviewing people who are of the same ethnic origin as the target population is important for designing health promotion campaigns for ethnic minority groups. As previously discussed, this is useful in the examination of the social and cultural aspects of the targeted health issue as well as economic and medical aspects. As Wingood (1999) shows, a health issue is often related to ones social situation, e.g. the correlation between lower gender status, mens domination of sexual relationships, lower demand to use condoms and HIV transmission. It is difficult to conduct a successful health promotion campaign without the awareness of these fundamental aspects of health. In addition to these factors for feasibility research, the target populations access to health information should be examined. This is a useful source for the latter process of campaign designs, i.e. the choice of mass media. At the same time, the language preference should be identified during this process, as many scholars in this study were recognised. After collecting information concerning the target population, campaigners should consider adopting the best theory/concept of health promotion into their campaign aims. This

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should be conducted with careful reference to social, cultural and economic information of the target populations (See the previously discussed cases of Kernohan, 1996; Paskett et al., 1999, Wingood, 1999). There are many well-known literatures concerning theories/concepts/models of health promotion in regard to this process, e.g. Downie et al., 1996; Naidoo and Wills, 1999; Burton, 2000; Katz et al., 2000). Additionally, Frankish et al. (1999) discussed theories that would be suitable for adoption by ethnic minority health promoters. Frankish and co-workers also discussed criticisms concerning unrealistic and inappropriate ways of adapting theories to the real world of health promotion18. In order to minimise these criticisms, DOnofrio (1992) introduced some useful ideas concerning the adaptation of theories into campaign planning decisions. In relation to the information gathered from feasibility research, campaigner should think about answering the following questions, e.g. what dimensions of the problem does the theory concern?; How does the theory explain the portion of the problem?; What additional information does the theory suggest that you should gather?.19 After considering these processes, campaigners can chose how best to convey their health message in order to approach their campaign aims. This should make clear reference to an explanation of the dimensions of the target health issue supported by theories/concepts. For example, if the cause of a health issue is based on ethnic cultural beliefs, group educational sessions with the use of translated materials, such as video, may be useful in

18

It could be one of the reasons that many scholars, including reviewed studies in this study, have not specifically referred to theories into their health promotion campaigns. 19 The questions continues as follows; How accurately does the theoretical explanation coincide with your own understanding of the problem?; What important aspects of the problem does the theory fail to consider?; What would an educational program based on the theory be like?; How effective do you expect the program would be in reducing the problem? Why?; If the program did result in change, then how would be theory explain it?; If you were guided by theory, what questions would you ask in program evaluation?; In your own judgement, how helpful is the theory in working with the problem? What are the limitation? (Frankish et al., 1999, p. 66)

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enhancing an awareness of the risks of the issue. This can be seen in terms of social learning theory (see Chan-Yip and Kramer, 1983; Kernohan, 1996; Wingwood, 1999; Paskett et al., 1999; Ngyen et al. 2001). In this process, campaigner should also give careful consideration to the effective use of mass media. Mass media is useful for contacting the majority of populations. If these educational sessions require many participants, media advertisement are useful for a participant recruitment purpose (see Lewis et al., 1998; Stevens et al., 2002). Additionally, if the public seek a health information source for mass media, media education programmes may be effective for the educational purpose of the population (see Ziga de Nuncio et al., 1999; Kings et al, 1999; Jenkins et al., 1999; Alcalay et al., 1999). These decisions are totally dependent on the results of feasibility research and other decisions associated with the baseline research through the first four phases of campaign design. In this review study, there was no study that mentioned the timing of conducting a health promotion campaign. In the case of ethnic minority health promotion, however, the timing of a health promotion campaign is crucially important. For example, Afifi (1997) reported that Muslims in Kuwait were more involved in religious activities than daily activities, e.g. watching TV, listening radio or visiting friends/relatives, during the fast of Ramadan. Therefore, it is possible to predict the small impact of media campaign during these religious fasting. On the other hand, Raja et al. (2000) suggested that Ramadan could be good opportunity to build in a health-promotion element, encouraging a reduction or a permanent cessation of health risks, such as smoking. This is because the main purposes of fasting during Ramadan is to teach a person discipline and self-restraint (Raja et al., 2000, p. 394). If the target health issue requires those personal qualities in order to reduce risks of the health issue, this period of fasting might well be an appropriate time promotion, especially in terms of

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classes or seminars. In any case, campaigners should carefully picture the target populations social and cultural (including religious) situations as well as their campaign topics and requirements In addition, the duration of the media campaign is important. The longer the campaign, the more opportunities are provided to raise peoples awareness of campaign. Indeed, Jenkins and co-workers noted that:

It is also possible that the duration of intervention may have been too short. In previous work, we have used media-led interventions to promote smoking cessation among Vietnamese-American men. In one 24 months study, we found no change in smoking status. However, in a second study, we found a small but statistically significant reduction in smoking prevalence after a longer 39-month campaign (Jenkins et al., 1999, p. 402)

However, almost all projects have limitation in terms of budget and time, and therefore it is difficult to decide an appropriate period of time for a campaign. The Lewis and co-workers paper (1998) was aimed at trying to answer this question. After using many paid and unpaid mass media messages as well as evaluating peoples responses to their campaign, they wrote that we found unpaid media coverage to be particularly cost effective (Lewis et al., 1998, p. 474). This finding suggests that media attention for their campaign would be a very useful method for both increasing the effectiveness of the campaign and considering cost effectiveness. After the campaign is completed, campaigners are strongly recommended to proceed with their evaluation. This is not only for the benefits of the stakeholders of the particular campaign, but also for the benefits for other health promoters/practitioners with reference of future health promotion campaigns. Oakley (2001) described that many reports concerning health intervention, promotion or education were poorly written, and people who want answers to the question what works in health promotion? are faced with many obstacles, 66

including how to find the primary studies, the fact that most research either does not report interventions or does not report evaluations, basic information about research design and methods is often missing and the conclusions presented by authors are frequently unreliable (Oakley, 2001, p. 22). Indeed, in this review study, it was very difficult to find out whether the principle campaign aims were approached or not, because of the different (or absence) measurements used in each project. As one of the solutions to this problem, it is a very good idea to use pre/post surveys for evaluating campaign with numerical results. Moreover, it would be useful and beneficial for the public if evaluators use pre/post surveys between two groups, i.e. controlled and uncontrolled groups, as far as s budget permit (see Kenorhan, 1996; Jenkins et al., 1999; Nguyen et al., 2001). Although none of projects reviewed in this study used qualitative methods for their evaluation, Oakley (2001) noted that it is perfectly possible to combine a range of questions in the same research design (Oakley, 2001, p. 26). In the case of ethnic minority health promotion, this evaluation method would be especially beneficial, this in order to clarify any cultural and social issues concerning a heath campaign, e.g. the context of message, delivery of message. For example, Kwan (2000) identified many dental health promotion materials especially made for ethnic communities that were criticised by the target (ethnic) community, this is because of culturally inappropriate materials combined with poor quality illustrations and text. This inappropriateness concerning health promotion materials did not appear through quantitative evaluation methods, i.e. pre/post survey. With this in mind, qualitative evaluation research methods would be very useful. As an alternative, it might be possible to evaluate campaign materials within a process of campaign design, as conducted by Ziga de Nuncio and co-workers (1999). Their study showed their evaluation results with statistical supports,

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and this could be very constructive in enhancing the quality of campaign materials, and thus its effectiveness20. In any case, Oakley (2001) suggests that qualitative methods should be designed and conducted in terms of standards for qualitative research, such as: an explicit rationale for conducting the study; clear statement of aims, context, sample and methodology; analysis of data by more than one researcher; and the inclusion of sufficient original data to allow readers to link evidence and interpretation (Oakley, 2001, p. 27).

3-4 Conclusion

Through these discussions, we can see that the process of designing and proceeding with a mass media health promotion campaign for ethnic minority groups is not significantly different from campaigns for the major populations. However, the key point in designing and conducting health promotion campaign for ethnic minority groups is that of target population focus. This is because many campaign factors are influenced by social and cultural aspects, e.g. quantitative dissemination vs. religious activities (see the Atkins guideline). Because of some inappropriateness in the general ideas of health promotion (i.e. Atkins guideline) for ethnic minority groups, health campaigners seem to adopt and develop health promotion methods with the suitable and appropriate way for ethnic minority groups based on their experimental data. The most important improvement of this adaptation is exploration and understand of the target populations social and cultural aspects as well as their health belief

20

Including evaluation of quality of campaign materials within a campaign process, however, requires more time and budget, of course.

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and behaviours. The process of designing and conducting health promotion for ethnic minority groups discussed in this chapter reflects this requirement. Because of this, the developed health promotion guideline outlined in this chapter may be useful for designing and conducting health promotion campaigns for ethnic minority groups. This is, however, not completed and proved at this point.

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Chapter 4 The Malaria Radio Campaign within Asian Populations in the UK: a case study

In previous chapter, we discussed through the results of a literature review the process of designing and conducting a mass media health promotion for ethnic minority groups. In this present chapter, we will discuss the eligibility and suitability of the previously mentioned guideline in relation to a specific case study, namely the Malaria Radio Campaign for Asian populations in the UK, conducted in 2001. Although the discussion will proceed by an examination of the reason behind the failure of this project, those reasons are not to be taken as negatives; rather, this failure will contribute to the development and improvement of the previously discussed guideline. This campaign project is divided into two sections: the first is designing, conducting and evaluating a campaign: the second part is examining the overall reactions among target populations towards the radio campaign (including the message content and delivery style)21. The second section is especially useful in relation to the discussion of organising mass media health promotion campaigns for ethnic minority groups in the UK.

21

This is not the campaign evaluation. It is rather evaluation of message delivery

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4-1 Case study: the Malaria Radio Campaign within Asian Populations in the UK

4-1-1 Background

The Malaria Radio Campaign within Asian Populations in the UK was launched in 1999 because of the recent increasing number of infectious diseases, especially tropical diseases in the UK. Some researchers have already warned about the risks in relation to growing numbers of international travellers and rising immigration levels to and from at-risk countries (Willson, 1995; DoE, 1999; BBC, 2002). Malaria is one of those diseases that enhance the risk of infection among major populations in the UK. In 1996 the United Kingdom reported approximately 2,500 of 10,000 total malaria cases in the entire Europe Union (Heymann and Rodier, 1998). The present and increasing risk from those tropical diseases was recently highlighted and emphasised by the government of the UK (BBC, 2002). The Advisory Committee for Malaria Prevention (for UK Travellers) indicated that those who travelled to malarious areas to visit friends and relations, e.g. ethnic minorities, represented particularly high risk populations (Bradley and Bannistarm, 2001). These health risks and associated precautionary behaviours have been discussed elsewhere, i.e. egocentricity (Beck, 1992; Skidmore and Hayter, 2000), and the side effects of anti-malarials (Prothero, 2001). However, there exists no pro-active campaign designed to inform of these risks and to encourage the atrisk population to take malaria prophylaxis.

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4-1-2 Design and planning of the Malaria Radio Campaign

A team in the Manchester Metropolitan University had developed this project with collaboration with the team of the Department of Health. Its remit was to approach two targets objectives: (1) to examine knowledge about health risks and travel concerning malaria among Asian populations in the UK; and (2) to improve those populations knowledge and health seeking behaviours towards malaria through a mass communication campaign. The

information gathered through the process of approaching the first objective was planed to use for the designing and conducting the mass communication campaign in the second objective. The location of the feasibility research was the area of Calderdale, Halifax and West Yorkshire22. The detailed result of this feasibility research was separately published in 2001 (Skidmore et al., 2001). This report identified the following points:

(1) Asian populations (in this case Pakistani populations), are reasonably knowledgeable about the malaria transmission process and its preventive methods (i.e. transmission by mosquito is widely recognised; and taking anti-malarials is an effective precaution); (2) The majority of Pakistanis informants are unlikely to take precautions in the UK because of the following reasons: (a) lay beliefs concerning the human immune system (e.g. people who were born in Pakistan have developed natural permanent immunity against malaria);

22

Skidmore et al. (2001) explained the reason of the choice of this research area as follows: this area was selected because it had a high concentration of South Asian communities. Thus, one minority ethnic group dominated the area of Calderdale reflecting the greatest concentration of the Mirpur community. This community group, originate from the Mirpur District of Azad Kashmir the Mirpur population were give priority for immigration at that time (since 1974) and resettled particularly in the region of Yorkshire (Skidmore et al., 2001, p. 11).

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(b) no time to seek travel advice due to frequent emergency travels (e.g. attending relatives funeral); (c) the expensive costs of anti-malarials, as well as vaccines, in the UK.

After this articulation of peoples beliefs and motivations The Malaria Radio Advertisement Campaign was planned based on the first report for the Malaria Awareness Project. In order to approach the second objective of this campaign, namely make Asian populations aware of the risks of malaria, and to encourage precautions, a radio advertisement at the national level was planned. JK Advertising in Birmingham produced the radio advertisement, in consultation with the Department of Health. The radio advertisement contained the following information:

1. in the UK two thousand cases of malaria infection were reported in the year 2000 ; 2. any natural immunity will be lost within a few months if one continuously lives in the UK; 3. a malaria infected person has a high risk of transmitting malaria to other members in a community even within the UK; 4. it is important to take anti-malaria medicine, and to use insect repellent whenever one goes to ones country of origin.

This information was combined within one radio advertisement and was delivered with ethnic music. The last information was presented without musical accompaniment. This

advertisement was translated into Hindu, Urdu and Bengali with the same structure (music and information).

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4-1-3 Conducting the campaign

The radio advertisement was broadcast through four Asian radio stations in order to cover the entire country, i.e. Asian Sound (Greater Manchester area); Sunrise FM (Yorkshire area); Spectrum Radio (Greater London area); Sabras (Midland area). The total length of the radio advertisement is approximately 30 seconds. The radio advertisement was broadcast 3-4 times per day during the day and night (between 6am and 11pm: the time band varied in each radio station) in December 2000 for four weeks in order to target, especially, people who visit their relatives/friends after Ramadan (the Muslims seasonal fasting); the advertisement appeared between scheduled radio programmes.

4-1-4 Evaluation 1 - post survey

Two evaluation measurements were set up. Firstly, the national anti-malarials prescriptions quarterly23 was examined pre/post campaign period. This data was, especially, used in order to examine the change in peoples behaviour, which represented the overall aim of the campaign. In terms of establishing an experimental design, the data examined trends before and after the radio campaigns and between the same period in year 2000 and 2001. There was no significant difference in the number of prescriptions before and after the radio advertisement campaign. Additionally, there was not a significant trend in the prescription of anti-malaria medicine in the same quarter (Jan.Mar. 2000 and 2001 (P=0.753). This indicated that the radio advertisement did not affect peoples behaviour in relation to seeking anti-malarials.

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The second body of data was collected through questionnaires (post survey). Questions were mainly asking about: informants access to ethnic radio programmes; recognition of the radio campaign; and their action for taking precautions against malaria infection. The informants were recruited from Manchester (the Vice-Consulate of Pakistan and the Pakistan Community Centre), Sheffield (the Pakistan Advice Centre) and London (the Pakistan Community Centre, the Asian Community Centre). A total of 127 completed questionnaires were used for this evaluation. The mode of informants age was 30-39 ate band; and distribution of informants was fairly even (male, 51.2%; female, 48.8%). According to this evaluation survey, accessibility to ethnic radio programmes were high (Table 4-1-1). Additionally, many those listeners had accessed to ethnic radio

programmes with consistency of broadcast time band of the radio campaigns during the campaign period (Table 4-1-2). However, in spite of the high rate of audience listening figures in regard to ethnic programming in general, and their listening consistency in terms of the specific times when the malaria radio advertisement was broadcast, the recognition of the malaria advertisement was extremely low (only 2 out of 78 regular ethnic radio programme listeners) (Table 4-1-3). In addition to this result concerning recognition of the radio campaign, 69.2% of informants who travelled for Pakistan after the radio campaign did not take anti-malaria medicine for preventive purpose.

23

This data is provided by the Department of Health.

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Table 4-1-1:

Listening habits of Asian radio programmes Number (%) Everyday 35 (44.9) 2-3 times/week 29 (37.2) Once/week 7 (9.0) 2-3 times/month 4 (5.1) 2-3 times/year 3 (3.8) Total (N) 78 (100)

Source: Author

Table 4-1-2:

Listening time bands of Asian radio programmes Number Early morning (appr. 6am-9am) 9 Late morning (appr. 9am-midday) 18 Early afternoon (appr. Midday-3pm) 9 Late afternoon (appr. 3pm-6pm) 13 Evening (appr. 6pm-10pm) 16 Late night after 10pm 3 All day 9

Source: Author

Table 4-1-3:

Recognitions of the malaria radio advertisement Number (%) Yes 2 (2.6) No 65 (83.3) I dont know 11 (14.1) Total 78 (100)

Source: Author

Further statistical analysis was conducted to examine the following relationships in order to strengthen the results of this post survey: (1) the impact of access to ethnic radio stations (both programmes and access times) and informants recognition of the radio campaign; and (2) the impact of the radio campaign upon informants behavioural change (i.e. taking precautions prior to their recent travel to Pakistan). The result of Pearsons correlation test did not show strong correlation between informants access to ethnic radio stations and recognition of the radio campaign (Table 4-1-4). Further, among the people who left for

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Pakistan after the radio campaign (after January, 2001), almost 70% (69.2%: 9 out of 13) of informants did not take anti-malaria medicine for preventive purpose. The result of nonparametric test showed that the trend between travel time (before/after the radio campaign) and taking anti-malarials was not significantly different (P=0.998) (Table 4-1-5).

Table 4-1-4 Results of statistical test (chi-square) of value, recognition of the radio advertisement Value (X2) df P With access time to Asian radio programme 6.063 6 0.416 With accessing time band 3.251 4 0.517
Source: Author

Table 4-1-5:

Travel dates and behaviours towards taking prophylaxis Taking anti-malarials for the last trip to Pakistan Yes No Travel before the campaign 22 (26.2) 49 (58.3) Travel after the campaign 4 (4.8) 9 (10.7) Total 26 (31.0) 58 (69.0)
Source: Author

Total 71 (84.5) 13 (15.5) 84 (100)

Consequently, the project team concluded that the radio advertisement was not broadly recognised, and thus the effect of the campaign upon changing the Asian populations behaviour was not significant. As a health promotion campaign, the Malaria Radio Campaign did not achieve its project aims.

4-1-5 Evaluation 2 qualitative research

After the result of the evaluation survey for the radio campaign, the project team expand the evaluation topic to answer the following question: why the radio advertisement was not more widely recognised, in spite of high proportion of listeners to Asian radio programmes? In 77

order to answer this question the second part of this evaluation will examine the use of radio as a campaign tool and the radio advertisement in terms of informants impressions and responses towards it. In order to investigate peoples reaction to the radio advertisement, eight individual indepth interviews, which were randomly selected from the list of the informants who had previously contributed to post survey and two focus group discussions were conducted24. Interviewees for the in-depth interview were fluent in English, these interviews were conducted in Sheffield and London. Group discussions were also conducted in the Pakistan Community Centre in Manchester, and in the Pakistan Centre in London. Those who participated in the group discussions were students in adult classes organised by those centres (female exercise class in Manchester; and English language class in London). All conversations and discussions were tape-recorded25. The participants in the in-depth interviews and the group discussions, firstly, listened the radio advertisement, and were asked to discuss concerning following topics: (1) impressions of the radio advertisement; (2) the quality and context of the radio advertisement as a health message; (3) suggestions for improving the radio advertisement. Both the in-depth interviews and the group discussions were given free time and a relaxed atmosphere to talk about any topics concerning health and malaria. Because of this, the length of interviews and focus group discussions vary. However, the average time for in-depth interviews was approximately 10-15 minutes; for focus group discussions it was approximately 25 - 30
24

Although in-depth interviews and group discussions should not be treated in the same way, it was found that the contexts of information gathered by these methods were very similar. Therefore the transcripts from those two methods were combined. 25 Language was not a significant problem for this qualitative research. As noted above, the in-depth interviews were conducted with English speaking Pakistanis25. In both locations the discussion groups consisted of 10 people. Four of them were fluent or had an intermediate level in English. Those who could speak English in the class voluntarily translated the interviewers English questions into Urdu, and the Urdu answers into English.

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minutes. In addition to those qualitative methods, the researcher used observational studies of informants behaviours as they listened to the radio advertisement (Poland and Paderson, 1998). An interpretational analysis method and quasi-statistical analysis method were used for this data analysis (Tesch, 1999; Stroh, 2000). In terms of the results, impressions of the radio advertisement among informants was negative (Table 4-1-6). Among the 28 participants for this evaluation, only two people showed supportive attitudes in relation to the radio advertisement. Even people who described positive impression at first started mentioning negative aspects of this radio advertisement later in the interview. The reasons why informants had negative impressions of the radio advertisement were various, but many informants described their negative feeling towards music that was used for this advertisement (Table 4-1-7). The majority of people who spoke about the music seemed not to be comfortable with the way in which the information was provided as a song. It is, thus, a difficult way to understand the context of the information to be imparted. Indeed, informants requested that the radio advertisement be played several times over until they fully understood the health message combined with music. Further, a common opinion among members of a group discussion in Manchester was that:

music should be got rid of. That was too loud, and disturbed the message (a discussion group A in the Pakistan Community Centre, Manchester)

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Table 4-1-6: Commonly mentioned words concerning impressions of the radio advertisement Negative expression Numbers of Positive expression Numbers of appearance appearance Not serious* 3 Good 6 Not good 2 Practical 1 Lavish 2 Clear 1 Not clear 2 Too short** 2 Not effective 1 * including some variations, i.e. less serious not seriousness. ** including some variations, i.e. being on for long. Source: Author

Table 4-1-7: Commonly mentioned words concerning music Negative expression Numbers of Positive expression appearing Noisy 4 Liking the music Loud* 4 No music** 3 Childish 2 1 Funny * including some variations, i.e. too loud.

Numbers of appearing 3 -

** including some variations, i.e. not musical, get rid of music, only music, not use music. Source: Author

In terms of the context of the message of the radio advertisement, again, informants described their negative opinion (Table 4-1-8). The majority of people considered that the information provided in the radio advertisement was too basic, which they have already known as common knowledge.

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Table 4-1-8: Commonly mentioned words concerning the quality of information Negative expression Numbers of Positive expression Numbers of appearing appearing Basic* 4 New 1 Not enough** 3 Too simple 3 Not new 3 Having known 3 Too general 1 Very limited 1 * including some variations, i.e. too basic,. very basic. ** including some variations, i.e. not musical, get rid of music, only music, not use music Source: Author

Informants are more likely to know and understand more advanced level of precautions of malaria. Because of these reasons, they showed very negative attitudes to the message delivery style, namely message and traditional music conversion. An informant at in the Pakistan Centre in London suggested a Q&A type of message delivery style26. A discussion group in Manchester also suggested a debate programme because you can get information, and also can think of the risk by your self (a discussion group A in the Pakistan Community Centre, Manchester). Another informant told that Pakistani should be given shock concerning the risks of malaria in the health message, especially at the beginning of the radio advertisement, because of their familiarity to malaria. Otherwise, according his opinion, people would not pay their attention to the advertisement. The common point of these opinions is that the Pakistani community is more likely to understand the risks of malaria and its precautions in the advanced level, if it comes out of discussion, conversation and social context, rather than being simply given to them. The approach of the radio advertisement in this project seems to be too soft to expect peoples attention and to lead peoples action.
26

It would start, for example, Are you planning to go to Pakistan?. Then a listener think Yes or No in terms of their situation; then the question would continue, for example, Have you taken medicines and vaccinations for preventing infectious diseases? Then a listener thinks Yes or No in terms of their situation. People who are planning to go abroad will be interested in answering those questions.

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The other point revealed through this evaluation, was the question for the choice of a campaign tool. Although the previous evaluation result showed that majority of informants were regular ethnic radio listeners, it was revealed that their listening behaviours seemed not to be serious for, for example, seeking information for radio programmes from this evaluation study. An informant in London said that he only listened to the radio when he was travelling by car for his work. Another informant said that most Pakistani women (house wives) listen radio in kitchen during their housework. The common points between these information is that: (1) people do, indeed, listen radio programmes, but they are likely to focus on their main activity, e.g. driving or housework, rather than radio programmes; (2) people had a very short time to access to radio, e.g. during commuting time. Under this situation, it would be difficult to encourage the use of precautions, or even to raise awareness through the radio advertisement with music, which was criticised by other informants because of its inappropriateness for delivering a serious health message. Further points that were found in regard to this study were issues related to informants social and cultural situations. An informant in London who is a mother of several children informed she knew the importance of precautions prior to her trip to Pakistan, but the costs for travel health are extra burden for her family after spending on the most necessary costs, e.g. air tickets for all family members, accommodation in the Pakistan27. As a result, travel health issues become a very low priority. In relation to informants cultural aspect, an elderly

27

She said that: when we decide to go back to Pakistan, for two or three years you save the money (travel costs) Then it costs around 500 to 600 per person. If you go there with other family (members), it costs like 2000. And now you have to pay airport tax, and have to pay security tax People do not want to pay my extra money. There are no money left. Why do people want to pay their money for infections? (A female informant in the Pakistan Community Centre, London).

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informant in Sheffield described that he would not take any medication, including precautions, because everything would be in the Gods hand. He said that:

It did not matter what information contained in the radio advertisement Even you take how many tablets, it doesnt matter. If you dies, you dies. Only thing which I can do is just carrying on [my life]. The God is the person who decide those kind of things (a male informant in the Pakistan Advice Centre, Sheffield)

Since these reasons to refuse to take precautions were associated with their economic or cultural aspects, it could be very common among all Pakistanis. Furthermore, these ways of mind suppose to be very difficult to change through a radio advertisement.

The Malaria Awareness Project can be summarised as follows: this project was targeted to raise peoples knowledge of risks of malaria and the importance of taking precautions of malaria, and to encourage at-risk Asian populations to take precautions. After feasibility research concerning peoples knowledge of malaria and attitudes to precautions, a radio campaign using a radio advertisement was designed and planned. In spite of the four-week radio campaign, the evaluation research showed that a very few informants recognised the campaign advertisement, and therefore a very few people started to take precautions prior to their recent trip to Pakistan. The second evaluation research revealed that the content and the message delivery style of this radio campaign was not appropriate for them. Furthermore, their concentration on radio information in general was poor from the point of view of absorbing the content of the radio message. Finally some other social and cultural factors, e.g.

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economic situation, religious belief, disturb to be encouraged to take any precautions against malaria regardless of the radio campaign.

4-2 Discussion: Analysis for the reasons of the campaigns failure

The most appropriate way to discover the reasons for the failure of this campaign is to reexamine its design and conducting process with reference of our discussion in Chapter 3 (the guideline of the process of designing and conducting health promotion campaign for ethnic minority groups). The following table is the summary of the Malaria Awareness Project in terms of our guideline (Table 4-2-1),

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Table 4-2-1: Summary of the designing and conducting process of the Malaria Radio Campaign Design process in the guideline The Malaria Radio Campaign discussion 1: Setting a campaign question Frequent travellers, such as Asians, in the UK are at risk populations of malaria infection. Health promotion campaign concerning taking precautions against malaria will decrease those risks of malaria infection. 2: Feasibility research concerning a Conducted in Halifax, UK. target health issue Main findings: 1: Pakistanis are knowledgeable about the basic malaria transmission process and its preventive methods; 2: The majority of Pakistanis are unlikely to take precautions in the UK because of lay beliefs (e.g. natural immune system28, urgent cases of travel and financial reasons. 3: Choice of campaign 1: Providing advanced information concerning imported objectives/aims malaria in the UK from other malarious countries; 2: Raising awareness of malaria risks through travel; 3: Encouraging peoples action to take precautions against malaria. 4: Choice of theory/concepts Not particularly discussed. 5: Choice of mass media and its/their Radio advertisement. way of usage (Health message was combined within a radio advertisement with ethnic music adaptation of Entertainment education strategy (Singhal and Rogers, 2001)? 6: Making campaign tools Radio advertisement with combination of ethnic music 7: Conducting campaign 4 weeks in December 2000 8: Evaluation 1: Post survey for examining recognition of the campaign; 2: In-depth interviews and group discussions for examining peoples reaction towards the radio advertisement.
Source: Author

At a glance, the basic process follows a general health promotion paradigm for ethnic minority groups. However, it is clear that a few of the procedures and information were missing, and that missing information seems to have cause the failure of this campaign.

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4-2-1 Finding 1 - The impact of missing information concerning peoples accessibility to health information and use of mass media on the campaign effect

Firstly, the feasibility research did not contain any studies concerning either peoples accessibility to health information, nor use of mass media (or at least, radio) unlike other similar media health campaigns, e.g. Alcalay et al. (1993), Ziga de Nuncio et al., (1999). It is not clear that the idea of mass media campaign was planned prior to this feasibility research or after. Even if the campaign team chose mass media as a campaign tool after the feasibility research, they must examine the tendency of target populations accessibility to health information sometime before proceeding with the radio campaign. This should be done in order to maximise the effectiveness of the campaign in relation to previous campaigns. However, the information concerning the target populations accessibility to health

information, and the use of mass media, seemed not to be considered all in any phase of the project. As a result, this missing information led the inconsistency in both the campaign teams expectations and target populations recognition of the campaign. In terms of the evaluation results, Pakistani informants were regular radio listeners, as consistent with the previous discussion (see Chapter 2 and 3). In this sense, the absence of such information seemed not to be an important issue for this project. If the campaign team used the data provided by other researchers for this campaign, it was of no helpful to the Malaria Awareness Project. The results of evaluation clearly revealed that Pakistanis were unlikely to be heavy listeners showing little concentration on the content of radio programmes. Furthermore, during the second evaluation research, informants reported that they were more likely to use television as both an information source and an entertainment
28

Many Pakistanis believe that they have permanent immunity against malaria if you were born in Pakistan.

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tool rather than radio. Indeed, informants at the Pakistan Advice Centre in Sheffield giggled when they were asked the question, Do you listen to radio? This is because, according to them, radio is a primitive information source compared to TV. Some of them also proudly said that they had set up satellite channels on their TV. Their preferences for TV (especially satellite channels) was explained by informants that TV is a much better information source because it provides more news concerning Pakistan with visual images than either terrestrial TV channels or radio. Apart from the information provided by the target populations, Sreberny (1999) also reported that more than 70% of ethnic minority populations (whom she interviewed) in the UK have, and use more than two TV sets, and over 35% of her informants use cable or satellite channels. Srebernys report is consistent with the information from Pakistani informants in this study. McLuhan (1964) noted that technological innovation in the media itself was an important media message. In other words, as more sophisticated technology for

communication is invented, more people seek this technology otherwise, people will miss the up-to-date information (a kind of threat). This is a discussion concerning media and society in general, which is also applicable to ethnic minority groups. Ethnic minority groups are parted from their original countries and therefore have a great enthusiasm to seek up-todate information, especially when it concerns their country of origin. In consideration of this point, one can understand why ethnic minorities, as the informants in this study showed, are likely to have more up-to-date mass media tools (as long as they can afford them), and do not tend to use radio as a major information source. The comment, radio is a primitive tool, from a Pakistani informant in this study supports this tendency of media usage in the UK. This

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study was conducted after September 11th in 200129 when Muslims, including Pakistanis, sought up-to-date information more enthusiastically than ever before because of their home countries possible involvement in international politics. Their attitudes to radio and

information from this media tool clearly show the unsuitability of radio as a campaign tool for the Malaria Awareness Project. It is questionable as to whether the campaign team considered those ethnic minority groups social trends, when choosing radio as a campaign tool. If the campaign team had examined peoples accessibility of health information in the process of designing the Malaria Awareness Project, the problem of recognition of the radio campaign may have been avoidable. Further, the campaign team may have had an opportunity to change their planned media tool from radio to other mass media tool during the process of choosing media tool and usage (at the process 5 on the Table 4-2-1). In some cases, the choice of radio as a campaign tool is inevitable because of tight project budgets (Swinehart, 1997). If this was the case with the Malaria Awareness Project, the feasibility research concerning target populations lifestyle and cultural aspect should be conducted more carefully, this in order to seek the most effective campaign tool. Indeed, during the evaluation research after the radio campaign, a Pakistani informant, who was the manager of the Pakistani Community Centre in London, noted that many Pakistani visitors to his community centre read Urdu language newspapers in order to collect information. Whilst conducting the evaluation research for the Malaria Awareness Project, the author, indeed, observed that many Pakistanis read Urdu newspapers, and that they freely discussed the news in the papers with other fellow

29

On this date, the USA confronted multiple terrorists attacks in New York and Washington. The terrorist group is assumed to be Muslim extremist so-called Al-Quaida. Because of the image the war between westerners and Muslims, many Pakistanis in the UK have been interested in the political decision of the Pakistani government since the September 11th. The author, indeed, was asked to join the discussion concerning the UK politics against Muslims (even there was no such policy existed) several times during the evaluation research.

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Pakistanis. As Alcalay et al. (1993) pointed out, information in peoples own language provides a much crisper and accurate understanding than information in a second language. Because of these reasons and their lifestyle, Pakistani seem to be more interested in reading Urdu newspapers than listening radio. This fact indicates that the campaign team had an alternative method for the Malaria Awareness Project, as an alternative to TV, as a campaign tool if they found radio to be an inappropriate method. Further, even if they decided to use radio as an campaign method, they would have had an opportunity to use other media methods, such as newspapers. All in all, missing information concerning Pakistani peoples access to health information and use of mass media may have caused the failure of this campaign.

4-2-2 Finding 2-The impact of missing theories/concept upon the campaign effect

The second point is the missing of theories/concepts for conducting the campaign. In the feasibility research, the campaign team isolated many factors that concerned the reasons for Pakistanis not taking precautions against malaria, e.g. misunderstanding of immunity, urgent cases of travel. However, there were no explanations in terms of connecting a radio campaign, and strategies for improving those negative facts for malaria prevention. Therefore, it was not helpful in terms of evaluating the Malaria Awareness Project post campaign, unlike other campaigns, such as Wingwoods the HIV Prevention Programme (1999). In the case of this project, the campaign team found that Pakistanis displayed an aspect of egocentricity in terms of their precautions against malaria (Skidmore et al., 2001). To

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explain, Pakistanis understood the mechanism of malaria transmission, and were aware of the necessity for precautions. But they were likely to believe that they would avoid malaria infection because of their beliefs of having immunity against malaria (even it is not right). Further, they were not thinking that they themselves could be a cause of malaria transmission. Malaria infection and transmission are, according to them, others affair. Under this egocentric attitude, it is questionable as to whether a one-way media message, i.e. a radio message, is effective and persuasive in changing attitudes and behaviours. How did a one-way message effect a change in peoples minds concerning malaria infection and prevention? - this question seemed not to have been considered amongst the campaign team. The evaluation research result showed that Pakistani informants are likely to point out the weakness of the radio campaign, i.e. the message delivery style, such as a combining of with message and music. According to the informants, this message delivery style was just noisy and nothing about it appealed to them. One of informants said that this message was understandable if only she sat and concentrated on it in a very quiet room. Some informants suggested that a debate or discussion programme, such as in the style of Question-Time on BBC1, would be a much better method to make people aware of the risks of malaria, as well as encouraging them to take precautions. According to these informants, radio listeners (Pakistanis) can, thus, share the core of issues with the participants of a debate programme. In this way, they can think about the solutions along with those participants. The same positive opinion towards debate emerged from a focus group discussion at the Pakistan Community Centre in Manchester. According to the informants, the focus group discussion itself provided a better opportunity to become aware of the risks of malaria because of a sharing of

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information with others. They also said that they were willing to take precautions after that session. Their preference for the self-understanding type of message delivery style provides us a reason to re-think the egocentricity aspect of malaria prevention among Pakistani people. With reference to the informants comments, they were not really showing individual ego refusing to take precautions for their own reasons, but rather, reflecting their own poor understanding of the impact of malaria infected individuals upon their society. Indeed, Werbner (1990) noted that Pakistanis in Manchester were likely to get together in order to take part in many activities not only within families, but also within communities, e.g. reading and learning Koran. Learning from discussions with others and sharing beneficial, including risk, information with others seems to be a very important aspect for any Pakistani community. Individuals are generally very co-operative with each other in attempting to understand unknown information, e.g. filling a form for an application. They are also very keen on having conversations, even when they are not acquainted (observational study at the Vice-Consulate in Pakistan in Manchester, 2001). Egocentricity aspects of Pakistani society, therefore, might be overcome by a deep understanding of health issues through sharing information with others. From the social aspect of Pakistanis close relation to community, it might be suggested that this aspect of the campaign may be more effective if strategies based on theories/concepts which focus on community/social learning for individual behavioural change is included, e.g. Cognitive-Behavioural Approaches (St. Lawrence et al., 1995; Frankish et al., 1999), or Reference Group-Based Social Influence Theory (Fisher, 1988). In terms of this theoretical background, it is possible to say that community health classes or

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seminars might be more appropriate campaign tools, rather than a single radio campaign. Additionally, this campaign method, especially in regard to community health classes, seem to be more effective in educating educate people who believe in Gods will as a cause of illhealth, including malaria infection. This is because they have an opportunity to think about the community benefit with his/her fellow religious counterparts. Another reasons for the failure of the Malaria Awareness Project was, therefore, that the campaign team did not closely examine the important findings through the feasibility research, i.e. egocentricity aspect of Pakistanis health seeking behaviours towards malaria. Added to this, Pakistanis social aspects, i.e. rejection of spoon-fed information, preference to self-understanding and social sharing of important information. This finding indicates that the health promotion campaign team are required to examine the target populations social aspect of health seeking behaviours as well as their motivations to take actions. On the other hand, the campaign team adopted one of the most popular strategies for gaining the populations attention, i.e. the entertainment-education strategy for designing the message delivery system. The entertainment-education strategy combined with use of the entertainment aspects of media (e.g. drama, songs etc.), and educational aspects, in order to increase audiences knowledge of a particular health issue, the desired effect being to create a favourable attitude and change behaviour (Singhal and Rogers, 2001). This type of message delivery system is popular for media health campaigns for ethnic minority groups. As we have previously discussed, for example, Ziga de Nuncios fellow workers (1999) used two types of radio advertisement with Spanish nursery lyrics, combined with music, in order to deliver immunisation information for children in the Latino population of California. As a result, his target population favoured the message delivery styles because of the

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advertisements use of music/song/rhythm. As this example shows, using the target populations ethnic taste is one of favoured message delivery style used by health promoters. However, in terms of the result of the evaluation study, the same type of message delivery style for the Malaria Radio Campaign worked negatively. The informants being especially critical of traditional music use. The most important reaction from the target populations is that they are likely to be offended by this particular message delivery method. Many informants noted the general popularity of the music used for this radio advertisement. However, their common opinion was that the music did not provide any serious image of health to listeners. As a consequence, listeners were not aware of the advertisement as a health-warning message. At the same time, many informants described their negative opinion concerning the radio advertisement (information with music) in terms of its being too childish. During interviews, some informants sneered at the radio advertisement after the researcher played it. Those who sneered at the advertisement were likely to be very critical towards it, using the words and phrases such as childish, too easy, or patronising. In short, the combination of message and traditional music was not favoured, rather, it created feelings of offence among the target populations. Why did this accompaniment of music and message give rise to feeling that can be associated with descriptions like patronising or not serious? This is intimately related to the social and cultural aspects of ethnic minority groups; one aspect is based on their social and cultural positions in the UK, and the second concerns their health behaviours. As Mirza (2000) discussed, ethnic minorities, including Asians, are struggling with long standing western myths6, such as their intellectual inferiority to whites. In order to oppose such myths, Asian parents encourage their children to obtain higher

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educational degrees, and as a result, the numbers of those who obtain British formal higher degrees matches the white population (Skellington et al., 1992; Modood, 1997; Mirza, 2000). However, in reality, their social conditions are not as good as their fellows in the white populations, e.g. ethnic minority groups have a higher unemployment rate (Modood, 1997). This history, i.e. the issue of challenging social myths and images, seems to stimulate their strong reactions against being treated in a childish way. The words used by informants concerning the advertisement, such as childish, too easy, patronising, tended to support this. In addition, their attitude, for example, sneering at the advertisement, is evidence of the hidden resentment against this intellectual assault or implied reduction in their status as adults. The informants negative behaviours towards the radio advertisement, which accompanied with music, also relate to their attitude towards health. As Skidmore and his coworkers concluded in the feasibility research report, Pakistanis in the UK may give low priority to health as an issue (Skidmore et al., 2001). However, once they have, or possibly have a health problem, they are more likely to seek professional advice (general practitioners GPs) than any other ethnic groups (except Bangladeshis in the UK) (Health Education Authority, 1994; Nazroo, 1997). This tendency suggests that they do not give low priority to health issues, but they do give low priority to preventive medicine. For them, health issues are a very serious matter, and therefore, they would tend to seek the GPs help. Therefore, in terms of their real health seeking behaviours, it is understandable that they display a negative attitude towards the radio advertisement. This is because of the less-seriousness implications associated with music. Health messages with music seem not to be trusted by the informants, and therefore, they are not successful in gaining either their attention, or effective

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in encouraging them to take precautions. This, again, seems to be a matter of misunderstanding the social myths and images associated with ethnic minority groups. To return to the process of designing this radio campaign, it is questionable as to whether the campaign team thought about the deep social and cultural feelings of the target populations and their ideas about health when adopting the entertainment-education strategy. It seems to be merely scratching the cultural surface of ethnic minority groups from a white perspective. In short, the applied message delivery style reveals the different perspectives of ethnicity between health promoters and target populations. This gap between the authoritys or institutional perceptions of ethnic minority groups and the ethnic minoritys actual requirements reminds one of the famous debate in post-colonial theory between Edward Said and Gayatri Spivak (Moor-Gilbert, 1997). In this debate, Spivak highlighted the difference in identity between ethnic minority groups who were forced into slavely before 1850, and those who were voluntary migrants after the World War II. The target populations, who are the recent focus for health services in general in the UK, are in exactly the same position as the later black population. Their ideas concerning their ethnic backgrounds would tend not be nostalgic in relation to their country of origin. Their idea of ethnicity is a more complicated matter, concerning their identity and social position in the UK society rather than nostalgia with reference to long-term conflicts in relation to their social situations. Importantly, mass media contribute greatly towards the creation of this sensitivity gap between the idea of ethnicity among ethnic minorities and the major populations stereotypical images emanating from media products. Because of its public role (requiring fair behaviour), the media are likely to support (consciously or not) stereotypical ideas

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adopted by the major populations in relation to minority groups, e.g. all the owner of corner shops are Asians (Sreberny, 1997). Sreberny reported that ethnic minority viewers complained about ethnic minority actors roles that seem to represent typical ethnic identities and social situations, e.g. lower class and unemployed black men in soap operas. The Broadcasting Standards Commission (2001) also reported the tendency towards stereotypical portrayals of ethnic minority groups such as their involvement in criminal activities; the idea of using ethnic music in relation to ethnic minority groups establishes the same kind of stereotypical understanding of ethnic groups. In short, no consideration is given to the complexities of social conflict within the minority group. The findings of this case study suggest that health promoters should establish a wider perspective towards ethnic minority groups, not only in the field of health, but also the field of community. There needs to be a special awareness of the effects of mass media upon the creation of the social image in relation to ethnic minorities. Mass media is not only a tool for message delivery, but also a contributor towards social image and social structure. If health promoters do not consider this complex interrelationship between mass media and ethnic minority groups, the health message will not succeed in gaining access to the community. Rather, it will act to contribute towards the creation of social offence and therefore rejection by the target populations. In order to prevent this type of mistake within a health promotion campaign, the campaign team is, again, required to examine target populations social and cultural aspects more carefully. Health promotion theories/concepts discussed elsewhere may provide some good clues for connecting the campaign strategies, e.g. choice of suitable campaign tools, and

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target populations social behaviours, and therefore, it would provide more effective ideas of choice of campaign methods and tools.

4-2-3

Finding 3-Misunderstanding of the suitable campaign period

The third point is the missing information concerning the suitable campaign period. Although this type of information was rarely studied in the previous works with relation to their health promotion campaigns (see Chapter 3), the Malaria Awareness Project revealed that this information is crucial for health promotion campaigns for ethnic minority groups. For example, this campaign, especially, targeted travellers who would return to Pakistan after Ramadan because of expectations of large numbers of travellers. As a result, the campaign period was set up during Ramadan in the year 2001 in order to consider the campaign effect after the conclusion of religious activity. The reality was, however, that after Ramadan was not a major travel season for Pakistanis in the UK. According to the result of the evaluation study, many Pakistanis usual travel season to Pakistan is April, and July to August (see Doi, 2001). This is because they are working within the UK, and therefore, the holiday seasons are more constant with the UK calendar. This tendency is especially observable amongst families with school-aged children, who accompany their parents on the trip to Pakistan. As Raja et al. (2000) discussed, Ramadan might be a good period to conduct health promotion because it is a season of self-restraint and discipline. However, it would not be an appropriate period to conduct the Malaria Awareness Radio Campaign because of its incompatibility within their travel seasons.

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The failure of the inconsistency of the campaign period indicates that, again, the importance of the content of the feasibility research in the process of designing and planning of a health promotion campaign for ethnic minority health. The campaign team chose this campaign period in terms of information from a few Pakistanis and information from mass media, i.e. after Ramadan, people visit their family in order to celebrate the end of Ramadan. However, Pakistanis in the UK, especially those who are working or have school-aged children, are more influenced by a westernised calendar, at least, according to the result of the evaluation study. The result of the campaign would have been very different if this single issue was considered.

4-2-4 Finding 4-The importance of the qualitative evaluation study within the campaign

The last point concerns the evaluation study. In this project, only a post survey was used for the evaluation of the campaign. In terms of the campaign objects/aims, i.e. raising the awareness of the campaign and encouraging people to take malaria precautions, the comparative study of pre/post survey may be more appropriate. The pre/post survey concerning taking precautions against malaria targeted to Asian populations is especially important for the evaluation of this campaign30 with reference to the campaigns objectives/aims. As a result, numerical data concerning the effectiveness of the radio campaign seem to be less persuasive (although the radio campaign itself was not significantly effective).

30

Although a prescription survey was conducted as an evaluation survey in this project, the data included other UK populations, e.g. white, Afro-Caribbean.

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On the other hand, the advantage of the evaluation study in this project is the introduction of a qualitative research. Many facts, which were discussed in this section, were found mainly through qualitative evaluation research. This provided very important information, especially, in terms of the target populations social and cultural aspects which were not revealed through a post survey. For example, the aspect of the target populations sensitive attitudes towards mass media (discussed as the finding 2) has not been discussed in either the textbooks of health promotion nor the previous research concerning ethnic minority health promotion campaigns. However, as previously discussed, this aspect is very important to consider in both the process of choice of campaign tools and by way of its usage, and thus, the effectiveness of health promotion campaign for ethnic minority groups. This finding suggests that qualitative studies concerning target populations social and cultural aspects should be included several times in the process of designing and conducting health promotion campaigns for ethnic minority groups. The timing of this type of study may vary in terms of individual campaigns. However, as this discussion has indicated several times, qualitative research concerning the target populations has better to be included in the phase of feasibility research, and before conducting the campaign. As the discussion of the first finding showed, some social and cultural aspects would be directly concerned to the phase of choice of campaign objectives/aims, choice of theory/concepts, or choice of campaign tools. In the meanwhile, other social and cultural aspect may be related to the contents of a campaign message, as the discussion of the third finding. A health promotion campaign is not only conducted for the prevention of illness or enhancing health, but also conducted in order to enhance individual and community skills for coping with the illness or health issue, as we have discussed in the Chapter 2. This health

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promotion purpose of knowing the aspects of target populations social and cultural aspects. It is necessary for the designing and conducting health promotion campaign. One of the causes of the failure of the Malaria Awareness Campaign was, therefore, the lack of research into the target populations unique point of view.

4-3 Conclusion

The Malaria Awareness Project including its radio campaign did not achieve its expected results in spite of the fact that its design process and methods of conduct is followed similar preparation and procedures to previously conducted mass media health promotion projects. With comparison of a developed guideline and the whole process of the Malaria Awareness Project, the latter project had some missing processes and information in order to produce a more effective health promotion campaign with use of mass media. In terms of these findings, the following points could be suggested for revising the design and the conduct process of the Malaria Awareness Project (Table 4-3-1).

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Table 4-3-1: Suggesting process of the designing and conducting the Malaria Radio Campaign Design process in the guideline The Malaria Radio Campaign discussion 1: Setting a campaign question No change 2: Feasibility research concerning a Needing change target health issue The following section and points should be examined: 1: Target topic related section - knowledge, attitudes and practices concerning a targeted health topic, i.e. malaria and malaria prevention 2: Health information related section - what type of information sources are used frequently; - what type of information do they need to know. 3: Mass media related information section - accessibility to mass media; - preference of mass media and reasons.: 4: Travel related information section - travel season to home country; - travel reasons; - companions for the travel, e.g. family members etc. Research methods: combination of survey, interviews and observations 3: Choice of campaign objectives/aims No change 4: Choice of theory/concepts Needing change Adopting the analysis of the results of the phase 2 e.g. Cognitive-behavioural approach, reference group-based social influence theory 5: Choice of mass media and its/their Needing change way of usage Combination of newspaper advertisement and health classes in community centres (radio advertisements can be used for advertise those classes) 7: Making campaign tools Needing change (because of phase 5) - Newspaper advertisement - Radio advertisement - Materials for health classes? 8: Evaluation of the campaign tools New process Examining target populations reaction to campaign tools - Research methods: combination of survey, interviews and observations 9: Conducting campaign Needing change e.g. before Easter vacation, before summer vacation (May?) 10: Evaluation Needing partly change 1: Pre/post survey for examining recognition of the campaign; 2: In-depth interviews and group discussions for examining peoples reaction towards the campaign contents, e.g. newspaper adverts, radio adverts and classes, for improving next campaigns in the future
Source: Author

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First of all, the topics of the feasibility research should be expanded. In this project, the campaign team collected malaria related information, especially, in terms of peoples knowledge and attitudes toward malaria and its precautions. However, they did not study health information related aspects, especially mass media use, in spite of the use of mass media in their campaign. Mass media seemed to be a very useful campaign tool for ethnic minority groups as previously discussed. However, this ethnic minority group used these information methods for greater variety of reasons than expected by the health practitioners, e.g. seeking up-to-date information rather than poor English language skills. At the same time, the opportunity to use up-to-date technology for ethnic minority groups is much more widely available than the campaign team thought. As a result, there was the gap between the campaign teams expectation, and knowledge concerning the use of mass media and the target populations actual use of mass media. Because of these missing information, the research team failed to reflect their findings properly in the feasibility research as of their campaign. Secondly, the research team failed to apply theories/concepts into the campaign. They found several interesting facts concerning the target populations knowledge, attitudes and practices concerning malaria and its precautions. However, they did not reflect those findings in the design of message delivery styles, but merely the contents of health messages. As a result, they chose a single mass media message tool which was either not properly used as an information source by the target populations, or which was not trusted by the target populations because of their social sensitivity. If they were to analyse the social and cultural backgrounds of these findings, they may find a group of more effective alternative campaign tools.

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Thirdly, evaluation of campaign tools is strongly recommended before conducting the campaign as long as time and budget permitting. As this study shows, people can show their opinion from a target populations point of view. Moreover, it is expected that they would provide further information concerning their social and cultural aspects related to the campaign content in this phase. For this reason, qualitative research methods are strongly recommended, as well as quantitative methods, this in order to collect detailed psychological and emotional information. Lastly, a final evaluation research is required. The necessity of this type of research is, first of all, to examine the effectiveness of the campaign for reporting stakeholders; secondly, to provide useful information concerning health promotion campaign with use of mass media for ethnic minority groups. As previously discussed, there have been still limited numbers of report concerning this topic. The more information that is accumulated, the better quality of guidelines developed. The process of designing and conducting the Malaria Awareness Project is not completely appropriate in terms of the guideline based on the previous health promotion campaigns for ethnic minority groups. There was missing information and processes that were indicated on the guideline. The major failure of this project was based on that missing information which deeply related to the ethnic target populations social and cultural situations. This point was, indeed, revealed through the previous discussions concerning developing the guidelines for designing and conducting mass media health promotion campaigns for ethnic minority groups. Because of the necessity of extra considerations for social and cultural differences among ethnic minority groups, researchers referenced in the previous chapter, seemed to develop their own methods for designing and conducting mass

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media health promotion campaigns, even if they followed common processes of health promotion campaign developed through experiences with standard (white) populations. On the other hand, the process of designing and conducting the Malaria Awareness Project generally followed the major procedure of designing and conducting mass media health promotion campaign. However, the campaign team did not deeply examine the social and cultural aspects of target populations. Rather, they seemed to sufficiently their western idea of health promotion into the Malaria Awareness Project within Asian populations. The failure of the Malaria Awareness Project is, therefore, a good examples to reveal the easy adaptation of western idea of health promotion design and perception of ethnic minority health issues (see Chapter 1). Further, the failure of this project indicates the importance of the point previously revealed by health promoters, i.e. understanding social and cultural aspects of target populations. Those points should be including in the guidelines for planning ethnic minority health promotion projects in order to provide more effective ethnic minority health promotion projects.

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Chapter 5 Conclusion

5-1 Summary of the study

Ethnic minority health issues are a new topic in the health service sector, especially in relation to the multicultural UK society. Health sectors in the UK are now struggling with an examination of the causes of these health issues, whilst at the same time, reflecting on findings of cultural differences among ethnic minority groups in terms of health service distributions. Added to this, they are urgently required to improve health situations among ethnic minority groups because of increasing numbers of migrants. Health promotion, as well as ethnic minorities health issues are, however, a relatively new field within health services. Only recently has it been suggested that the crucial purpose of health promotion is the empowerment of individuals and communities. These methods of health promotion are still being developed through discussions based on the experiences of health promotion programmes. Indeed, academics (Atkin, 2001) are only recently developing the guidelines for mass media health promotion for general populations. In consideration of this general turmoil in the field of health promotion, the methods of health promotion for ethnic minority groups have not been sufficiently developed as yet. In order to design and conduct health more promotion projects. Health practitioners who are responsible for health promotion for ethnic minority groups need to consider both the fields of ethnic minority health and of health promotion. The most common procedure used by health promoters for ethnic minority health issues is the adoption of the discussions and models of general health

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promotion. These models have been developed through experiences associated with major populations. The question is how the process of the campaign design and methodology developed through the experiences with major populations are compatible with those who have cultural and social differences from the major populations (Chapter 1 and Chapter 2). The adaptation of existing health promotion designs is clearly shown through the discussions of previous health promotion campaigns for ethnic minority groups. In terms of previous ethnic minority health promotion projects, processes and methodologies used in each campaign vary, as well as the research aims. However, the process of designing and conducting health promotion projects is generally consistent with the Atkins health promotion guideline. Nevertheless, it was shown that the campaigns that applied theories and principles for understanding the target populations social and cultural situations are more likely to achieve their campaign aims and objectives than those who merely adopted the health promotion methodology into ethnic minority health promotion campaigns. As a result of this review, we can develop a brief guideline for designing and conducting ethnic health promotion campaigns. This guideline, however, requires the more careful considerations of the target populations social and cultural aspects (Chapter 3). The conclusions of the literature review are, indeed, supported by the case study of the Malaria Awareness Project. The several reasons that contributed to the failure of this mass media health promotion campaign for Asian populations in the UK, are all indicated in that poor understanding and lack of information concerning the target populations social and cultural issues concerning both the targeted health issue, and mass media use. It suggests that adopting health promotion discussions, developed through previous experiences with major populations, are acceptable for designing and conducting health promotion campaigns for

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ethnic minority groups. However, health promoters are required to examine and understand ethnic target populations reactions associated with their social and cultural dimensions. This is aiming to minimise risks of the simple adaptations of existing health promotion discussions.

5-2 Issues of recent ethnic health promotion and future implication

The discussions in this study repeatedly indicate the importance of examining the ethnic target populations social and cultural aspects in order to enhance the effectiveness of health promotion projects for ethnic minority groups. The most important point is that health promoters are required to understand these aspects not only in relation to a target health issue, but also with the wider context. In this study, this point was clarified by the application of some examples: the target populations of the Malaria Awareness Project showed their negative opinions towards the radio advertisement to completely different perspectives from health, e.g. mass media contributions towards the creation of stereo- typical images of ethnic minority groups (Chapter 4). Apart from this project, Wingwood (1999) also discussed the poor powerrelation between man and women among African-American in the USA was one of the causes of HIV/AIDS infections among females (Chapter 3). These examples suggest that health issues and social and cultural aspects are closely linked, especially, in the case of ethnic minority groups. The correlation between socio-cultural aspects and health issues has been discussed as an important point in understanding ethnic minority health issues by those who are involved in ethnic minority health research (Chapter 1). Without this information, according to some

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scholars, e.g. Papadppoulos and Alleyne (1998), Henley and Schott (1999), health professionals may not be able to provide appropriate consultation concerning treatments and preventative medicine. In this sense, concepts of ethnic minority health issues are exactly consistent with the definition of health by the WHO31. The problem is, however, that health promoters are likely to forget this point within the guidelines of health promotion. Or they merely occasionally glance at the socio-cultural aspects of target populations within the designing process. In Chapter 3, we found that Paskell and co-workers (1999) referred the PENIII model for their FoCaS Project (Chapter 3). This model was developed through the discussion of the necessity of considering cultural appropriateness and sensitivity within the ethnic minority health promotion. In spite of the existence of this model in the field of health promotion, the majority of health promotion projects discussed in Chapter 3 did not apply this model for their projects. Further, the team involved in the Malaria Awareness Project did not consider this model for their project. The PENIII model is, of course, not a perfect solution for all health promotion projects for ethnic minority groups. However, it could be useful in consider and examine, at least once, the process of project designing. It is disappointed that many ethnic health promoters have not mentioned this model. Those health promoters experiences seem to indicate that they are still struggling with designing and conducting their project with use of a general health promotion

31

WHO defined health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (adapted from Phillips and Verhasselt, 1994, p. 3; Phillips et al., 1998, p.98). This statement demonstrates the necessity for a consideration of the total balance of physical and mental aspects of an individual body and its surroundings. For example, Phillips and Verhasselt (1994) showed the complicated connection between physical environment (e.g. soils, water air etc.), the scale and nature of human activities (e.g. agriculture, industries etc.), Biological environment (e.g. flora and fauna etc.) and human health. Poor quality of each factor, according to them, will cause the damage of human health, and thus this condition would not be considered as healthy. Their explanation of health implies that a healthy condition will be developed through satisfactions of various factors, e.g. adequate income, absence of social discrimination, adequate education as a member of society etc.

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guideline, and occasional implications of knowledge and information concerning target populations. This fact also denotes that the existing process of designing and conducting health promotion traps health promoters, rather than applying these discussions within the situations of each ethnic minority target populations. Although it was not clearly elucidated in this study, there were, indeed, very limited numbers of health promotion projects that studied the reaction to the content of campaigns, e.g. whether a health message is culturally offensive (Ziga de Nuncio et al., 1999). Almost all health promotion campaigns discussed in Chapter 3, including the case study in Chapter 4, followed the process of a general health promotion designing and conducting procedure in order to focus on enhancing effectiveness of health promotion campaigns. This process which developed through experience with major populations are not focusing on the socio-cultural eligibility and suitability of campaign context for the target ethnic minority groups (Sreberny, 1999). In this study, we especially focused on mass media health promotion campaigns. This is because of its common use within health promotion campaigns, both for major and minority populations. Mass media is widely used for health promotion because of its characteristics as a form of mass communication and entertainment. The characteristics of entertainment is a positive effect upon major populations (entertaining-education strategy), but the finding in this study revealed its characteristics are not always welcomed by ethnic minority populations (Chapter 4). The topic of negative reactions towards mass media among ethnic minority groups has never been discussed in the field of health promotions in general, although this has been discussed in the field of Communication Studies focusing on ethnic minority groups (Sreberny, 1999).

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These facts indicated that health promoters are not sufficiently using the potentially fruitful resources of discussions occurring within ethnic minority groups, which have accumulated in other field of studies of ethnic minority groups, e.g. Sociology, Anthropology, Politics and so on, for designing and conducting health promotion campaigns for ethnic minority groups. In other words, they are still likely to consider health promotion within the category of classic public health, and have not seen this field of subject from perspectives of ethnic minority groups. The confusions among health promoters is, of course, understandable because the area of health promotion for ethnic minority groups has not been developed enough in health service sectors. Indeed, raising the awareness of ethnic minority issues in health service sectors is far behind comparing to the field of academic. In academia, scholars have especially focused on this topic, and have accumulated related information since early 1980s, as we have discussed in Chapter 1. Those research results strongly suggest the necessity of considering social and cultural determination in ethnic minority groups, in order to improve those issues. However, the UK health policy and services for ethnic minority groups have not been adequate in following those suggestions emanating from academia (Smaje and le Grand, 1997; Blackmore, 2000; Kings Fund, 2000). This slow movement towards the awareness of ethnic minority health issues within health service sectors seems to be observable within the field of health promotion. This is because the field of health promotion itself is not a completed area of subject (Chapter 2): and, ethnic minority health in multicultural society is also a new target population in the health service sector. The problems appearing in this study seem to be all related to the gap between fast growing demands to conducting health promotion campaigns for ethnic minority groups and

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limited availability of well-organised data and guidelines for this subject. As we have seen in Chapter 3 and 4, many health promoters were seeking information and data from previous campaign results for ethnic minority groups (although they have been very limited), and guidelines in general health promotion debates, e.g. Atkins guideline (1999). Health promoters for ethnic minority groups collect missing information and data in these references with their feasibility research results. Moreover, they are likely to collect relevant information concerning their ethnic target populations from existing discussions in different subject fields. These methods, however, are insufficient in providing an understand of the target ethnic minority groups and to conduct effective health promotion campaigns for those groups. The gap concerning perspectives of the use of radio between health promoters and Pakistanis discussed in Chapter 4 was a good example to support this point. Additionally, the variety of approaches to campaign aims, which were shown in Chapter 3, well represented the confusion among health promoters who are struggling to find the appropriate methods of health promotion campaigns for ethnic minority groups. We should accept the fact that methodologies developed in the field of health promotion are not perfectly aligned in terms of their application for ethnic minority health promotion. Occasional applications of information concerning ethnic minority groups into designing and conducting for health promotion campaigns are likely to be at variance with the reality of ethnic minority groups, thus leading to the failure of health promotion campaigns. The findings of the Malaria Awareness Project clearly support this point. It is reasonable to conclude that a general understanding of the ways of designing and conducting health promotion campaign might provide some directions for health promotion campaigns designed for ethnic minority groups. However, discussions and information from

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the perspective of studies of ethnic minority groups should examine the details of health promotion campaign. One could suggest that health promoters should communicate with other fields of study more carefully prior to the health promotion campaigns as well as communicating with target populations. Additionally, they should provide a greater variety of theories/concepts/under-standing of ethnic minority groups into the process of designing and proceeding heath promotion projects. The core concept of health promotion, empowerment, started from the field of social development. Obviously, the core concept of health promotion has been developed with the relation of society. Therefore, it is clear that other fields of study, apart from health, will provide more clear ideas and information concerning target populations, and may minimise the failure of health promotion campaign. Health promotion for ethnic minority groups is a sensitive field of health research and application.

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