By Hema Vishwanathan

Getting the right policy decisions is in large part a function of luck. Everything depends on having the right bureaucrat in the right place at the right time.

Advertisers are masters of the art of persuading people to buy stuff! How can we use their skills to promote health literacy? What lessons can we learn from them? Let me illustrate this point with two personal examples. It is my hope that we can adapt these to promote health literacy as well.

Before we start , lets run through these basic marketing thumb rules:

• Define and describe your target audience: Who are you addressing? Before communication can begin, you need to know who this person is (demography), where he or she can be found (geography) and how he or she can be reached (media).
• Understand your target audience: All good communication begins with understanding the customer and looking into her needs, wants and expectations. Needs are both overt and subliminal and the world of advertising has mastered the art of addressing subliminal needs in subtle yet powerful ways. Greater impact is achieved through fulfilling subtle needs as compared to the more overt needs.
• Decide on the message and keep it simple: The third requirement is to get a clear handle on the message that you want to deliver. What do you want to say? What does the consumer (patient/ audience) want to know? Somewhere in the wide gap between what you want to tell and what they want to know, you need to strike common ground. The point where they intersect is a good starting point because it is only when communication starts from a point of mutual interest that it has any hope of going forward in a productive way.
• Say it again and again: Communication needs to be repeated - over and over again. Messages do not go out easily, even when talking one-on-one. There are gaps between the intended and the received message. There are gaps in attention span and perception. There are distractions. Worse, when mass media channels, such as television or radio beams out messages to millions of people in an impersonal fashion, the gaps can be huge. In addition to the problems mentioned above - attention, intention, perception and distraction - there could be the problem of noise and clutter. Hundreds of messages are trying to reach out to the same person - and he really does not want to listen to any one of them. They are trying to grab his attention at a time when his interest lies elsewhere.
• Use modern-day communication tools: Communication today is a different ballgame altogether. It is continuous, instant, and hydra-headed and multiple armed, so that it often defies comprehension and measurement. Todays flavor of the month can be a billion dollar blockbuster - or end up in the garbage heap - and its impossible to predict this with any degree of accuracy. The good news is there are now myriad opportunities to reach out to the end-consumer - through the Internet, mobile phone, through search engines, messaging, and free-todownload apps. The opportunities to connect have multiplied and become omnipresent.
• Get the policy makers on your side: Without political will, all public health efforts will come to a naught. Of course, getting the right policy decisions is in large part a function of luck. Everything depends on having the right bureaucrat in the right place at the right time. If you get lucky in finding someone who is willing to listen and is somewhat committed to improving public health, take it that half your battle is won. Without this kind of a person in the chair, all well-meaning efforts are likely to go down the drain very quickly.

Case Study One

Our first story unrolled in the mid-1980s when WHO expressed concern over the steep rise in diarrheal disease among children in India. WHO made the assumption that the deaths must be happening because mothers were ignorant and probably stopped giving the child food and fluids when he/she got diarrhoea, in an attempt to stop diarrhoea. A communication strategy was being planned when a few senior officers at UNICEF decided that the assumptions needed to be checked out. I was fortunate to be in charge of the nationwide research that sought to understand what mothers actually did when the child developed diarrhoea.

In the first phase of the study, we went to mothers from over 150 villages spread across the country and asked them: "What would your grandmother have told you to do when a child had diarrhoea?" That simple question revealed a long list of fluids and semi-fluid options that completely stunned the decision-makers who had assumed that mothers would be ignorant. It revealed that the traditional knowledge on the subject of rehydration was excellent. We found that mothers knew about rice water, dal (pulses) water, buttermilk, barley water, breast milk, coconut water, khichdi (a mixture of rice and pulses cooked together), sago porridge. the list was long and rich. The tradition was and had always been to give fluids and semi-solid foods to a child during diarrhoea.

But why, then, were children dying of diarrhoea and dehydration? If the knowledge was so good, what was the problem? The second phase of the study looked into what mothers had actually done in practice. So we went to nearly 10,000 mothers across the country whose children had had diarrhoea in the last 15 days and asked them: "What did you give to the child when he had diarrhoea?"

The answers once again stumped us. These others had given nothing other than tea, milk, water. The rich tradition of rehydration, about which there was still some residual knowledge, had in fact been lost in practice. Lack of time, lack of conviction and the desire to be modern had led the women to shun "grandmothers methods" although there was no equally effective alternative available to replace the old cures.

The study also found that mothers were not keen on giving a homemade sugar-salt solution to the child. This lacked the scientific aura of expensive medicines, or impressive injections. If she must do something at home, we realised, she would prefer to rely on a commercial packet of ORS. In addition, we tested (and found) that it was difficult to get her to add the right quantity of salt to a litre of water.

Armed with all this data and with the help of the Health Secretary, the findings were presented to the Parliamentary Consultative Committee on diarrheal disease. These were accepted and the revised National Diarrhoea Management Plan (NDMP) was drafted to place major emphasis on well known, localised, home available fluids and soft food as well as on breast milk for infants; in addition, the child was to be given ORS. That was the time ORS was deregulated and made available over the counter (OTC). The revised NDMP planned a major social arketing effort to make ORS widely known and available.

Based on all these findings, we launched a major communication campaign, under the aegis of the Ministry of Health that ran from 1988 to 1998. Television channels beamed out messages on the public service channel (Doordarshan) as well as a few private channels reminding mothers that some of the best remedies for diarrhoea were to be found right there in the kitchen, remedies that had been known to Indian mothers for many centuries. In addition, she could also approach her nearest health worker for a packet of ORS and keep the child continuously rehydrated. The campaign worked very well and resulted in a clear decrease in diarrhoeal deaths.

Case Study Two

The second case study is about a communication on Infant Immunisation. When the Government of India decided to make the Universal Immunisation Programme (UIP) a public health programme in 1987-88, it set up a Technology Mission to ensure a successful adoption of the programme. It was planned as a phased rollout, with the first pilot being carried out in 12 districts across the country. Once again, I was fortunate to be in charge of the research team that was asked to look into the problem of programme dropouts because it was found that most mothers tended not to finish the course.

We realised that an important part of the job would be to convince parents that it was important to get the child immunised. In addition, communication was needed to persuade grandparents, with whom the idea of disease prevention did not cut any ice. It made no sense to them to take a healthy child and get him injected and then have him feel unwell the next day! However those who worked on this programme knew that the results would be visible only 20-30 years down the line, a prophecy that has come true today. A follow-up study provided an interesting revelation. When we asked mothers what they feared more "disability or the death of their child?" over half said that they feared disability more than death. This was even truer in the case of a girl. If a child became disabled, the worry and difficulties lasted for a lifetime and spelled financial disaster for the family. While a childs death was also deeply feared, the idea of a child becoming permanently disabled was much more traumatic because it was felt to be a fate worse than death.

This insight provided the communication handle that we needed. It was decided that our communication would play on this fear factor and use polio as the leading message. Posters and advertisements used pictures of a young boy severely disabled by polio. The message was - you can prevent this from happening to your child by getting your child immunised today. It worked. Today we have over 75% infants covered by BCG and DPT 1. It is a joy to learn that India would be declared polio-free by 2014.