Translating cultural differences for health messaging

August 1, 2018  |  Daphne Metland

Creating behaviour change messages in international markets presents a whole host of unique challenges. The most fundamental is understanding a whole new audience, with their own needs, preconceptions, and levels of health literacy.

Here at Thrive, we believe that focus groups are a vital tool for developing the deep understanding of communities that makes behaviour change techniques so successful.

One example of the value of focus groups is our work in Dharavi slum in Mumbai – the location for Slumdog millionaire, and one of the biggest slums in the world.

According to a recent World Health Organisation report, one woman dies every five minutes in India from pregnancy and birth related incidents. We visited Dharavi to carry out research for a mobile phone messaging programme to help improve health outcomes among pregnant women and their babies.

The women in the slum live in makeshift houses with no running water and no toilets. But when we invited some to a focus group, they turned up in beautiful saris and jewelled bracelets. They dressed up in their wedding saris, walked through grimy streets at 30-degree heat to sit on the floor in a local health clinic and tell us about their lives.

We thought six to ten women would come, but word spread and we had about 30 women in the room and another 10 or so crowding around the doors and peering in the windows!

Dharavi women

At first they were shy to talk about being pregnant and having babies. But like women the world over, once you chat a little to make them feel comfortable, they were soon competing to tell their birth stories.

What we learn from this process is invaluable. We are used to performing rigorous research, and always have all the stats at our fingertips. And we also visit hospitals and conduct in-depth interviews with key healthcare experts, to better understand the situation on the ground. But how nothing can substitute for the real, unfiltered experiences of communities and service users.

One of the main causes of maternal death is anaemia. These women are so lacking in iron that once they start bleeding at the birth they don’t stop.

We knew that iron tablets are free to pregnant women, and were keen to understand why take-up of this offer was so low. Local doctors and healthcare providers believe that it was because the pills can cause constipation, but we wanted to hear from pregnant women themselves.

We asked the women in our focus group the same question. There was a silence, then a bit of whispering and giggling. Then one brave woman spoke up. “That’s not the reason,” she said, “it’s because we don’t want our babies to have dark skin!” Iron tablets are black. They make the faeces black. In India having a fair skin is rated very highly, and is seen as a passport to a good job and a good marriage. So the thought that these pills would make their baby’s skin darker was a great disincentive for these women.

We listened and learned. We wrote messages explaining how iron pills could save their lives, how they would help their baby grow strong, how to cope with constipation and how they would NOT change the colour of the baby’s skin.

This is just one example among many of how focus groups can reveal fascinating local beliefs and behaviours. Only by truly understanding a local audience, is it possible to effect real, lasting behaviour change.