Engaging Social Media for Health Communication in Africa: Approaches, Results and Lessons

"...health-related social media interventions should be grounded in a theory of change, enhance meaningful participation of critical actors in the development process, and address the problem of inequities."

This paper outlines the promise of social media in health communication in Africa and the major limitations of their application, followed by 5 illustrative case studies. In exploring the global context: the shift toward e-health communication, Adebayo Fayoyin argues that social and digital technology has great potential for transforming health education and communication globally; for example, by eliminating some of the inherent limitations of traditional health communication through improved customisation, contexuality, interactivity, and mixed media utilisation. However, he suggests, significant caution is necessary with regard to assessing the true extent of its impact within the pathway of social and behaviour change. To explore these observations further, Fayoyin examines:

1. Social Media for Health Education on Ebola Outbreak in Nigeria: It is noted that many commentators have attributed the success of the response to the 2014 crisis in Nigeria primarily to the impact of digital media. At the time, Nigeria had over 130 million mobile phone users and 67 million internet subscribers, as well as active social networks which played a significant role. Fayoyin provides many examples. For instance, several Twitter handles were established, sharing regular information, and the United Nations Children's Fund (UNICEF) organised a campaign on Facebook which disseminated timely information and also deployed an army of U-reporters (a group of young people involved in an innovative youth participation programme) for information monitoring, reporting, and sharing information with relatives and friends. To assist in making messages on the virus "go viral", the World Health Organization (WHO) and the United States (US) Centers for Disease Control and Prevention (CDC) provided appropriate information. Countless SMS (text messaging) platforms were used to circulate information on the signs and symptoms of Ebola. National bloggers and celebrities joined in the campaign for information blast on Ebola, using their multiple platforms to educate their networks and constituencies. Health workers also used a combination of Android Apps, Facebook, Twitter, and Google Trends to identify topics of interest on the issue and communicate such to the public. However, Fayoyin asserts, critical questions need to be answered: How do we attribute specific success to social media in the process? Why has such an "information blast" not created similar breakthroughs for other health pandemics like HIV or malaria or changed the behaviour on condom use in many countries? And if social media was pivotal to the success in Nigeria, why did it not perform the same way in other countries?
2. Social Media for Group Communication on HIV with Men Who have Sex with Men (MSM) in Ghana: As outlined here, FHI360 initiated a social media campaign with MSM in 2013 with the aim of building a relationship with them and sharing information via existing social media platforms, such as Facebook, Badoo, and Grindr. Both official and closed Facebook pages were deployed in reaching and opening a conversation with the members. One-on-one interaction through identified social media platforms was integrated into the package of communication. As findings from the programme demonstrated, 15,440 unique MSM were mobilised, and many of them became more predisposed to seeking customised services. However, traditional modes of engagement with MSM leaders were integral to the intervention. Initial and ongoing face-to-face consultations were established with key influencers of the group. "Thus even with the use of social media as the dominant tool, interpersonal communication was found to be appropriate for group mobilisation....From this case, it is argued the integration of the virtual and physical space, even in designing and implementing social media interventions for health communication was fundamental to the results attained. In this case as well, it would be difficult to arrogate any 'uber effect' solely to social media."
3. Mobile Phones for Polio Campaign in Somalia: To address re-emergence of the virus in 2013, development partners in Somalia (Oxfam, UNICEF, and Hijra, a local non-governmental organisation, or NGO) decided to experiment with the use of mobile phone technology for polio health promotion. The education component comprised 4 interactive daily SMS sessions intended to reach 100,000 people in 17 districts (there was also distribution of non-food items as an incentive scheme for promoting adherence to immunisation schedule through an mVoucher mobile system). As a result of the numerous intervening variables in the programme design and implementation, it is difficult to attribute the high uptake of polio immunisation directly to the mobile information dissemination. "[T]he incentive scheme of non-food items and the novelty of digital media might have played a critical role in the programmes results. This again demonstrates the need for a robust investigation of the impact of the various variables in programme delivery in order to isolate cross cutting, compounding or mutually reinforcing variables in health communication."
4. Mobile Phones for Maternal Health Education in South Africa: In 2013, health and development partners established MAMA South Africa to disseminate culturally sensitive information to expectant mothers via an SMS messaging service in 5 different languages and a social networking platform called MXit. The intervention includes a platform, Mom Connect, designed to link pregnant women and mothers to health care workers through mobile technology as well as an interactive question-and-answer portal. Critical health messages on pregnancy and child birth issues are sent on mobile phones to pregnant women and mothers registered in the scheme. The intervention also updates client medical records in real time for health workers to have adequate information on which services to provide. Timely health messages made available across handsets and mobile carriers also bridges the information gap in ante-natal and maternal care. An assessment showed that over a million women have been reached through various messaging services. Anecdotal feedback suggests that the mobile health information programme is relevant and appropriate in maternal care and has contributed to improving mothers' knowledge on maternal and child health. The messaging service developed under the MAMA programme has also been integrated into the national health messaging architecture on maternal and child health.
5. Multi-country Social Media Programme for Youth on Sexual and Reproductive Health (SRH): In the last 10 years, Marie Stopes has been promoting sexuality education through SMS for youth across the continent. An assessment of the intervention suggests mixed results. While it provided information at scale, it observed that knowledge and information sharing did not necessarily translate into behaviour change. In Kenya, a similar mobile-based messaging campaign, Mobile for Reproductive Health (m4RH) has been running in the country for nearly a decade. In 2015, another SMS infoline was established by the Family Planning Options (FHOK) to increase SRH information and knowledge among young people. "These are two of the numerous E-Health communication solutions for sexuality education and HIV prevention in the country, which have now been extended to other countries in East Africa....Ultimately, messaging is expected to lead to discussion of sensitive issues, and finally behaviour change. However, the extent to which this assumption is validated through impact assessment is yet to be convincingly established."

In the next section of the paper, Fayoyin articulates 5 main themes with implications for the study and practice of communication:

• There is "an avalanche of social media interventions" - "Strategic alignment of social media interventions will be more impactful rather than the current fragmentary efforts supported by different development agencies."
• There is "a flood of messages" - Fayoyin underscores the need for a stronger conceptual underpinning of e-Health communication interventions in relation to the pathway to social and behaviour change. "While social media platforms are appropriate for message internationality in health education, they may not be particularly effective in addressing underlying structural issues and deep-seated cultural practices. Also, social and behaviour change is a complex process and merely reaching specific individuals with information will not result in behaviour change. To this end, it is critical to consistently apply a theory of change construct to each social media intervention in order to determine their level of social and behavioural outcomes."
• There is a "focus on digital innovation", yet "[h]aving the gadget is not the same as using it for health outcomes or for predetermined behaviour by health communicators."
• There is "inequity amidst social media ubiquity" - "Although the reach of digital interventions is significantly higher than the traditional Information Education Communication (IEC) process of engagement, it still has limited coverage and access. Equity issues are not limited to access but to utilisation."
• Social media interventions are often expert driven, yet there needs to be a stronger emphasis on the voice of the beneficiaries.
• There is a need for enhanced partnerships - "[A]dditional strategic thinking around sustainable relationships for public good will enhance the role of the private sector in health communication and overall international development. Also, widening the focus of partnership beyond corporate institutions to networks and communities helps in community E-Health communication approaches."

From the analysis, Fayoyin offers several conclusions and implications for communications along these lines:

• Theory: "...Media use in health communication is intended to contribute to specific or overall areas of change, such as risk perception, vulnerabilities, individual agency and levels of influence in social change. Thus far, substantial theorising is lacking or weak in the literature. Hence, developing appropriate theories of change for effective grounding of social media interventions is of utmost urgency..."
• Practice: "...A wider space for critical users of social media needs to be created for effective design and execution of such programmes. This will also eventually influence the current development discourse, which is still largely driven by experts."
• Policy: "Systemic policy and programme framework for effective mobilisation of the power of social media for wider development outcomes is paramount."
• Research: "... The research agenda should include impact and outcomes of interventions and greater hybridization of platforms. More amenable and accessible monitoring and evaluation skills and insights are required for effective e-health communication programming."
• Training: "...Courses that integrate informatics, data sciences, epidemiology, social marketing, philosophy, communications and human rights might need to be considered to provide the development industry with inerrant combinations of insights, perspectives and skills. Non-traditional frameworks that connect even disparate domains of knowledge will be necessary in formulating social media programmes for scale and agility in a highly contested and rights-oriented digital world."