Media , Health & Health Promotion in Nepal

It has been recognised that the media can affect our perceptions, views and tastes on a wide-range of issues. The mass media in it various forms (newspapers, television & radio, the internet and Twitter) and formats, have a far reaching influence through, for example news programmes, documentaries, advertising and entertainment. At the same time the mediacan also be seen as a channel for agencies responsible for public healthto get their messages across to the population. Public health agencies are always searching for ways to disseminate health information and messages to their intended audiences. These are, of course, global concerns, but as both public health and the media are part of the society in which they operate there will be locally specific issues and considerations. To date most of the research into the media and public health has been conducted in high-income countries, and there has been very little research in Nepalon the interaction of public health and health promotion with the media. This overview paper highlights some of the key issues that public health practitioners, media editors and journalists, health policy-makers and researchers could consider.


Introduction
The mass media in Nepal, as elsewhere,play an important role in modern society in general and in public health in particular.In Nepal every day there is at least one health story in the media, be it about the discovery of a new drug,some kind of health scare, or new public health advice.It is therefore important that public health professionals are aware of the media's potential impact on health perceptions of the population.

Media and health: key issues
Dahlen and Homer remind us that the media both generate and reflect public opinion [1].The media offer information, news and entertainment, in doing so they have the potential to educate, help set the policy agenda and influence the views and expectationsof their audiences.At the same time the media can be (arguably should be) powerful observers and critics of the establishment.Curran explains, '… the media can also be viewed in a more expansive way, in liberal theory, as an agency of information and debate which facilitates the functioning of democracy' [2].The media play a significant role in maintaining a functioning democracy by reinforcing order and stability and replicating societal norms.Hence, the media are referred to as the fourth estate, as one of the pillars of democracy (besides the original three estates Legislature, the Executive and the Judiciary).Long before television, radio, Twitter and social media in general the role of the press was envisaged in the Edwin van Teijlingen, 1-3  Freedom of the Press Clause in the First Amendment of the United States of America's(USA) Constitution as both a critic and educator [3].However, while the media may hold this important role, we need also to remember that the media need to make money, be it through subscriptions or through advertising revenue.Even the public media often need to reach targets in terms of readership or a share of the national audience at the 20.00-21.00prime television watching slot.

Health coverage media in Nepal
Media in Nepal have grown substantially since 1990, which before that wereall state owned [4].According to the United Nations Democracy Fund there were 99 daily newspapers and 399 weeklies in Nepal in 2009 [5].Radio has long been the most accessible form of mediawith more than 2 million people owning a radio in Nepal in 2006 [6].Television is growing, with 15 stations now broadcast in the country [6], and the Internet is reaching 3.1 million people [7] with Facebook now the most popular social networking site with over a million people accessing it each day.Other social media such as Twitter are less popular with the populous at large, but quite prominently used by journalists to gather news [8].
Media is being accessed by Nepalis to learn about topical health issues.There have been a number of studies looking at the role of the media in relation to health.Devkota and colleagues examined media exposure and sources of information among 120 parents in Kathmandu Valley on childhood immunisation [9].Respondents were asked whether they had listened to or watched particular health programmes on radio or TV,including 'Jivanchhara,' one of the most popular television series on Nepal Television and 'Jana Swyasthya', a long-running(50 years) programme on Radio Nepal.The study found that 49%of parents reported watching 'Jivanchhara', although only 31% knew the correct broadcasting time, whilst 28% had listened to 'Jana Swyasthya'.Kumalet al. analysed three major newspapers' coverage of health issues over a threemonth period in 2012.They found over five hundred news items, only ten percent of these were frontpage news, 44% related tohealth policy and nearly a quarter (24%) focused on health workforce issues [10].Overallfar more health news was negatively reported (65% vs 35%) than positively reported [10].
A recent study on the impact of mass media on antenatal care in rural Nepal reported a positive association between exposure to mass media (radio being most popular medium, followed by television) and the uptake of antenatal care [11].Consequently, Acharya et al. advocated increasing the awareness of rural women through massmedia to help improve the utilisation of antenatal care in Nepal [11].This research ties in with research on the way pregnancy and childbirth are portrayed in the media [12].
Ojhaet al. explored the appropriate mass media for increasing awareness about positive mental health.Exit interviews were conducted with 400 outpatients in two mental health hospitals in Kathmandu in 2005.The researchers suggested that while the majority of participants knew about the existence of mental health care facilities through conversations with friends and family, the awareness of information regarding mental health was low.It was suggested that policy makers and government agencies should be aware about the role of mass media in the promotion of mental health services in Nepal and that campaigners should focus on increasing public awareness through the medium of television [13].
Researchers in the United Kingdom found when conducting a scoping review of the academic literature around childbirth and early labour that most depictions of childbirth on television show it as being medicalised, meaning that birth is risky and dangerous and something to fear andthat women turn to media to learn about childbirth despite the fact it is mostly negative.Luceand colleagues also state that the literature indicates that birth as a normal 'everyday life event' is missing in Western countries: '…television is genre that is known to stretch the truth.This medium requires drama, danger, crises and unusual events such as unpredictable and fast deliveries and doctors as heroes, hence a typical birth with a normal slow and lengthy labour without interventions and pain relief and attended by a midwife is less likely to be shown [12].
Those in the mass media often like to regard themselves as standing up for good causes.This is referred to as media advocacy, for example when a newspaper or radio station starts campaigning against an injustice or for a change in legislation.Media advocacy has become an established health promotion strategy, following the Ottawa Charter for Health Promotion in 1986.Health promoters often seek a 'partnership' or 'shared agenda' with the mass media when communicating health information to the general public [14].
There are two advantages to such a partnership, first, public health agencies often do not have to pay to get the VIEW POINT message across, and secondly, because the message does not come from a public health department (boring health professionals and perceived busy bodies), the message might be more acceptable to the audience.If the initiative is perceived to be originating from the media then the message can be more implicit and subtle.For example, the message can be built into popular television programmes or radio dramas.Many health promotion messages originating from public health agencies have to be more explicit and directed to reach those people in the population with poorer health literacy.
The disadvantages of these partnerships should not be ignored.First, those working in media and public health may have different priorities and second, they may see very different solutions to the health problem raised.Moreover, the media have been accused of shaping public opinionin a particular, often negative, way on issues such as childbirth, sex education, healthy (unhealthy) eating, etc. [12,[15][16]As Stallings'sociological analysis suggests the media represent "some conceptions of risk but not others."[17] Understanding howmass media operate Some say it is a prerequisite to gaining the cooperation of those who control access to media time and space to improve the coverage of health issues about which the public needs, and often wants, to know.Consider the question: "Can we make strategic use of mass media to apply pressure to advance healthy public policy?
Public health needs the media to convey its own messages to its audiences.Mass media campaigns are still a staple of public health.Nutbeam reminds us that many such programmes were found to be effective in the late 20 th century but only among people who were better educated and richer [18].It seems pre-internet mass media were more likely to reach those better-of people, with higher health literacy, skills and economic means.These factors helped them to understand and respond to massmedia health messages.
Wakefield and colleaguesin their review of mass media campaigns found that passive exposure to health messages was frequently unable to compete with other influences such as product marketing and socio-cultural norms in changing behaviour [19].As a consequence public health is increasingly turning towards social marketing, and exploring how the use of the mass media can get public health messages across to target audiences by harnessing the power of commercial adverting.For example, the producer of toothpaste who utilises public health messages advertising the need to brush your teeth with their brand of toothpaste or a fruit companythat offers education materials free-of-charge to schools in the USA.Robinson et al. found that 'when campaigners combine mass media and other communication channels with distribution of free or reduced-price health-related products' there is an improvement in healthy behaviours [20].

Leaflets
from charities, non-governmental organisations (NGOs) or international nongovernmental organisations (INGOs) can also be regarded as health promotion, for example a leaflet produced by an NGO on the problems withnot taking up skilled attendance at birth.Such programmes may also harness the media to get the message out.Charities may try to build relationships with journalists and editors to 'adopt the media' to push their messages out.It is worth bearing mind that most of the health communication interventions in Nepal are funded by INGOs [9].
Increasingly public health advocates have used the mass media not just as a vehicle to get a message to the general public, but also to speak to politicians.The latter must have had some effect as the most recent National Health Policy 2014, specifically emphasised health promotion, creating healthy environments, and service users' participation [21].Many politicians are avid media followers, especially if they are named or their party is implicated in the public health story.The same is true for multinational corporations, large public bodies and INGOs.Many of these organisations keep a close eye on the media, not just the news, to keep track of how their organisation is portrayed and perceived by the general public, potential customers and even suppliers.Those working in public health should be aware of this and use this knowledge when designing public health messages and campaigns.

Practical advice
So now that you, the reader, are convinced about the value of media, how do you begin to harness the media?
• The first thing to remember is that the mass media are looking for new stories every day; there is nothing exciting about yesterday's news.Journalists talk about a story having a 'hook' or a good angle-what is it about the story that is new and interesting and will engage the reader/viewer?You should always have a press release available with a quote from the head of your organization, and also summarise what your message is and the relevant contact details for the best person to contact should the media require more information.It also would not hurt to have digital photos and/or video available to provide.This will save the media time, and also give your story an edge over the other stories that are being pitched that day.
• If you are asked to speak to the media, the first and most obvious advice is to be prepare and make sure you know your facts and figures.If you do not know them, don't try and guess on the spot, make a note and tell the journalist you will look it up and call them back.That also gives you one more opportunity to speak to the journalist before they run their story.
• Public health professionals, or others in the business of promoting health, should consider media training on how to get a clear and concise message across in the short amount of time that is usually set aside for an interview.Learn to speak to the media and where appropriate simplify the message for general consumption.
• There is no such a thing as an 'off-the-record comment' for a journalist.Be aware that what you say before a formal interview starts, or after it is finished, may be included.Similarly something that you say in confidence may very well be included in a media report: be it a newspaper article or an edited interview on radio or television.Always ask for the interview to be recorded and never ask to review the story before publication-you need to build trust.
When you are invited to speak to a journalist or reporterhave a look at one of the many pages of advice to health researchers and professionals such as the one of the University of Manitoba (see: http://chrr.info/resources/media-tips).

Final thoughts
The media offer a vital outlet for health promotion advice and health information more generally.Both the general public and health care workers learn about health and medical issues through the mass media; although it is, of course, not the only source especially for health care workers.We must all be aware that the media can misrepresent health issues, statistics and their likely effects.Such misrepresentation is partly through selective reporting and partly through sensationalising issues and focusing on negative effects.Always remember good news is often 'not' interesting enough, you need something that will answer the most basic of questions that the media asks: Who? What?When?Where?Why? and How?Who is this story happening to?What has happened (the event)?Where has it taken place?Why is it happening now and how has this all come about.If you can answer those questions going into any conversation with the media, then you know you have at least covered the basics.