RETHINKING THE APPROPRIATENESS OF HEALTH EDUCATION MESSAGES : PROBLEMS , PRINCIPLES AND GUIDELINES

This articie is based 011 research to design a //Jodel for appropriate health education messages in a lI1ulti-cllltural developing community The Ph.D study was completed at the Uni\'ersit), of Srellenbosch ill 1998. Nowadays the media are playing all increasi/lgl)' powetful role at aft/evels of health educalioll ill developing alld developed couflfries alike. The inappropriateness of media messages, though. is a major contributing faclor illlhe j1ucfllalill8 effectiveness of health educalion programs. There are a number of variables such as elllfllral relevancy and familiarity of medical termil/ology used that tletermil/e the appropriateness of health education messages. Messages that are culfllrally iI/appropriate could lose its credibility and could even result in polarising the health beliefs of tlifJerent communities. It could also reinforce risk behaviour. thereby making it most difficult to accomplish disease prevel/tion alld health promotiol! objectives. This article presellls a theoretical perspective ill this regard. It leads to the HAMSOC model Ihat indicates key principles for improving rhe appropriaul/ess of health edl/catiol! messages ill a multi-culmral developing commullity. Practical gllidelines alld examples are givel/ regardillg tile modificatioll of iI/appropriate messages withill this particular cOllfext.


INTRODUCTION AND BACKGROUND
Over Ihe paSI IWO decades different channels of communication, particularly Ihe mass media.have made an increasingly powerful impact on public awareness and knowledge about health and illness.Owing to the freque nt coverage of AIDS related aspects in the mass media, Berridge (1991: 179) refers to AIDS as the fi rst "media disease".Communication is also at the heart of health promotion, because people arc involved in the process o f giving and receiving information, learning from each other and empowering others in order to make informed decisions.Consequentl y, Ihere is a growing awareness amongst health professionals that health problems nowadays cannot be dealt with effectively wi thout considering the role of communication in general.and media in particular, in the development as well as prevention of diseases (Kickbush, 1996:259;Parish, 1999:44).The South African health authorities support Ihis viewpoint.In 1994 the Minister of Health made the foll owing public statement: ••Wc need the media.The concepts of promotio n and prevention needs mass communication.We should develop a dynamic working relationship with the media.They need 10 make news; I need to gct messages ac ross" (Robbi ns, 1994:3).
While modern lechnologies play an increasingly powerful role in the dissemination of health in fonnat ion, there arc still speci fic problems in health communication that need urgent attention.Many health educators in developing countries such as South Africa, lack the necessary skills to communicate and use media effecti vely (Hugo. 19%:80;BUller, 1999: 14).In addition, the media used in health education programs arc o ften inappropriate, for a num ber of reasons.This ineludes inappropriate technology for delivery of health education messages (Robson, 1989:65).and the presentation of information in communication codes that arc not suitable on the basis of visuallileracy (Baggaley. 1989:99). ---18----------------------~--~~----~--~--------- It seems that there is sti ll too much emphasis on the role of technology as such, and too little emphasis on information design.Various experts such as Atkin and Arki n (l990), Tones ( 1991 ), Livingston (1993); Hubley (1994), as well as Maibach and Parrott (1995) agree that the inappropriateness of media messages playa significant role in the fluctuating effectiveness of health education programs.Woodcock, for example, contributed adolescents' abil ity to recall specific teaching methods in sex education in a speci fi c case to the inappropriateness of educational videos (1992:5l7).Levin in tum ( 1996:282), points out that most health promotion materials are written at a reading level too difficu lt for the majority of the American popUlation to comprehend .What we tend to overlook, are the potential negative effects of inaccurate or misleading information , in the sense that it could promote rather than change or prevent risk behavior.Therefore, Wallack (1990:147) warns health communicators and health educator.;against inappropriate messages as a source of "anti-health education".The following remark in a field stud y to assess the effects of mass media campaigns about eati ng habits in the United Kingdom doesn't require any explanation: 'There's such a lot of nonsense spoken about food, particularly on the electronic media, so I tend to ignore it" (Goode d aI. 1996:292).In South Africa the same pattern occurs.The controversial musical play, Sarafina II. is a good example .Thi s particular play indeed met the requirements of entertainment in using popular local methods of health education (by way of music and theatre).On the other hand, it seemed to fail as a public AIDS education tool, thus having only limited value according to the "edutainment" formula.Also in this case, the feedback from a member of the audience proves that we .stillhave a lot to learn.After seeing the playa (HIV positive) respondent made the following comment: "Tot pouse toe het die stuk my net geleer dal, as jy uitvind jy het Vigs, moet jy kerk toe gaan en op God vertrou" (Snyman, 1995:20).
It is important to nOle that one cannot take it for granted that media effects on the wide mnge of audiences involved in health education and health communication are always positive (in terms of promoting health y lifestyles).Inappropriate.inaccurate and mislead ing messages could reinforce health risk behaviour,.rather than reducing or preventing it.Authors such as Graeff d aI. (1993) as we ll as Maibach and Parrott (1995) make it quite clear that inappropriate media messages could have serious effects on the lifestyle and health behav• iour of individuals.Baggaley performed extensive research on smoking prevention and AIDS TV campaigns in a number of countries during the eighties.His ' studies showed that inappropriate messages (by putting too little emphasis on educational aspects) could result in polarising public beliefs regarding health and diseases (Baggaley, 1986:43;1988:7).McBean (1996: 14) reports that some mass media messages in the Caribbean region actually promote, rather than change teenagers' behaviour that could increase their risk of AIDS.He poi nts out that television and film still tell the public that ad ults enjoy free (unprotected) sex, that alcohol is the solution to solving sexual connicts and that those who feel depressed often resort to desperate measures, including vio• lence or drug abuse.These two examples hopefully make us more aware of the potential undesired effects of inappropri• ate media messages in society.

PROBLEM STATEMENT AND OBJECTIVE
One of the critical influencing factors that has not received sufficient attention when it comes to appropriate messages in health education is socio-cultural sensitivity.According to Webb (1994:207) AIDS messages in the United Kingdom are often inappropriate for specific ethnic population groups.In one case the message has offended black communities.leaving many groups angry and not prepared to participate in HIV/AIDS education programs.Is this perhaps the reason why AIDS educat ion campaigns in South Africa.like many othcr health education interventions up to this point have had much less impact than expected?In view of this the foll owing research question was formulated : How could we improve the appropriateness of media messages for health education within a culturally diverse society?What is currently missing is a model that clearly specifies the key principles and factors that determine the appropriateness of health education media messages within this particular context.We need a better understanding of the relationshi p between health communication, appropriate technology, health education and cultural issues of health and well-being.According to Ram (1989:9), the impact of modern information technologies in public health promotion could be increased if a functional context exists for making medical information user-friendly.He explains as follows: " Health is an abstract idea that is much better understood in the context of per.;ons and places.Medical knowledge needs to be put in simple and under.;tandablelanguage backed up by appropriate technology".The proposed mode l is based on the hypothesis that message ap propriateness for health education in a multi-culluml society could be improved by applying the principles and strategies of health education, appropriate media and technology, as well as socio-cultural sensi tivity respectively.But we must go beyond mere theoretical discourse.If possible, such a model should include practical guidelines for improving the design of health learning materials and health education messages.The objective of this study was to generate a mode l that meets these requirements.

Basic concept and structure
From a brief analysis of the literature one can conclude that there is some or other link between primary health care (PHC), health education.health communication and media usc.PHC refer.; to essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community can afford.PHC includes at least education concerning prevailing health problems and the methods of preventing and controlling them (Brink, 1989(Brink, : 1346)).To Werner and Bower (1982: 15-1) there is no doubt that such a link does exist.The authors discuss basic - --------------------------------------------------------'19-- principles and examples of appropriate and inappropriate technology as well as low-cost materials for health education in developing communi tics.Hubley (1994) also covers various appropriate media for heallh education in developing countries in detail.Scholars of development communication (Fuglesang, 1973: McAnany, 1980;Marchant. 1988) rder to the IEC (lnfonnation, Education, Communication) strategy applied to fac ilitate commun ity development activities in Third World countries.Since public health education could be viewed as pan of comm unity development activities.the IEC concept is also found in health communi cation in developing countries (Hubley, 1994: 17;Temu, 1997: 18).
From a structural viewpoinlthe HAM SOC model is based on three cornerstones.nam' cly Heallh Education, Appropriate Med ia and Tec hnology, and Soc io-cu ltura l sensitivity (HAM SOC is the acronym for these th ree cornerstones).It is argued that the appropriateness of health education messages in this panicu lar contc' xt is the result of the interaction between the three primary components, as illustrated by the overlapping areas in figure I.In other words, each individual cornerstone has an influence on the olher two componcnts.The centre area of the figure where the three cornerstones ove rlap.symbolically indicates that the ideal strategy is to put equal emphasis on all three primary components to achieve the best results.Each of these cornerstones covers a number of theoretical issues that can not be discussed here in depth.For example. the selection of relevant content and the most suitable methods of delivery thereof spring to mind regarding heal th educati on.whik appropriate media use includes the selection of a suit able mcdium (or med ia) to achieve stated object ives and long tam outcomes.
In order to go beyond the surface of the basic structure, figure 2 presents a morc dClaikd picture uf the mult i•dimensional phenomenon we arc deal ing with.It shows a number of important features.Apart fro m the three cornerstones (identified in figure I) figure 2 indicates the primary outcome, eight generic principles for effecti ve media use.as well as three secondary compone nt s. namely Communication, Media Acculturation, and the Context respectively.The primary outcome is the improved health and wellbeing of: individuals (eg. a diabetic patient.alcoholic.teenager with eating disorders, HJV or TB infected patient.etc.): fami lies or particular groups (eg.drug addicts, teenagers and adolescent s with unsafe sexua l habits, mothers at a neonatal care clinic, etc.): and certain communi ties in need of health education (eg.communities with a high inc idcnce of TB.HIV infection and ch ild malnutrition).

Socio-cultural
Sensitivity , The different contributing components have varying levels of importance.Therefore.the primary outcome (health and well-being) lies at the first (widesllmost general) level.The second level comprises eight principles for eff~tive media use, namely effectiveness, efficiency.evaluation, appropriateness, etc.The third (and most important) level includes the three cornerstones, three secondary components and the major target groups.
We must point out that while some principles and components are more important than others, none of the indicated factors could be ignored.Tn other words, all of them play some or other role in message appropriateness.At the same time, the three primary components are equally important, because the model is based on a holistic approach.This means, for example, that if the principles of one of the cornerstones are ignored you will very likely end up with less The same applies to the communication dimension and contextual dime nsion.For example, you can only deal with communication as pects effectively if you consider the principles and processes o fheallh education full y, on the one hand, and the use of appropriate media and technology, on the other hand.In simple terms, the primary components act as the cornerstones for the secondary dimensions.while the secondary dimensions indicate ~e main variables that should be considered as the result of the interaction between the primary components.
One is aware that a graphic diagram falls shon in giving a full picture o f reality.It must be emphasised that message appropriateness, like communication, is definitely not a static phenomenon with fi xed highly controllable variables.
In fact, message appropriateness is a relat ive phe nomenon and the re fore a certain message is always appropriate only fo r a specific need, audience and si tuation.In other words.the same medium or message could be highl y sui table for a cen ai n aud ience.but completely inappropriate for another.In view of this.some of the key pri nciples o f the HAMSQC model need funher clarification and discussion.

Principles
It 's tIle message (ill the medium) that counts We cannot contest the fac t that media can make both commu nication and learning more stimulati ng and effecti ve.
However.all health educators should be reminded that the effectiveness of media is firstly determined by how yo u use it.In this regard Tones ( 1993: 135) points out that some health workers still regard the modern mass media as "magic bullets" in the fi ght agai nst d iseases like HIV/AIDS.The pri nciple is that media should always fonn an integrated part of educational programs as a whole, instead o f being used as crutches to prop up med iocre teachi ng (Green & Simons• Mon on. 1984:296).Another imponant implication is that the emphasis should be o n how you formulate your information (by usi ng d ifferent communication codes).rather than on technological gadgets .In the late seve nties Salo mon (1976:26) concluded that technologies o f transmission per se make hard ly any d ifference in learni ng; it is the symbolic code (text, pictures.sound, etc.) into which a message is dressed that affects learning.The point is that we must pay much more attention to specific media aspects in communicating health education messages.
All audience-cell/red approach Probably the biggest lesson health communication prac titioners have learnt over the last decade is that the effecti veness and impact of media messages in health communication depends in the first instance on a clear audience-oriented approach (Maibach & ParroH, 1995:67), A decade ago health education programs often fell short in this respect, as Wellings ( 1987: 146) reported about weak points in some public AIDS prevention campaigns: " Blanket messages aimed at a homogeneous at-risk population will be inappropriate because, for the purpose of preventi ng Aids, such a population docs not exist".This means that we must focus on well defi ned targets (outcomes as well as audiences).This requires proper target differentiation in the planning phase of a health education program or mass media campaign, before focussi ng on the needs and circumstances of a particular (single) target group.A number of academic scholars and health education practitioners support this particular viewpoint.Berridge ( 199 1:179), for example, has concluded that the analysis and formulation of guidelines regarding media effects in health education should stan with a study of "differential (media) effects on different groups of society".One find s that an increasing number of developing countries have taken this to heart, as illustrated by specific criteria and requirements for planning public mass media communication campaigns (Aghi & Carnegie. 1996:24 ;Temu, 1997: 18 Stanton.1997:39).
In South Africa thc advertisi ng industry.as panicipants in the design of health education messages via the mass media.also recogni ses the importance of market segmentation.This is not done along cultural-ethic lines anymore.but on the basis of media user tre nds.Green and Lascaris ( 1988:66) summarise the approach nowadays: "Our burgeoning, multi-ethnic populatio n is all set to outgrow and overpower the old racial barriers.But ironically, in a media sense audiences will be more divided than ever before.The difference wi ll be that in fu ture, segregation will not normall y be purely along racial lines.We foresee a continuing trend toward narrowcasting (as opposed 10 broad-casting)".For this reason the SABC has taken speci fi c steps towards making both television and radio programs more relevant to the needs and cultural background of different communities.Consequently, a num ber of (local) community radio stations all over South Africa were introduced to complement programs of general nature.The same princi ple w~applied in the restructuring of the television chan nels by the SABC.The program ';Cape at Six" which features program content of events in and around the Cape Peninsula is a typical example of the results of the target/audience differentiated approach.

Sensitivity to socio-cultural vari4bles
The emphasis on target differentiation would most likely lead to an increased sensitivity to socio-cultural issues in health education and communication.It is important to note that Whitehead (1992 :154) descri bes the insufficient attention to socio-cultural factors as the ' "mi ssing link" in health education.She argues that the successful breaking down of barriers of misundersta nding in health communication depends primari ly on sensitivity to d iffere nt socio-cultural aspects of health.illness and disease.As far as media is concerned, authors in both developed and developi ng countries since the late eighties have emphasised that health learning materials should meet the requirement of socia-cultural sensi tivity (Mares eI a f.1984:64; Bhopal & Donaldson, 1988:139;Folmer eI aI. 1992:45;Livingston, 1993: 189).
Socia-cultural sensitivity, within this particular context, refers to a clear awareness of the role of different socio-cultural variables in the acceptability of health messages and learning material s for specific audiences.as well as showing respect for the differences in life values, habits and beliefs of individuals.It ties up with strategies for analysis of underlying factors (eg.personal lifestyle) that should be considered in the planning of disease prevention interventions on the primordiallevel (Beaglehole et al. 1990:80).

Appropriate media and technology
Most governments are aware of the widening gap between the technological rich (the "haves") and technological poor countries (the "have nots").This has forced developing countries to adapt certain available resources imported from the wealthy nations to fit local needs and socio-economic conditions accordi ng to the princ iples of appropriate technology.This practice is fou nd , inter alia, at all levels of formal education.including medical education (Michel, 1987: 125;  Maskaliunas et al .1995:5).The development of appropriate technology is also common practice in health education.
Under the general theme "'New horizons in health" delegates at the XVlth World Conference on Health Education and Health Promotion held in Puerto Rico in 1998, identi fied the development of appropriate information and communication technologies for health education as a key challenges for the fu ture (Arroyo. 1998:5\).Within the conte xt of heal th education appropriate technology is a fashionable way to say that you do th ings in a low-cost, effective way that local pea-pIe can manage and control themselves (Werner & Bower, 1987: 15-1).The term 'appropriate media ' refers to content, communication codes and media formats that fit the literacy level as well as cultural and socio-econom ic background of a particular target audience in achieving speci fi c health communication objecti ves.The South African wind-up radio is a good example of appropriate technology that fits the needs and conditions of devel9pi ng countries.This radio operates for about fony minutes py way of a simple wind-up ge nerating system.The C i ne m ~ Donkey project, where health ed ucation fil ms are tran~ported over heavy terrain in rural areas o f Northwest-Ke nya by means of a donkey (Henrich, 1989: 10). is another excellent example o f appropriate media/technology where poverty prevents health educators fro m using more sophisticated modes of communication.On a less sophisticated level.developing countries ha\'e a long tradition of using so-called "traditional" or "popular'" media suc h as various form s of puppetry.music.songs.nannel boards and vi llage theatre for community health education (Hubley, 1994:23 1).A unique feature of these methods of health educatio n is that people fro m local communities produce them.They use materials that are locally avai lable.At the other end of the scale, appropriate technology for health education could also include more sophisticated modes tools of communication such as the Internet-web.and satellite television (Fodor, 1996:5;Ski nner, 1997:23).According to Gebreel and Butt (1997:33) health education by means of simple low tech media can be as effecti ve as hi gh tech communication media.

Practical guidelines
As stated be fore.a key objective of the model presented here is to set guidel ines for improving the appropriateness of media messages in health.education.The val ue of the model would be much more evident if some practical guidelines arc included here.for example on how to modify pictures that are inappropriate for a particular audience.A detailed discussion about making media messages more appropriate for health education in African context was published elsewhere (Hugo, 1998:87).Therefore, onl y general guidelines are fo rmulated here.As a rule of thumb.all message design processes in health education should give equal emphasis to the principles of health education, appropriate media/technology and socio-cult ural sensitivity.In simple terms.it means that each and every message is always viewed within the broader context of a specifi c situation.Socio-cu ltural sensitivity should be refl ected in media use and health learning materials design in at least the follow ing ways: • An increased awareness that health communication always takes place agai nst a certain socio-cultural background that affect the appropriateness of media and technology. - When media messages in health education and communicatio n reflect socio-cultural sensitivity, the audience is more likely to perceive the information as relevant to their needs and preferences.This in turn, could have a positive effect on the impact and final outcome of a program or media campaign.This was illustrated in a num ber of studies over the past decade (Harris, 1988: 104;Cella, 1992:377;Rossiter, 1993:3 16;Brown et aI. 1996:1 17).
• An increased awareness that the meaning of communication codes could differ dramatically across different cu ltures.
In 1990 an outdoor advertisement by the South African Breweries at a public bus tenninal in a rural township depicted an Indian football player enjoy ing a beer.Later inhabitants from the local township pointed out the inappropriateness of this poster -the goalkeeper was a Muslim, but as we know, Muslim s don ' t take alcohol (Green & Lascaris. 1990: 11 8).On the topic of AIDS , Hill and Murphy (1992:152) report that aboriginal groups in Australia had misconstrued the meaning of the word "condoms" a~ referring to the local fruit "quandongs".The local community believed that eating this particular fruit would confe r protection against AIDS.1986: 129;McBean, 1996:13).
• Analysis of the effects and the potential barriers regarding the use of specific codes of communication with different audiences and in different health education settings.
There is a range of communication styles in which health education messages can be dressed.Some audiences are more likely to respond favourably to humour, while in other cases you should rather use a fear arousal or emotional approach.Hard lessons have also been learnt in the field of tec hnology and health learning materials transfer across international borders.Pulling your information on pamphlets and posters on ly when the majority of the audience is illiterate, is completely inappropriate.In this case, radio or television is much more suitable, because the audience does not have to read the information .During the late e ighties Robson (1989:65).for example, identified several technical weak points in audio-visual materials imported from the USA for patient education at the Baragwanath hospital.The materials were not originally designed for South African audiences, the language was inappropriate, and some visual images (eg. of locations where recordings had been done) in video material were unfamiliar to local audiences.
• The design of health learning materials and messages that reflect the cultural diversity of society within an audiencecentred approach.On a practical level the implication is that you should mod-ify inappropriate mcssa~e designs (text.visuals, etc.) to make it more suitable for you r target audience.There is a range of vis ual communication conventions for low-literate audiences in deve loping countries that should be followed.It includes the use or non-use of specific graphic symbols (eg.mathematical symbols to ind icate "correct' or "i ncorrecC).graphic techniques to depict depth and relat ive size of objects, as well as the use o r colours with specific symbolic meanings (Ely. 1989: Linney. 1977).As far as verbal com• munication is concerned a most interesting trend in somc communities o r South Arrica is called the "code mixing" and  Anthonissen, 1995:73 ).What would be the effect of using this style in communicating health messages to certain local audiences such as teenagers?This strategy has been applied in several projects to improve the appropriateness of health learning materials for speci fi c audiences.
• Participation by the target audience in the design of media campaig ns for health education and health learning materials for patient education.Linney (1977) and others (Austi n. 1995:130) emphasise the importance o f involving members o f the proposed audience in the process of designing health learn ing materials.There are various excellent examples from developing countries to illustrate the application of this strategy in health education materials development.Recent casc;s include the design of an educational card game about child safety in South Africa (Hugo, 1994: 145).yo uth health campaigns in Latin America (Cardaci, 1997: 20), a program about youth substance abuse in the Pacific (Stanton, 1997:39), and AIDS education programs for school children in Zimbabwe (O'Donoghue, 1997:7).Another case was a public health education project via broadcast radio in Mozambique (Bonati, 1997:8).In this case a group of chi ldren participated in the production of a series of radio programs.It gave the planners and producers the opportunity to get direct feedbac k from the children on what they really wanted and how they perceived health issues.
• Pre-testing of prOtotype learni ng materials and messages as part o f formati ve assessment in the media production process.
The main objective of foonative assessment in the media production process is to ide ntify specific aspects that should be modified to improve the level o f appropriateness.There is probably no better way of gelling the "real facts" on whether your messages and materials are suitable or not than through feedback from target populations themselves.Consequently, authors such as Dowling (1991) and Folmer et aI.( 1992) emphasise the important role of formative assessment in health learning materials development.This educational principle has been applied in combination with various research and development studies to improve the quality of health education materials (Baggaley, 1986:44;Jackson & Laking, 1986:101 ;Hugo, 1995: 11).

SUGGESTIONS MODEL
FOR TESTING THE The HAMSOC model would remain an academic exercise if it is not ap pl ied to improve the quality and suitability of health education messages for particular audiences.We therefore suggest that the model should be implemented and tested in health education and diseases prevention programs for selected target groups in South Africa, in orde r to assess its value.Such impact stud ies could foc us on topics like HIV/AIDS or TB prevention, adolescent sexuality.and teenage substance abuse where effective and e ffi cient education is highl y needed.The first obvious program aspect where the model could probably make a valuable contri• oot ion is in the design of health leaming materials (posters. pamphlets, etc.) for patient education :u pri mary health care clinics.In this regard a critical important as pects is the extent of socio-cultural sensitivity in appropriate message design.It is advised that the indicated guidelines should be used as a slarti ng poi nt for drawi ng up a suitable checklist for sociocultural sensitivity in health message and learni ng materials design.Such a checklist could include the following basic questions: Have yo u done a proper analysis of media effects and possible misunderstandings that could be caused by the sociocultural profile of your audience?Does the design of your materials and messages re nect respect for the cultural.ethnic, sexual and/or reli gious diversity of society?Is there any gender, language, sexual.eth nic or religious bias present?Do you use more visuals to present your message to audio Have you used the educational level and communication skills (including the level of visual literacy) of your audience as basis for the message design?Are you using the local language and subject tenns the audience is familiar with?Are you avoiding academic jargon for lay people?Are cenain ethnic groups presented by way of unreali stic or over-simpli fied stereotypes?Is any fonn of message modification (eg text.pictures, etc) necessary to make it more acceptable for the audience?
Have you done the nticessary modifications and have you done another field -test to assess its appropriateness?
One could draw up similar checklists with qualitative criteria to assess whether the programs meet the requirements of both health education as well as appropriate media and technology use respectively.

CONCLUSION
The design of appropriate media messages for health education is not an easy task.However.improvements can be made to current practices.The model presented here offers some clarification on the dynamics involved in the planning and design of appropriate messages for health education within a multi-cultural setting.In summary.an effective health education and communication strategy is characterised by clear objectives.a well-defi ned target audience.carefully chosen med.ia fonnats and carefully designed messages to match the differentiated needs and profiles of our multi-cultural society.Hopefully the practical guidelines and examplcs wi ll also contribute to health education messages of a higher quality.In short, media messages for health education in developing countries should be user-friendly, acceptable to the audience.culturally appropriate.non-patronising, easy to understand.visually attractive.and accurate.

Figure 2 :
Figure 2: The HAMSOC model for appropriate health education messages in developing communities

Figure 3 :
Figure 3: Modification of inappropriate graphic elements for AIDS education med ia messages with a reduced impact on heal th education and health pro motion outcomes.Likewise.the three secondary com po nen ts.namely Communication, Med ia Acculturation and Socio-cultural context have the same level of impon ance.
GESONDHEID VOL 4 -No 4 -1999 appropriate components, we can take a closer look at the interaction between Appropriate media and teChnology, with Socio-cultural sensitivity.When one conside rs the dive rse ly d iffere nt mass communication infrastruc tures and availability of educational techno logy in developed countries compared to less developed countries.decisionsregardingappropriate media and tec hnology are quite im pon ant.Whether we use high tec h or low tec h or no tech will be determi ned by educational , economic and logistical fac tors such as the learning outcomes o f a program.aswellas the usabi lity, availability.accessibility,and affordability o f d ifferent information delivery tools.From a different pers pecti ve the appropriateness of media and technology is also influenced by di fferent sociocultural factors regarding your target audience.These include their language of communication, educational level , health beliefs, habits and familiarity with the media you propose to use.In the process of media acculturation one should at least pay attention to the potential barriers in technology transfer and the modification of inappropriate messages(text, graphics, photos, etc.)to make it more suitable for a particular audience.This requires.inter alia, the identification o f the most suitable medium of communication in a panicular situation by way of media selection.It also requires proper attention to consideration of socio-cultural issues that could play a role in message modification (eg. the level of visual literacy ofthc audience).
••code switching" phenomenon.This refers to the mixing of terms rrom different local languages and alternating use of different languages by bilingual groups.Typical examples of code mixing arc "Local is lekker" and "We'll sommcr havc a quick indaba to di sc uss the matter" (Kaschu la & • The mod ification of health messages and health learning material s. accordi ng to findin gs of [onnative assessment.tomake it more suitable for a panicular aud ience.This particular guideline foc uses on the fin al step in the design of ap propriate messages.namelythemod ificatio n of inappropriate messages or material s.Even in this regard there arc numerous exce llent examples to explai n the essence of message modifi cation.A pictogram used by the Sout h African health authorities in AIDS prevention campaigns during the earl y nineties showed a silhouette image of a yellow hand as identification symbol of all local AIDS preven-.tionprograms and supplementary educati onal material s.Unfort unately.th is pictogram communicated con nicting messages.sincemanyAfricancommunities got the (incor• rect) idea that o nly people with ••a yellow skin" could get AIDS (Cape Metro, 13 Aug 1994).As the result of thi s mis• conceptio n. the original pictogram was replaced with the international symbol for AIDS prevention, namely the depic• tion of a twisted red ribbon.Figure3illustrates anmher example of modifications made to an inappropriate visual for AIDS education -in this case from Egypt.It presents the message to illiterates that yo u must never rc• use condoms.The "cross ou("' gra phic symbol indicating " not allowed" or "don' t do" are not fam iliar 10 Egyptians.Consequently, the original drawing (a) was modified (b) by re placing the inappropriate part with a graph ic element similar to those used in "No parking" traffic signs.TIle modifi ed version was more acceptable to the local communities