Journal of Health Communication International Perspectives

ISSN: 1081-0730 (Print) 1087-0415 (Online) Journal homepage: http://www.tandfonline.com/loi/uhcm20

Community Perspectives on Communication Strategies for Alcohol Abuse Prevention in Rural Central Kenya Nancy Muturi To cite this article: Nancy Muturi (2016) Community Perspectives on Communication Strategies for Alcohol Abuse Prevention in Rural Central Kenya, Journal of Health Communication, 21:3, 309-317, DOI: 10.1080/10810730.2015.1064496 To link to this article: http://dx.doi.org/10.1080/10810730.2015.1064496

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Journal of Health Communication, 21:309–317, 2016 Copyright # Taylor & Francis Group, LLC ISSN: 1081-0730 print/1087-0415 online DOI: 10.1080/10810730.2015.1064496

Community Perspectives on Communication Strategies for Alcohol Abuse Prevention in Rural Central Kenya NANCY MUTURI

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A.Q. Miller School of Journalism and Mass Communications, Kansas State University, Manhattan, Kansas, USA

The current study explores community perspectives on alcohol abuse prevention strategies in rural Kenya. Data from focus group discussions with members of community organizations and in-depth interviews with a snowball sample of key informants revealed that rural communities view national alcohol abuse prevention interventions as ineffective and messages as unpersuasive in changing this high-risk behavior. The use of ethnic languages, stronger fear appeals, and visual aids were recommended for alcohol prevention messages aimed at communities with low literacy. Community members favored narratives and entertainment-education strategies, which are more engaging, and print media for their educational value. Health activism, although common, was viewed as less effective in motivating individuals to change drinking behavior but more effective in advocacy campaigns to pressure the government to enforce alcohol regulations. This study suggests further empirical research to inform evidence-based prevention campaigns and to understand how to communicate about alcohol-related health risks within communities that embrace alcohol consumption as a cultural norm.

Effective public health communication is crucial for preventing health-related risks and for achieving positive outcomes on an individual, community, and societal level. Health communication is an evolving field and has emerged as an important tool for achieving health objectives (Bernhardt, 2004)—whether to avert a global epidemic, change attitudes and risky behaviors, or support organizational change in eliminating health disparities (Hinyard & Kreuter, 2007). Preventing health risks that lead to disparities by attempting to understand beliefs and attitudes that lead to risk-taking behavior is at the heart of health communication practice (Rimal & Lapinski, 2009). Alcohol abuse is a risky behavior that is associated with a variety of serious illnesses and injuries and often leads to preventable deaths. It is a global public health concern that causes a significant disease, social, and economic burden. The World Health Organization (WHO) has estimated that there are about 2 billion alcohol consumers worldwide and 76.3 million with diagnosed alcohol use disorders. Alcohol is associated with about 200 diseases and conditions, and by 2012 about 3.3 million people had died from alcohol-related causes (WHO, 2014). Less developed countries that are faced with other global health epidemics such as HIV and AIDS experience the greatest impact of alcohol (Baliunas, Rehm, Irving, & Shuper, 2010). For instance, the WHO (2011) reported that low-income countries consume about 48% of unrecorded Address correspondence to Nancy Muturi, A.Q. Miller School of Journalism and Mass Communications, Kansas State University 105 Kedzie Hall, Manhattan, KS 66506, USA. E-mail: [email protected]

alcohol—homemade alcohol, illegally produced or sold outside of normal government controls—compared to 11.2% consumed in developed nations. In the African region, unrecorded alcohol is the most popular alcoholic beverage, with a consumption rate of 51.6% (WHO, 2014). This signals a trend in alcohol consumption in the region. In 2006, eastern and southern regions in Africa were estimated to have the highest consumption of alcohol per drinker in the world, and the prevalence of hazardous drinking patterns, such as drinking a large quantity of alcohol per session or being frequently intoxicated, is second only to Eastern Europe (Needle, Kroeger, Belani, & Hegle, 2006). In Kenya, the National Authority for the Campaign Against Alcohol and Drug Abuse (NACADA) reported that alcohol consumption has reached epidemic levels in some areas. Central Kenya, for example, has a consumption rate (consumption of alcohol in the past 30 days) of about 77% among men ages 19–24 years and about 79% among those 25–35 years (NACADA, 2010), which surpasses the national average rate of 14.5%. Alcohol consumption plays a role in the central Kenyan culture and has been traditionally viewed as strengthening relationships among individuals, families, and communities (Muturi, 2014b). In recent years, there has been an increase in the consumption of harmful, second-generation alcohol in central Kenya. This alcoholic beverage is made from millet, sorghum, and maize that has been adulterated with car battery acid, methanol, ethanol, fertilizers, formaldehyde, and illegal substances (e.g., marijuana and other additives) and is unmonitored for quality and strength (NACADA, 2010). Consumption of this toxic alcoholic beverage has resulted in numerous deaths and left devastating social, physical, and psychological effects on drinkers and society

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310 as a whole (Muturi, 2014a). For instance, on May 6, 2014, more than 60 people died from drinking alcohol laced with poisonous industrial chemicals to make it stronger. Other victims were hospitalized and blinded as a result of consuming the contaminated beverage (BBC News, 2014). Although few incidents receive media attention, such outcomes are common in rural communities affected by this deadly form of alcohol. National prevention strategies include regulations to require warning labels on alcohol containers and laws to limit supply and consumption. For instance, the 2009 Alcoholic Drinks Control Bill restricts alcohol consumption to 6 hours between 5 and 11 p.m. on weekdays and 8 hours, beginning at 2 p.m. on weekends (NACADA, 2010). Other strategies include media campaigns, activism against alcohol abuse, and faith-based interventions through education and counseling for affected families (Muturi, 2014b). Such interventions have failed to modify behavior, as evidenced by the high consumption rate. Continued alcohol abuse in spite of documented health implications calls for alternative communication and prevention strategies developed with input from those affected. Health communication seeks to inform and enhance knowledge and understanding of health risks and to motivate change in risk-taking behaviors. This understanding is important in risk communication because ‘‘people do not typically respond directly to real risk but act on their beliefs or perceptions’’ (Sjoberg, 1998, p. 277S), which often vary by culture. Given the widespread and toxic alcohol use it is important to understand the role of alcohol within a culture, how people relate to it, and their views on the most appropriate means to communicate about harmful usage, which is the focus of the current study.

Theoretical Perspectives Alcohol abuse has received scholarly attention from various perspectives—economic, psychological, sociological, and medical and public health. The current study looks at this problem from a communication perspective and draws on McGuire’s (1999) information processing theory to explain the communication and persuasion process. In this classic theory, McGuire (1999, 2013) outlined the communicationpersuasion matrix, a framework for constructing persuasive messages in public communication campaigns. The framework consists of five input variables: source, message, channel, audience, and destination (Atkin & Rice, 2013; McGuire, 1999, 2013). The source must possess credibility, attractiveness, and power and be engaging (attractiveness and likability) and relevant (similarity and familiarity) to the audience. Message characteristics include the structure and type of argument, type of appeals, message style, and repetition (McGuire, 2013). The communication-persuasion matrix is one of the most comprehensive applicable conceptualizations used to guide health communication campaigns besides the social marketing framework (Atkin & Rice, 2013). It is particularly useful in determining the effectiveness of message source, content,

N. Muturi treatment, and dissemination channels. The matrix facilitates the creation of a well-designed and culturally relevant communication intervention that incorporates visual aids and provides these message characteristics. For instance, research has shown that pictures, compared to text alone, markedly increase attention to and recall of health education information (Houts, Doak, Doak, & Loscalzo, 2006). In terms of effectiveness, Peregrin (2010) noted that visual communication is 55% effective, whereas vocal and verbal communication are 37% and 7% effective, respectively. The use of visual aids enhances the effectiveness of both vocal and verbal communication. In addition, the participatory approach used to inform this study stresses the importance of engaging members of the community in defining health risks and in dialogues about possible solutions from a wider community perspective (Muturi & Mwangi, 2011). This approach engages populations that are less well understood and may be hard to reach through mainstream communication processes, providing them with opportunities to be involved in the process of moving toward the desired change. In addressing alcohol abuse, the dialogic approach ensures community engagement in identifying contributing factors as well as prevention strategies and messages that are community- and culture-centric (Muturi, 2014b).

Research Questions This article is part of a larger study that sought to engage communities in gathering their perspectives on the excessive alcohol consumption in rural central Kenya. This article focuses on their perspectives on communication and prevention strategies that they deemed appropriate for rural central Kenya. It is based on two research questions: (a) What are the prevailing perspectives among community members of current alcohol abuse prevention interventions? (b) What are prevailing views among community members on types of communication that would be more effective in preventing alcohol abuse in central Kenya?

Methods Data collection took place in Central Province, Kenya, through seven focus groups and 12 in-depth interviews following approval by an institutional review board on research involving human subjects. Focus group participants were recruited through community-based organizations, including churches, women’s groups, and other community development groups. Six members, one from each community, were asked to coordinate focus groups by recruiting eight to 10 other members who could openly discuss alcoholrelated issues. Announcements were made at various community organizations requesting members to participate in the study. To be eligible participants had to be between 18 and 65 years old, the age group that is mostly impacted by alcohol abuse (NACADA, 2010), and had to be sober to participate in group discussions. One male group was too large and was divided into two groups, for a total of seven

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Alcohol Abuse Prevention in Rural Kenya focus group discussions (four male and three female groups) with 60 participants. In addition, 12 in-depth interviews were conducted with key informants who were selected using snowball sampling. Snowball sampling allows the sampled units to provide information not only about themselves but also about other units (Frank & Snijders, 1994), especially when dealing with hard-to-reach target groups. Focus groups served as initial points for the snowball sampling of key informants for this study. Selection criteria for key informants were based on McGuire’s (2013) and McGuire’s (1999) source characteristics—credibility, attractiveness, power, and viewed as engaging and relevant to local communities. Informants were selected based on their ascribed role in society (e.g., government administrators), their credibility based on expertise (researchers and health and media professionals), and their likability and potential to influence and engage the community in dialogues (e.g., community and religious leaders). They were considered opinion leaders by a referring individual or group with a vested interest in the alcohol abuse problem in central Kenya. The interview guide, also used in the focus group discussions, was composed of 12 questions that focused on root causes of excessive consumption; types of alcohol consumed; the perceived severity of alcohol abuse; perceived health risks associated with alcohol abuse; and prevention strategies. Prompting was consistently done throughout the discussions for clarity and elaboration of participants’ statements. The study applied the researcher-as-instrument approach, which in qualitative research refers to the researcher being an active respondent in the process and is achieved by facilitating interaction that creates conversational space with the study participants (Pezalla, Pettigrew, & Miller-Day, 2012). The researcher becomes an instrument in data collection and analysis through the relationships he or she builds with research participants (Brodsky, 2008). Such relationships are critical for gathering information that would not be obviously accessible, especially in rural and tightly knit communities. Focus group discussions and some interviews were conducted by me (a multilingual) in the Kikuyu ethnic language while the research assistant took notes and recorded the discussions. This required translation of transcripts, which was done simultaneously with transcription by two research assistants, both native Kikuyu speakers, who were recruited from a local university. I then read through the transcripts while listening to the recordings to ensure accuracy (Easton, McComish, & Greenberg, 2000). Data were analyzed using procedures and techniques of grounded theory (Strauss & Corbin, 1998), one of the most influential models for analyzing qualitative data (Lindlof & Taylor, 2011). Based on the grounded theory model, analysis starts with the creation of categories that most often emerge from literature. After transcription, the line-by-line, colorcoding method was used to examine the transcripts closely and to identify recurring themes and commonly repeated phrases and statements. As Brodsky (2008) pointed out, the researcher plays a key role in analysis, interpretation, and meaning making, using all of his or her personal and

professional skills, training, knowledge, and experience as instruments to produce a coherent authentic picture of the research as the researcher saw and experienced it. This process started with open coding, which involved the identification of discrete concepts or categories (Dutta & Basu, 2007) that were based on theory and reviewed literature in this study. This was followed by axial coding used to examine deeper meanings of participants’ statements under each thematic category, a process that Lindlof and Taylor (2011) referred to as integration and dimensionalization, two key components of grounded theory.

Results The study sought community members’ perspectives on communication and prevention strategies for alcohol abuse in rural central Kenya. This included their views on current interventions that address excessive alcohol consumption and what they believed would be more effective for their communities. Several themes emerged from the study, which included message framing, information packaging and delivery, as well as communication channels and strategies that participants believed would be more appropriate for motivating behavior change. The following sections discuss the themes in more detail. Nature of the Message Message content, framing, and appeal all play a role in health communication, specifically in influencing change in knowledge, attitudes, and behavior. Participants discussed various prevention interventions, which included media campaigns as well as government restrictions for alcohol supply and consumption. They, however, did not think the information provided had much impact simply because it was too subtle and unpersuasive. Across the study, they emphasized the need for strong messages on the impact of alcohol abuse explicitly demonstrating how alcohol impacts the consumer’s internal organs. In one of the women’s groups it was noted, ‘‘They should show pictures of how it [alcohol] affects the body. You might think they [consumers] will not look at those kinds of pictures but they will look out of curiosity.’’ In another group a participant stated: People should also see what [second-generation] alcohol is made of and all the things added to it, including dead rats or a women’s underwear. You can get sick from thinking about it. The weak-hearted will never drink it again if they see that. But they just hear it and won’t believe it because what they drink looks clean. They don’t know what is in it.

Discussing the impact of explicit images in attracting people’s attention, one woman reminded others of a man who had recently died from severe liver cirrhosis: Like the man who was vomiting his own liver. That is what people need to see so they know what will happen to them. Everybody, including children, came to see him right before he died because they were curious and that is something they will not forget.

312 Men also indicated the greater impact of more explicit messages and a stronger fear appeal in increasing knowledge among alcohol consumers. They conceded that people drink because they lack understanding of the health implications of alcohol abuse. One participant emphasized: Most people who drink don’t know how bad it affects them because it happens over time, very slowly. You hear it every day that drinking is bad for you, but how bad it is? They even write it on the bottles. I want someone to tell me how it affects me, don’t just tell me it is bad or it will kill me, show me how bad it is.

N. Muturi and communication channels) but also on promoting understanding of the risk factors was strongly emphasized. Appropriateness of Language in Health Messages The language used in health messages also needs to be relevant to the targeted audience. This was brought up in all groups, who noted that current communication interventions have failed to impact behavior because the target audience does not understand the message. As one man observed, ‘‘Even if they see those writings they do not make sense to some of them. If they want to drink it nobody will stop them.’’ Another man noted:

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Use of Visual Aids In discussing information dissemination strategies for rural Kenya, communities indicated the importance of using visual aids in message packaging, which they believed would have a greater impact in message retention and relevance. Visual aids include the use of pictures and audiovisual communication material that will demonstrate the nature and severity of the health problems associated with alcohol consumption. As participants in the women’s group affirmed: Seeing pictures is different from hearing it from the radio because maybe they will see something that will speak to them. It is best if they could see people they know or who look like them. They need to see the pictures because if they see something it will stick in their minds. The cinema should show them how the alcohol damages their bodies. If people can see images of him [alcoholic] before and how he has improved, it might persuade others who are struggling with it. Some of them want to stop but they can’t.

Not all participants, however, agreed on the effectiveness of explicit images. Some men felt that this would turn them away mainly because, as one said, ‘‘they know these things [health consequences] but nobody want to think about it until they see some signs.’’ One of the interviewees thought strong fear appeal might be more effective among non–alcohol consumers and younger adults who have not started drinking, but it may lead to message avoidance among alcoholics. A few men also indicated the possibility of message avoidance, noting that the approach has not been successful among cigarette smokers. One respondent observed: Look at the cigarettes. They write messages on the packet telling us we are going to die. I have never seen anyone who stopped smoking based on what they read on the package. What makes you think they will stop drinking from reading what is written on a beer bottle?

Others, however, agreed that regardless of appeal messages need to be reinforced through other forms of preventive education. The need to focus not only on disseminating messages (e.g., on cigarette or alcohol packages or other media

I find it a problem when everything you see is written in English. Look at this group, nobody here can speak English except for you and him [referring to the moderator and research assistant]. Some of us did not finish primary school. How are we expected to read and know what liver cirrhosis is [pronouncing it as si-ki-ro-sis]?

Another man clarified: That is what they write on the bottles, and sometimes they write in large letters that it can be harmful to those who are under 18 years. What about those of us who are older than that? Does that mean we can drink as much as we want? That is what someone in my age group would think.

All groups discussed the failure of current national campaigns to use ethnic languages and the extensive use of the English language on warning labels and other prevention messages. As one participant observed, ‘‘Sometimes they write it in large letters thinking it would help us read. Yes, we see the letters but that does not mean if I see those words I can read and understand what it means.’’ Interviewees also acknowledged the government requirement for warning labels but doubted the labels’ effectiveness. As one of them pointed out: The labels have to be written in English because that is the official language and they expect everyone to know it but many of these people [consumers] drop out of school in Class 4 or 5 so even reading anything in their [ethnic] language might be a problem. It is a very sorry state!

No warnings labels are used on unrecorded alcohol that is brewed in rural and slum areas in spite of its high alcohol content. ‘‘You only need a small glass,’’ one consumer confirmed. Mass Media Strategy Use of appropriate communication channels is necessary not only in disseminating information but also in engaging communities in the communication process. While discussing appropriate channels, an overwhelming majority throughout the focus groups agreed that the radio would not be appropriate for alcohol abuse prevention. They associated radio with government propaganda and corrupt politics, which

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made it inappropriate in their view to communicate about health messages. As one male participant clarified, ‘‘I don’t think radio would be a good one. If you remember what happened in 2007 [postelection violence] a lot of people died because of the radio. People don’t trust it anymore.’’ Another participant also noted that ‘‘ . . . the radio is for politicians who pay a lot of money to the radio people. You can tell whose side they are on by listening.’’ They viewed radio as nonpartisan and an untrustworthy source of health information among rural men. Women, in contrast, saw the radio as ineffective because the target audience would not pay attention while intoxicated. Some of the statements made in that regard included the following: They have no time for radio because when he comes home he is drunk and will not pay attention to what the radio is saying. Some of them fall asleep even before they get to bed, and some of them do not even reach home. If the radio says something that they don’t like they might break it or throw it away. They will not listen to it if it is talking about drinking because they might feel like it is talking about them. Some of them will come home and if the radio is on they will say, ‘‘Take this thing away from me or turn it off. It is making too much noise.’’ Some men only talk when they drink and doesn’t matter what is on the radio they don’t want to hear it, especially when they drink.

Print media, specifically those with visuals (e.g., magazines and educational brochures), were, however, viewed as a more appropriate channel, especially if written in local languages because of the need for education in rural communities. As noted in one group, ‘‘People are hungry for education and they need something to read. If I have something like a magazine I will read and pass it on to my friends.’’ Sharing of information and reading material that focuses on any community-based issues was viewed as a common practice in rural communities. Such material can be distributed within community and church organizations where people gather. As one participant remembered: We used to read newspapers that were given to farmers and people read and passed them on to their friends and neighbors. Although it was about farming, there were other things we learned from them and some people taught themselves to read that way.

Given the scarcity of health literature in rural communities, the source of reading material did not matter to them as much as the language used. As one man emphasized, ‘‘They can be sent from anywhere, even from abroad, like New York, but when they come here they should be translated in Kikuyu [ethnic language].’’ In low-literacy situations print media—from short brochures to lengthy newsletters— were viewed as more educational. They are also an important resource for literacy, for entertainment, and for initiating discussions and community dialogues.

Use of Mobile Technology Information communication technologies (ICTs) have been adopted in many developing countries and widely used in health communication and social change programs. The participants discussed the potential for mobile technology in disseminating alcohol-related information in the rural communities. In spite of the high penetration of cell phones, participants did not view them as feasible channels for alcohol abuse prevention: Many of those who drink heavily do not own a mobile phone. Some of them prefer to buy beer rather than phone credits [air time]. Others will sell the phone to buy beer or it is stolen when they get drunk.

As one woman complained: I can’t even count how many phones I have bought because every time I buy for him and he [husband] goes drinking he doesn’t come home with it. He says it was stolen but I can’t tell if that is true.

Participants discussed the prohibitive cost of effectively operating a mobile technology and using it for information access. Although receiving calls and other information through text messages was free, it would cost to call, send messages, or seek information. Low literacy and the impact of alcohol abuse on the brain are barriers that make it difficult for alcohol consumers to read digital messages. Mobile technology was, however, viewed as appropriate in preventing initial alcohol consumption. A female participant purported: The phone might work only for to those who are not yet drinking but not for those who are already addicted. The younger children that you want to target cannot afford one so that won’t work, maybe for the youth, but for some of them it is already too late.

Mobile technology was also viewed as an effective tool for reinforcing government laws that regulate alcohol sales and consumption if initiated by community members. Although they were skeptical about the feasibility of this because of corruption among leaders and the police, one group agreed that ‘‘people can call to report those drinking and selling during the day.’’ Mobile technology was also viewed as an important tool for supporting those who are impacted by alcoholism, including women and children. Entertainment-Education Strategy Lack of entertainment in the rural context was viewed as one of the leading causes of alcohol abuse. In terms of addressing the problem, suggestions were made to create entertainment for rural residents while educating them about alcoholrelated health problems: If you bring a cinema here, like on a Sunday evening, people will come and watch. That is the best way to attract

314 boys and men because they drink because they have nothing to keep them entertained. Just make sure you teach them before they watch so you can keep their attention.

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Any form of rural entertainment would attract everyone’s attention regardless of gender and would be an effective strategy for message delivery, especially given the limited sources of health-related education. One male participant confirmed, ‘‘I am sure women too will come and watch it if you advertise it in churches and in schools. They will bring their children too.’’ As some participants recalled, this approach had succeeded several years ago in farmers’ cooperatives communicating about family planning and to some extent HIV=AIDS prevention. One middle-age woman vividly recalled its effectiveness: They used to bring them [show videos] to teach people about family planning many years ago but I still remember them. They showed real cinemas but each of them had a message. That was the last time we had cinemas here.

Narratives as a Prevention Strategy The use of narratives to engage rural communities in telling their stories was viewed as a relevant strategy not only for entertainment but also for education about alcohol abuse. Female participants in particular noted the importance of a storyline that would show the deteriorating health impact of chronic alcoholism. As one woman elaborated, ‘‘If you can make a cinema to tell a story of someone from the time they were healthy and follow up with them until they die, that might speak to a lot of people.’’ Sharing personal stories of the impact of alcoholism on families and communities was also discussed in various groups, who noted that many families have been affected and can relate to them. According to one woman, ‘‘We need people to come up and tell their stories. A mother can share her stories about how the family has suffered, including the children.’’ Another one maintained: It is best if someone who has stopped drinking can come and talk about his life as an alcoholic and what he did to stop drinking. That might help anyone who has been thinking about stopping but doesn’t know how.

The importance of narratives in intergenerational communication and social change was addressed in the in-depth interviews. Participants observed that traditionally the older generation educated the youth through telling stories, spending time together to pass on wisdom, but today the only time they were together was at the bars. This intergenerational gap was attributed to unhealthy drinking behaviors among youth who, as one participant pointed out, ‘‘have nobody to advice [educate] them.’’ Health Activism as a Prevention Strategy Activism about alcohol consumption was widely discussed throughout the study mainly because of media coverage of

N. Muturi community protests against production and consumption of second-generation alcohol. Community activists had also organized numerous protests against alcohol consumption, especially because of its deadly impact on consumers’ health and the well-being of families. Activism was, however, mainly undertaken by women and was concentrated in urban and semi-urban settings. Men did not believe it would be an effective persuasive strategy for rural settings. From the perspective of one man: Women will take to the streets but they will only do so because of their husbands. What about those who are not married? My wife might protest against me but who will protest against him [pointing at another man] and others like him? I don’t think that is the way to get us to stop drinking.

Activism in rural communities was also viewed as ineffective based on the gender-power relationships and social norms in relation to marriage: If my wife protests against me I will tell her to go back to her parent’s home. The money that I drink is mine and I don’t care if it comes from her. She makes it from selling vegetables that come from my land and I can use it the way I want. She cannot tell me what to do with it. If she refuses she will be asking for a fight and she will have to leave.

Men agreed on the need to direct such activism against the government to prevent the supply of second-generation alcohol. ‘‘Women will protest, but they will not help because they are not preventing it from coming.’’ Another man added: The only way is to drain the pipe that is bringing it to us. If that pipe is dry then people will have nothing to drink. Or they can make it in a way that it will not kill people. That is what women should be protesting, not to those who drink.

Women also agreed that protesting against alcoholic spouses might lead not only to domestic abuse but also to loss of family, property, and social status as wives. The lack of economic power makes rural women vulnerable and powerless in regard to preventing alcohol abuse within their households. According to one woman: We would like to go and join the protests because everybody is going through the same thing but when you go back home you are on your own. He can beat you up and you have nobody to protect you and your children. If you have nowhere to go, it is best to stay away from it and pray to God that things will change.

Activism in Kenya has historically been focused on environmental issues. For instance, the 2004 Nobel Peace Laureate Professor Wangari Maathai led numerous protests through the Green Belt Movement against the government to conserve the environment. Health activism is, however, a new

Alcohol Abuse Prevention in Rural Kenya phenomenon in Kenya, with neither a clear leader nor agency to support it. Thus, the protests have been sporadic, with no measurable impact. In the interviews one of the respondents who had worked with community activists expressed why activism would not be effective as currently practiced:

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Kenya has very limited activism. Even when people complain, that voice does not put enough pressure for the government to take action. We have seen women protesting in the streets . . . but the reaction we see from the government is by clusters, there is nothing cohesive. So to me the government should be pressured to act. I don’t know by who but someone needs to put pressure on the government to enforce the laws that are in place. That is what the women should be doing.

A need for leadership in health activism was emphasized in this interview, particularly in rural settings where government regulations have failed due to limited law enforcement. Women also highlighted the lack of strong leaders in rural communities who could mobilize people in health activism or other forms of activism.

Discussion This study sought to explore community perspectives on alcoholism in rural central Kenya and communication strategies participants believed would be most effective for prevention. Asked for their views on current strategies for alcohol abuse prevention, participants indicated a need for messages to be more explicit and to include strong fear appeals. This finding is consistent with studies that have shown that under certain conditions increased fear arousal and perceived threat are positively associated with recommended attitudes and behavior change (Stephenson & Witte, 2001). In the African context studies have found an association between strong fear appeals and explicit messaging and lower infection rates in Uganda (Green & Witte, 2006) and the need for more explicit HIV and AIDS messages in Kenya (Muturi & Mwangi, 2011). Others have, however, noted that strong fear appeals may not result in a desired change because a cognitive assessment of the threat contained in such messages may result in null or boomerang effects so that individuals reduce intentions to engage in protective behavior (Basil & Witte, 2012). In the extended parallel process model, Witte (1992) postulated that a strong fear appeal may activate a fear control mechanism, which may include defensive avoidance. As a result, Witte postulated, people may avoid thinking about the health risk, arguing that the risk is overstated and less severe, or become fatalistic, arguing that the risk is part of life and there is nothing they can do to prevent it. In crafting effective health communication messages, packaging and delivery are as important as content and framing. The current study found that rural communities prefer the use of visual aids in communicating about the impact of alcohol abuse. As demonstrated in previous studies, visual communication is appropriate in rural communities that predominantly have lower literacy and numeracy skills and therefore have problems understanding and using basic

315 health information (Houts et al., 2006). Peregrin (2010) suggested that ‘‘those with low literacy skills require simple, easy-to-understand visuals that focus on what they need to do’’ (p. 500). The use of visual aids would be relevant for rural Kenyan communities that are facing alcohol abuse problems, although it might be more effective if combined with verbal communication to enhance understanding of health messages. With regard to communication channels, participants indicated a preference for print media as opposed to radio and other electronic channels (e.g., television and Internet) that are commonly used in current prevention interventions (Muturi, 2014b). This finding is in line with a previous study in rural central Kenya that did not find radio appropriate in communicating reproductive health messages among women (Muturi, 2005). Print media, however, were viewed as more appropriate because of their educational value. If the language and images are culturally appropriate, print media become an important resource for literacy, for entertainment, and for initiating discussions and community dialogues in low-literacy situations. The potential for ICTs in communicating about alcohol abuse was also viewed as limited, especially in terms of reaching consumers, although the potential and success of e-health has been documented elsewhere (e.g., Kreps & Neuhauser, 2010). ICTs such as mobile phones and other digital devices enable more engagement of communities in addressing issues that impact them. For instance, interactive radio gives listeners an opportunity to participate by calling in with their views and opinions about the topic that is on the air. In spite of their potential, study participants did not perceive these digital technologies as effective tools for communicating about alcohol-related risks mainly because of the impact of alcohol on individuals’ cognition and mobility. Rather, the technologies would be more useful in reinforcing nonconsumption behaviors and government prevention policies. The entertainment-education strategy, which is the insertion of health messages into popular programming (Singhal & Rogers, 2004), was viewed as appropriate for addressing alcohol abuse because it would appeal to the majority of residents across ages. Given the oral nature of rural communities, communal viewing of audiovisuals with health-related content would lead to community dialogues if communities view messages as relevant. The entertainment-education strategy, which has been applied widely in health communication efforts in many less developed nations in Asia, Africa, and South America (Singhal & Rogers, 2004), is not only educational but also persuasive in reducing risky behavior, promoting prosocial behavior (Moyer-Guse´, Mahood, & Brooks, 2011), and retaining messages. In using this approach it is critical to provide accurate information to avoid misleading vulnerable media consumers and those with low health literacy (Brodie et al., 2001). Other considerations might include infrastructure needs and capacity to ensure proper usage of media and technology for entertainmenteducation purposes. Narratives were also viewed as appropriate because of their cultural relevance. Whether in digital or face-to-face interpersonal formats narratives have an entertainment value

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316 due to stories shared. Narrative forms of human interaction and communication, including storytelling and testimonials, have increasingly been explored in health communication as an effective way of creating awareness and increasing knowledge and in some circumstances offer an effective tool for motivating and supporting attitudes, beliefs, and health behavior change (Hinyard & Kreuter, 2007; Larkey & Hill, 2012; Moyer-Guse´ et al., 2011). Within the African context, the use of narratives is a common mode of communication that is associated with the oral cultures and low literacy. As Houts and colleagues (2006) explained, people in low-literacy cultures place more reliance on spoken explanations and need help in remembering what they hear. Finally, as an emerging theme, health activism in alcohol abuse prevention was widely discussed. Defined in terms of ‘‘efforts, often grassroots, to change norms, social structures, policies, and power relationships in the health arena’’ (Zoller, 2005, p. 341), health activism has been used effectively in addressing a range of issues, including social norms and policies in public health and medicine, the elimination of racial discrimination in health care, and the establishment of public health warnings about the dangers of tobacco use (Parker et al., 2012). For instance, the Treatment Action Campaign was launched in South Africa by a small group of political activists who viewed equitable access to health care and HIV medication as a human right. The campaign strategies included protests, mobilization, and legal action to pressure the government to provide affordable antiretroviral medication and support other HIV-related interventions (Heywood, 2009). In Kenya the civil society has used activism to protest against alcohol abuse in affected communities, but there has been no evidence of effectiveness. Participants in this study discussed the need for leadership in alcohol prevention activism, but they viewed such activisim more as a strategy that would influence policy decisions rather than prompt change at the societal level. The fact that alcohol is consumed in many global cultures and plays an important role in social gatherings, rites of passage, and local economies (Ashley, Levine, & Needle, 2006) makes activism against its consumption more challenging as a preventive strategy.

Conclusion This study explored community perspectives on communication strategies for the prevention of chronic alcoholism in rural central Kenya. Results from this and previous studies have shown that rural communities are aware of the severity of the alcoholism problem and the health consequences and impact of the problem, not only on individual consumers but also on their families and the community in general. It is clear from the current data and from numerous alcoholrelated fatalities that current prevention interventions in Kenya, which include media campaigns, laws and regulations that limit alcohol supply and consumption, and community activism, have not succeeded. This study provides insights into the challenges of using mainstream channels and strategies while focusing on rural communities that are characterized by low literacy and

N. Muturi poverty. For instance, although radio and other forms of mass media have been used successfully in many health communication and development programs in many countries, they were not viewed as appropriate for addressing alcoholism in rural Kenya. Similarly, e-health or the use of ICTs in health care and communication, including digital and mobile devices, which have been promoted widely in health care, were deemed inappropriate for communicating with heavy alcohol consumers. However, print media were viewed as appropriate, as a good resource not only for health information but also for literacy building, although the language should be appropriate. Information could be supplemented by educational sessions to enhance understanding of the information. The entertainment-education strategy and narrative strategies that the communities suggested are not only educational but also more engaging. In addition, message comprehension is important for behavior change. Although Kenya is multilingual, tailoring messages toward different ethnic groups would ensure relevance and comprehension. Furthermore, the nature of the message as well as the appeal should be considered and tailored to the target audience. Rural communities have indicated a preference for stronger fear appeals with explicit messages. This may be appropriate for other cultures and communities across the country. The message and appeal may also differ based on the nature and severity of the health impact. Further research is needed to examine prevailing attitudes within communities and how to effectively communicate about the health risks associated with alcohol abuse in a society that embraces alcohol consumption for socialcultural reasons. From the lens of participatory communication, such understanding would inform interventions that are culture-centric and ensure that health communication interventions are executed within the proper social and cultural context. Empirical research is needed to evaluate the impact (or lack thereof) of current communication and prevention programs to develop evidence-based health communication campaigns against alcohol abuse in Kenya. Given that alcohol abuse is a global public health concern, evaluating alcohol-related activism for its effectiveness in the context of developing countries that face gender inequity, low literacy, and other socioeconomic challenges is another area for further research.

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