THE USE OF TRADITIONAL FOLK MEDIA TO CONVEY DIABETES MELLITUS MESSAGES AT PUBLIC HEALTH CARE SERVICES

1 ABSTRACT Diabetes awareness amongst indigenous language groups needs to be presented in a culturally sensitive manner. This study presents the use of traditional folk media to convey diabetes messages to adults attending public health care services in a sub-district in the Free State province of South Africa. A quasi-experimental pre-test post-test design was employed and random sampling of public health care services (n=26) was done in order to sample three services for control/experimental sites respectively. Conveniently selected participants (n=183) underwent pre and 4-week post-testing using questionnaires. Experimental group participants received six key diabetes messages conveyed via storytelling (n=2), poetry (n=2), and song/ dance (n=2). The profile of participants in both groups was similar. Responses to messages from pre-test to 4-week post within the experimental group for storytelling, poetry, song and dance were statistically significant. Comparing the experimental and control group change from pre-test to 4-week post, statistically significant differences were found for one message using storytelling and another using poetry. The authors conclude that traditional folk media can be used to raise diabetes awareness among indigenous language groups.


INTRODUCTION
In recent years, a number of scholars have recognised the role that communication plays in enhancing health intervention efforts (Ebina et al. 2010;Freimuth & Quinn 2004;Pienaar 2016;Suresh 2011). Studies linking the domains of health and communication have shown that the use of purposeful and eminent communication can increase the probability of achieving desired outcomes from According to the latest International Diabetes Federation Atlas report (IDF 2019), approximately four and a half million adults in South Africa (12, 8%) are living with Diabetes Mellitus (DM), indicating a rapid increase from the 2017 figure of three and a half million (6%) diabetes cases (IDF 2017;IDF 2019;Statistics SA 2017). The World Health Organisation (WHO) (2015; 2016) cautions that one in two people worldwide are living with undiagnosed DM, suggesting that an estimated two million people in South Africa are living with undiagnosed diabetes. This means that South Africa has the highest ratio of adult diabetics on the African continent (WHO 2018). Furthermore, several studies indicate that this global phenomenon seems to be widely prevalent in low and middle-income countries where low levels of DM awareness have been identified (Whiting et al. 2003;WHO 2015).
DM has been among the top ten causes of death globally for over a decade and it maintains its position in the top three causes of death in South Africa (Statistics SA 2017). Research predicts that diabetes will be the leading cause of death in South Africa by 2040 (Kahn 2018;Statistics SA 2017). South Africa is a middle-income country, and because the prevalence of diabetes is rapidly increasing in low and middle-income countries (Statistics SA 2017;WHO 2015;WHO 2018), the need for effective health communication strategies to address the pandemic in these regions is obvious. Ideally, the latter should lead to desired intervention outcomes that appeal to people's culture and way of life.
The role of a health communication practitioner in these circumstances is to generate intervention programmes that will educate, inform, support and attempt to change the misperceptions that individuals, who belong to particular communities, may have due to poor knowledge on health issues (Abdoli et al. 2012). In South Africa and other low and middle-income countries, DM's management relies heavily on public health care services (Green 2017). This service is habitually characterised by low patient attendance, poor organisation of services, poor management of complications, inadequate staff and limited consultation periods, which leaves little or no time for patient education (Whiting et al. 2003). Although South Africa's public health care systems have improved over the last couple of years (Visagie & Schneider 2014), inadequate resources, insufficient staff and little to non-existent patient education remain factors that challenge public health care systems. Due to the unstable economic status of many low and middle-income countries, the aforementioned challenges are likely to prevail for a number of years. This necessitates the consideration of innovative and cost-effective communication strategies for raising diabetes awareness in South Africa and other low and middle-income countries (Chen & Feely 2014, Rimal & Lapinski 2009Visagie & Schneider 2014). Countries where traditional folk media was used with success to convey communication and awareness of health issues in low and middle-income countries include India, Ghana, Mexico and the Philippines (Gupta et al. 2003;Kumar 2006;Mohanty & Parhi 2011;Panford et al. 2001;Rimal & Lapinski 2009;Yoshida et al. 2012). Ravindran (1999: 32) describes traditional folk media as "conventional mass communication that embodies the beliefs, cultures, norms and values of a variety of indigenous groups and communities". This medium of communication is symbolic in nature, and it embodies cultural values that are consistent with the belief systems of individuals who reside in communities where folk media are embraced (Mishra & Newme 2015). Traditional media are trusted among locals because it incorporates signs and symbols that are familiar to them; additionally, traditional folk media hold promise for promoting new ideas while reviving cultural and social norms (Chapke & Bhagat 2015;Prasad 2013). Using traditional folk media as a medium for health education and promotion affords health communication practitioners with credible, lowcost and culturally sensitive means of employing health communication interventions in low and middle-income countries and communities (Mohanty & Parhi 2011). Other benefits include the fact that traditional folk media are flexible and can be adapted to suit/satisfy the communication needs of audiences; it does not require any specific literacy levels; it appeals to people's emotions; and it can be enjoyed by people of all ages. Moreover, traditional folk media can be presented in the local language of the people and allow for close proximity to audiences (Kahssay 2017;Ritu 2010;Sharma 2015). This aspect allows for immediate feedback from audiences; thus, enabling practitioners to modify performances to match an audience's needs where necessary (Kumar 2006).
Traditional folk media exist in various forms, with each form having variations of different types. For example, we may distinguish between the oral tradition and material culture as forms of traditional folk media. The oral tradition includes a number of folk media types such as poetry, music and theatre. Material culture includes aspects of folk behaviour such as the skills needed to create crafts, cultural clothing, or architectural designs (Kumar 2006;Nag 2013;Prasad 2013). For the purpose of this study, folk forms from the oral tradition, namely storytelling, poetry and song and dance, were explored.
Storytelling, which provides a complete emotional experience for audiences, is one of the popular forms of traditional folk media because it speaks to their hearts and minds (Mishra & Newme 2015). This folk art form is highly persuasive in nature and often replicates the realities of audiences, which helps in stimulating environments where health messages can be disseminated in communities and be adopted by the locals (Kumar 2006). Similar to storytelling, poetry capitalises on a strong emotional appeal, and it is better suited for conveying new ideas because of its potency to connect with audiences' cognitive senses. Traditional folk poetry allows both performers and audiences to explore their creativity and imagination, as this folk form visualises the invisible (Gwyndaf 2006;Kumar 2006).
Traditional folk song and dance have been used historically across several communities in the form of raw expressions for communicating messages about socio-political or religious issues (Kumar 2006;Mishra & Newme 2015). This medium is persuasive and can unite masses; it is also highly flexible and can be composed in the spur of the moment. The messages transmitted through the lyrical contents reflect current realities and can be adapted as and when necessary. Traditional folk song and dance are entertaining, intriguing, informative and interactive. This folk form involves the use of informal choreography and an intense melodic exchange between performers and audiences; thus, promoting participation and creating a sense of unity (Kumar 2006;Mathiyazhagan et al. 2015).
Health communication practitioners should however note that every community has a unique set of traditional folk media and that not all forms of this indigenous communication will be appropriate for conveying health information (Kumar 2006;Mishra & Newme 2015). Nonetheless, traditional folk media mirror the past, present and future of indigenous groups; if adopted from a participatory approach it can be used to denounce misconceptions about a number of health conditions, including DM.

METHODS
This study used a quantitative quasi-experimental pre-test post-test design. Random sampling of public health care services (n=26) was done in order to sample three services from Thaba 'Nchu (control) and three services from Botshabelo (experimental). The participants (n=183) consisted of conveniently selected adults who attend the sampled health care services. The control group (n=63) undertook pre-test and 4-week posttests, with the experimental group participants (n=120) undertaking pre-test, post-test and 4-week post-tests using structured questionnaires. The compiled questionnaire focused on the six key diabetes messages identified by Reid et al. (2018) in a study conducted in the Free State province's public health care service.
The questionnaire was administered in a private section of the sampled public health care services and the participants were requested to indicate whether they agreed (red) or disagreed (blue) with the statements put to them by means of touching one of two coloured balls placed in front of them. The lead author and a trained assistant delivered diabetes messages (n=6) to experimental group participants. All of the traditional folk media interventions were used, namely storytelling, poetry and song and dance to deliver two messages per medium. The interventions were in the participants' mother tongue, Sesotho, and lasted between three to five minutes per intervention. The traditional folk media presentations took place in the waiting area of sampled public health care services.
Frequencies and percentages for categorical data and medians and percentiles for numerical data were calculated per group. The groups were compared by means of the Chi-square test or Fisher's exact test for categorical data, and the change within a group was compared by means of McNemar's test for categorical data.

FINDINGS
There were more female participants in both the control group (63.5%) and experimental group (69.2%) compared to males (36.5%; 30.8%). The age distribution among the participants in both the control and experimental groups was similar, with the median ages at 48 and 52 respectively.

Storytelling
As might be expected, the retention of messages conveyed via storytelling, poetry and song/dance improved drastically from pre to post-testing, most probably also influenced by the short interval between testing. The difference between the participants' responses to both messages conveyed via storytelling at the pre-testing phases of the study (control group = 78%; 73%, experimental group = 56%; 75%) and 4-week post-testing (control group = 81%; 81%, experimental group = 89%; 92%) seemingly suggests that the storytelling intervention was successful in conveying diabetes information to the participants.

Poetry
The participants' reactions to messages presented via poetry indicated differences between the responses provided at the pre-testing (control group = 90%; 44%, experimental group = 89%; 79%) and 4-week post-testing (control group = 86%; 64%, experimental group = 95%; 79%) phases of the study. Responses to the messages presented via poetry show that the experimental group participants were able to retain and recall only one of the messages conveyed through poetry (message 3), while no differences were found in the participants' responses between the pre-testing (79%) and 4-week post-testing (79%) phases for message 4. Statistically significant differences were found because of the changes that occurred within the control group, as seen in Table 2.
Despite only observing a difference in responses for one message conveyed via poetry, it could still be deducted that poetry as a traditional folk media intervention possibly holds some degree of promise for conveying diabetes information successfully.

Song and dance
The study observed incongruent responses between the pre-testing (control group = 95%; 41%, experimental group = 95%; 71%) and post-testing (control group = 84%; 59%, experimental group = 94%; 78%) responses to messages conveyed via song and dance interventions. The participants' responses demonstrate two things. Firstly, that a decrease (1%) occurred in the percentage of correct responses for one of the messages (message 5), four weeks post-intervention. Secondly, that an increase (6%) occurred in the percentage of correct responses for the other message (message 6), four weeks post-intervention. These changes did not demonstrate any statistically significant differences (see Table 2).
Even with the inconsistent findings, it is important to note that the participants' responses to song and dance interventions are indicative that on the surface it appears as if song and dance interventions have some potential to convey diabetes messages successfully.
The observed differences in the control group participants' responses between pretesting and post-testing were unexpected, as they did not receive any interventions.
The reason for this occurrence remains unclear. However, the responses are indicative of an oversight stemming from the fact that the control group participants were not requested to declare whether they had been exposed to any other diabetes information/intervention since the pre-test, before undergoing the 4-week post-test.
The p-values reflected in Table 2 are presented in this manner as a result of the participants' non-homogeneous responses for the pre-test in both the control and experimental groups (see Table 1). Table 2 reflects the p-values within and between the control and experimental groups depicting changes between the messages conveyed in the pre-and 4-week post-test phases; therefore, the traditional folk media intervention shows more promise in use.
Looking at group comparisons from the pre to 4-week post-test phases, messages one to three in the control group were not statistically significant (p-value 0.6; 0.19; 0.43). However, messages four to six in this group were found to be statistically significant (p-values 0.03; 0.04; 0.03). On the contrary, in the experimental group, both messages presented via storytelling and one using poetry (messages one to three) were of statistical significance, while one other message presented via poetry and two using song and dance (messages four to six) were not (see Table 2). When looking at the comparison of the control and experimental group differences (between group comparisons from the pre to 4-week post-test phases), statistical significant differences were found for messages 1 and 4. This, despite the seemingly inconsistent results depicted in Table 1, demonstrates that for this study storytelling and poetry were the most successful traditional folk media in conveying diabetes messages to the participants.

Storytelling
In this study, the first intervention conveyed messages through storytelling that focused on two major themes. Firstly, the messages addressed the misconception that diabetic people cannot integrate into society nor continue to live a normal life. Secondly, the story was used to discredit the popular myth that all diabetic people undergo amputations. The characters in the story resembled the average participant; thus, making it easier for them to relate to the story being told.
The findings of this study demonstrate that the participants had higher acceptance of messages conveyed through storytelling and that these messages were best retained and recalled four weeks post-intervention. As noted in the literature, several authors are in agreement that when people tend to relate to the characters in a storyline, they are likely to be swept into the world of the story, where cognitive and emotional processes take place resulting in improved interest, understanding and engagement (Neely 2016;Newkirk & Solomon 2014;Van Krieken et al. 2017). This was consistent with the findings of Goddu et al. (2015) who investigated whether the use of narratives could be an effective strategy for diabetes awareness among African American females. The latter found that the participants reacted positively to interventions conveyed through storytelling. Goddu et al. (2015) also found that the participants' attitudes, behaviours and knowledge about diabetes had been positively influenced.
The participants also stated that the stories made it easier for them to take in large amounts of new information; thus, making the messages more memorable.
Similar to the present study, several other studies have documented successes in using storytelling as a culturally sensitive tool for health promotion and education interventions in indigenous communities where community members often have insufficient health information, poor access to public health care systems, and low literacy levels. For example, a study conducted in the indigenous community of Bougainville, Papua New Guinea, evaluated the efficiency of a culturally relevant health education programme on type 2 diabetes through interactive storytelling interventions (Rowse et al. 2013). The interventions made use of stories to encourage discussions related to the causes, symptoms and risk factors associated with type 2 diabetes. Rowse et al. (2013) found that participants responded positively to the storytelling interventions and demonstrated improved understanding of the topics addressed through the storytelling interventions, especially as the community had very little knowledge about diabetes. This compares favourably to what was found in the present study. These findings echo the views of Neely (2016), who asserts that traditional folk storytelling has been used for centuries across cultures as a sensemaking tool that encourages people to confront their realities.
Similarly, Bertera (2014) found that storytelling could be used to convey diabetes information and reduce health disparities in populations with low literacy levels. The author conducted a study that merged the oral tradition of storytelling with the Hispanic medium of Fotonovelas to create a storytelling slideshow in order to improve diabetes and hypertension knowledge and self-efficiency among older African American community members. Despite the fact that Bertera (2014) employed storytelling in a different context, the results still demonstrate that the use of storytelling slideshows were of benefit in increasing self-efficacy, especially in older participants with the lowest health literacy levels. Authors (Gucciardi et al. 2019) also explored ways in which storytelling could promote disease self-management among people with type 2 diabetes in Toronto, Ontario. The study results suggest that storytelling facilitates knowledge exchange and collaborative learning; thus, it can be used to support several core aspects of diabetes management. A considerable amount of literature has been published on the power and influence that lies in storytelling as a communication tool for health promotion and education (Houston et al. 2011;Larkey et al. 2009;LeBron et al. 2011;Manglona et al. 2010). Data from several studies have pointed to the importance for health communication practitioners to note that the use of storytelling is most effective when applied to cultures and communities who have existing oral traditions (Kumar 2006;Mishra & Newme 2015). Additionally, some studies (Bertera 2014;Nguyen et al. 2018) have demonstrated that folk storytelling can be employed through modern forms of technology and still maintain elements of cultural sensitivity because of its inherent ability to connect to people's roots and emotions. Storytelling signals great potential as a tool for raising health awareness and mobilising social change in low and middle-income communities globally.

Poetry
The second intervention used traditional folk poetry to convey messages containing two other themes. Firstly, the poem addressed the fact that exercise is an important component of diabetes management/prevention and that a 30-minute walk per day could improve one's well-being drastically. Secondly, the poem stressed the importance of maintaining a healthy body weight. The findings demonstrated that participants were only able to recall information related to message three (about exercise) and unexpectedly regressed to their initial responses prior to the intervention for message four (about weight loss). The findings may be indicative that the participants were possibly not entirely accepting of the information conveyed to them about the importance of weight loss but were rather responding to the premise of what was being conveyed to them through the song and dance intervention. The findings seemingly suggest that the participants understood what was being conveyed to them; however, the intervention was not adequate to change their current stance on the importance of losing weight. Issues concerning unwavering convictions resulting in resistance towards the need for weight loss among black communities, akin to the present study, have been discussed by a number of authors. For example, research has provided evidence on the existence of a prominent widespread cultural perception that being overweight is associated with wealth and high social status in predominantly black communities in South Africa (Akinrinlola 2012: 3;Franklin et al. 2015;Kruger et al. 2005: 40;Phajane 2016: 5;Puoane et al. 2010: 32). Other studies have also explored the possible effects that these perceptions may have on health interventions focused on raising awareness against the rise in non-communicable diseases (NCDs), as most of these NCDs have obesity as a shared symptomatic factor (Kruger et al. 2005;Puoane et al. 2010). The present study did not investigate whether cultural perceptions on weight loss had a possible impact on the participants' responses. Therefore, additional studies investigating this viewpoint are required.
These findings suggest that poetry has the potential to convey health messages successfully; however, further research regarding this technique is required. Contrary to one of the findings in the present study, other investigations have reported being successful in exploring the use of traditional folk poetry as a communication tool for conveying information about type 2 diabetes and other NCDs.
A study conducted in North Carolina used oral poetry performances among African Americans to pilot a study aimed at improving HIV/Aids related attitudes and selfefficiency, and mitigating the stigma in the communities (Isler et al. 2018). Although the work of Isler et al. (2018) investigated a different NCD to that of the present study, the findings suggest that the use of poetry holds promise in promoting dialogue around HIV/Aids, as it can help reduce the effects of stigma as well as raise HIV/ Aids awareness. Studies looking to raise diabetes awareness through folk poetry can borrow from and build on the findings of Isler et al. (2018).
Despite the rich literature documented on the use of traditional folk poetry and the benefits it holds for health promotion and education, it appears that only a limited number of studies have documented using this communication tool for raising diabetes awareness. This could imply that previous studies could only be considered a first step towards a more holistic understanding of the application of traditional folk poetry for diabetes awareness and that more work is necessary to understand more completely what this communication tool can offer.
Nevertheless, the above-mentioned studies, including the present study, reveal the potency of folk poetry as a communication tool that can effectively engage individuals (Isler et al. 2018). It can also evoke the cognitive senses; thus, making it a suitable folk media technique for conveying new ideas in culturally appropriate ways (Ritu 2010).

Song and dance
The final intervention was presented using song and dance. The two key themes were about highlighting the importance of taking diabetes medication even when one starts to feel better and encouraging the practice of eating small portions of food throughout the day as opposed to eating one large meal a day. The intervention used the popular tune of a Sesotho wedding song "Sana Marena" in combination with a traditional knee and shoulder dance, which is performed by Sesotho women, called "Mokhibo". The latter were chosen in order to grab the participants' attention, interest and engagement using a familiar tune and dance routine.
Similar to the participant's reactions to messages conveyed through poetry, in this study the participants' reactions to messages conveyed through song and dance were inconsistent and statistical differences were found. The responses to message five (about medication adherence) demonstrated a lack thereof on the participants' ability to recall the information conveyed via song and dance interventions four weeks postintervention. Conversely, the participants' responses to message 6 (about eating small meals) were indicative that some of the participants retained the information conveyed to them, and were able to recall the information four weeks post-intervention. These results again suggest that song and dance interventions have the potential to convey messages, which contain health information, effectively but further research is required regarding the use of this technique.
A preliminary study aimed at testing a dance intervention to explore the role of peer support in improving A1C, weight and body fat in African Americans with type 2 diabetes found that dancing in a supportive community-based environment might be an effective strategy for diabetes management. The findings suggest that diabetes educators could use community-based dancing to assist those with diabetes to engage in more physical activity, and improve diabetes outcomes and overall health (Murrock et al. 2009). Similarly, the American Diabetes Federation (ADF) through the Feria de Salud festival (Festival of Health for your Family) makes use of Latin music and dancing, among other activities, to draw in people from in and around the Hispanic community in order to teach them how to dance and how dancing can be done at home as a form of exercise. The programme led to increased awareness about the importance of living a healthy lifestyle among the members of a Hispanic community where diabetes statistics were very high (ADF 2008).
Traditional folk media clearly holds the potential to convey health communication messages across a wide spectrum of low and middle-income communities, as is reflected in the discussion above. Folk arts are trusted, respected and relatable to members of these communities; thus, making them credible sources for conveying new ideas and information to stimulate progressive health and social development in these communities.

CONCLUSION
Traditional folk media have the potential to be used as effective modes of communication. Based on the results of this study and previous studies, it can be said that traditional folk media seem to embody great advances for health communication intervention efforts. Its ability to bridge socio-economic gaps, connect people and cultures, and break down barriers in the most simplistic forms while maintaining strong cultural significance is an indication that traditional folk media is useful and should be preserved across cultures.