RUNNING HEAD: INTERVENTION AUDIENCES IN ROMANIA Constructing the disadvantaged Roma audience: Public health communication and politics

in contemporary Romania

Throughout the last century, researchers, political lobbyists, and activists have advanced, celebrated, and critiqued different paradigmatic approaches to development and international communication. The initial approach, the dominant paradigm of development communication, framed change as a top-down project of persuasion and influence; it promoted a powerful effects model of the mass media, which many believed to foster modern attitudes and beliefs (see Sparks, 2007, for discussion). In response to critiques to, and the practical failures of, this approach, various discourses of media and cultural imperialism have ensued, as well as a more inclusive participatory paradigm. The former presents less interest here, as it is chiefly concerned with the negative effects of consuming an overwhelming amount of non-local media. The latter, associated with the revolutionary voices of the 1970s, promoted media use as a means to give voice to the voiceless, to assist the local poor throughout the world in areas they themselves would see useful (though theoretical and organizational challenges, somewhat predictably, have plagued such efforts). While these academic debates have unfolded, governments and non-profits nonetheless have forged ahead and continued to fund communication projects around the globe, particularly in the arena of public health. Our goal here, modestly approached with examples from Romania, is to introduce (or at least re-introduce) such intervention projects into our larger discussion about the role of mass communication in global change. Many health communication projects explicitly solicit belief and behavior change in absence of consideration of the unintended consequences of modernity promotion.

INTERVENTION AUDIENCES IN ROMANIA 2 Communication scholars, in turn, often have contributed to developing health-promotion efforts from a practical perspective as interventions towards change, rather than offering an analytic understanding of those interventions as part of broader socioeconomic or cultural processes or perspectives (Burrows, Nettleton, & Bunton, 1995; Southwell, 2000). Similarly, many communication researchers have undertaken what might be called administrative research in service of health-promotion endeavors rather than focusing on relationships and implications produced by such efforts. There are ways in which communication research might do more than assist the implementation of such interventions, however. For example, reflexive inquiry regarding the language that practitioners use in planning and conducting health communication projects should be useful. Language about health, after all, positions and creates relationships among individuals, environments and institutions. Language communicates and creates knowledge and truths (Jensen, 1999). Study of language can contribute to an understanding of discourse here understood as an institutionalized way of talking (and thinking), composed of a system of rules, codes, and limits to communication, leading inevitably to a process of myth-making that guides and constrains understanding of social phenomena (Burton, 2005). By understanding how health intervention workers talk about and to their intended audience, we should see with greater clarity the aspirations, limitations, and prospects for such efforts. The concept of audience has its roots in early communication research that envisioned audiences as concrete, measurable entities to be observed and measured (e.g., Lazarsfeld & Stanton, 1941). Owing its roots to marketing strategists preoccupied with selling to audiences through the media, however, the audience term sometimes has been bound up with a desire for control over (and a consequent need for knowledge about) the group conceived as an audience

INTERVENTION AUDIENCES IN ROMANIA 3 (Ang, 1991; Gandy, 1990; Mosco & Kaye, 2000). More contemporary communication scholarship sometimes has conceptualized the notion differently, taking into account the implications and constraints of our growing understanding of differences in interpretation and cultural contexts (Ang, 1996; Livingstone, 1998a, 1998b; Hagen & Wasko, 2000; Schiller, 2000). Among this array of audience conceptions, the notion of an analytic audience (Anderson, 1996) refers to an entity produced within discourse among critics of practitioners. We apply the analytic audience here as a unit of analysis in a sense that can vary from project to project. An analytic audience is a topic for discussion a useful discursive construction, that is rather than a group of participants in, or observers of, a discussion. Whereas an administrative focus might ask questions about the measurement of audiences as existing entities, an exploration of the constructed analytic audience allows us to approach questions regarding how institutions characterize such entities and how conceptualizations might differ (Southwell, 2000). This approach is useful in understanding the active and productive role that institutional discourse plays in envisioning social relations and hierarchies. As suggested, in the realm of health communication projects (local, regional, or international), audiences have been traditionally conceptualized as helpless and needing intervention, as lacking the skills and knowledge to improve their lives, and without a futureoriented perspective (Sparks, 2007). A series of historical developments have contributed to shifts in the political and theoretical understandings of development and, it follows, of audiences for projects of development. The end of the Cold War, the wave of social movements and radicalism, and finally the fall of Communism in Eastern Europe and the demise of the Soviet Union all have marked transformations of ways of talking and interacting towards social

INTERVENTION AUDIENCES IN ROMANIA 4 development. The present study concerns contemporary health communication projects implemented in developing Eastern Europe, funded by the developed world, and having as a goal health education and ultimately social change. It represents an example at the intersection of different institutional discourses about and towards an audience historically conceived as problematic: The Romanian Roma. Before we proceed to a detailed analysis of this project, the situation of the Roma warrants clarification. The Problem of the Roma In recent decades, public manifestation of any type of discrimination against groups and individuals has been frowned upon in many parts of the world, and in many societies such discrimination has been legally penalized. Nonetheless, groups of Roma (who are called many names, among the most common Gypsies or Travellers) are one of the most ignored, misinterpreted, or mistreated cultural groups, as documented by scholars in a variety of disciplines and recognized by human rights organizations (Erjavec, 2001; United Nations, 2001). Representations of Roma are sites of multiple strands of stereotyping and contradiction, in nearly all communities and nations where they reside, in Eastern and Western European and American contexts, as well as within local political and economic discourses and in popular culture artifacts. Negative imagery of Roma as criminals, alongside nomadic and bohemian Roma / Gypsy representations, coexists with positive representations of Roma traditions and collectivity (Cohn, 1973; Crowe, 2000; Csepeli & Simon, 2004; Erjavec, 2001; Kende, 2000; Lemon, 2000, 2002). The common denominator shared by scholarly and popular literature about Roma groups around the world is that they are one of the most excluded cultures from dominant public discourses. Most generally, the Roma are an exemplar of the deviant other, defined in the post-colonial literature as an outsider, backward, foreigner, irrational, disempowered version of

INTERVENTION AUDIENCES IN ROMANIA 5 the self here, the non-Roma (Barker, 1999; Hall, 1997; Mignolo, 2000; Said, 2003; Shome & Hegde, 2002; Todorov, 1999). Knowing the other becomes a matter of control (of the others past, history, environment, and symbolic representations), a tendency well established historically and powerfully still visible in the contemporary European space and discourses (Charnon-Deutsch, 2002). In the European context, since the fall of Central and Eastern European Communist regimes in the 1990s, the social treatment and representation of Gypsies in Western and Eastern Europe have been continuously changing, guided by, and expressed as, overt discrimination and violence (Brearley, 2001; Papadimitriou, 2001), or public outrage in the face of such continued intolerance (Bancroft, 2005), often manifested in conjunction with policy changes funneled by concerns raised by international human rights organizations (Blasco, 2002; Vermeersch, 2002). With the increased opening of the European Union borders and ensuing amplified population movement, the attention to minorities, (illegal) immigration, border control, and labor migration have taken the focus on the agenda of international organizations such as the European Union, the North Atlantic Treaty Organization, the United Nations, or the Council of Europe, to name a few. Coinciding with socio-economic and political international policy-making, a growing movement of activist non-governmental organizations has emerged, giving attention, protection, and a louder voice to minority and Roma issues. The latter also pay specific attention to media coverage and therefore draw attention to communication elements that appear problematic as regards Roma and human / minority rights. The Romanian Roma constitute a minority group that present political concern for both the Romanian government (and local majority population) and international institutions. Faced with recent economic and political pressures to integrate into the NATO and the EU, Romania

INTERVENTION AUDIENCES IN ROMANIA 6 has been challenged by Roma emigration and immigration, crime and poverty, unemployment, mass illiteracy, and poor health education. Government data assesses the Roma population size to be 2.4% of the countrys population (Recensmnt, 2002), whereas local Roma groups consider it to amount to 9.9% of the total inhabitants (Liegeois & Gheorghe, 1995). In light of these ideas, specific communication efforts intended to address the health of the Roma are compelling. A number of such projects have been active in recent years; several programs, co-sponsored by the Romanian government through its Ministry of Public Health (MOPH) and international organizations, have focused on health education among Roma groups. Here we assess how documents linked to some of those recent health projects present evidence of thinking about Roma and those working with them as audiences. Method This project is a study of the relationship between discourse and health intervention audiences. Discourse analysis (Fairclough, 1995; van Dijk, 1993) entails uncovering links between texts, discourse practices, and sociocultural practices (Fairclough, 1995). Discourses are productive (Foucault, 1990) because, by talking or writing, reality is perpetually recreated (Richardson, 2006). In other words, discourses offer possibilities of communication out of the range of rules and boundaries that they set in place in a particular historical conjuncture. An investigation of language, text, discourse, and social construction of audience must necessarily also take into account the visual representation of that audience. Visual communication is assumed to show how individuals internalize social relations and subsequently re-present them. Images carry meanings that are not always immediately present in verbal speech because they encompass attitudes, emotions, and physical reactions (Lears, 1985; Schneeweis, 2005). Non-verbal communication is conveyed through body language, proximity, orientation,

INTERVENTION AUDIENCES IN ROMANIA 7 appearance, head nods, facial expression, gestures, posture, eye movements, and eye contact (Fiske, 1990). This project assumes that audiences are visually represented within the same discourse as they are linguistically constructed. Description of materials We analyzed four health communication efforts. The first is Cultural Diversity for the Family Doctor: Introductory Guide to the Diversity of the Roma Culture (CDFD).1 The second is Manual for Participants: Training Workshop for Roma Health Mediators in Reproductive Health (MP).2 The other two documents, dating back to 2001, are a poster and a brochure created by a Romanian countys Direction of Public Health. Importantly, all of the projects in question involved external funding. The CDFD and the MP received assistance from the JSI Research and Training Institute, based in the United States and described below, and the United States Agency for International Development (USAID). The Direction of Public Health poster and brochure were funded by a European Union program, as described later. The CDFD explicitly identifies family doctors as its audience, whereas the MP addresses Roma health mediators. Both documents were created in 2007 with specific audiences in mind by the same partnership program between the JSI Research and Training Institute and the Romanian Family Health Initiative. The JSI Research and Training Institute is a US-based nonprofit organization working towards improving individual and community health throughout the world (JSI, 2008). The Romanian Family Health Initiative is a program formed in 2001 as partnership between the Romanian MOPH, the USAID, and the JSI Research and Training Institute.

1 2

In Romanian, Diversitate cultural pentru medicul de familie: Ghid introductiv n diversitatea culturii Rome. In Romanian, Manual pentru participanti: Atelier de instruire a Mediatorilor Sanitari Romi in domeniul Sanatatii Reproducerii.

INTERVENTION AUDIENCES IN ROMANIA 8 The CDFD is a collection of several essays, written by journalists, scholars (a university lecturer in Romany language and literature and a graduate student in political science), a local activist working on the project of Health Mediators, and a program coordinator for the JSI Research and Training Institute. The topics covered include (a) the history and culture of the Roma peoples and the Romanian Roma; (b) a lengthy review of traditions, customs, myths, values, and ritual practices in the Roma cultures across Romania and their relationship to health topics and taboos; (c) an introduction to the discrimination and marginalization of the Roma; (d) a description of the health mediator program; and, finally, (e) a presentation of the results of a study on the accessibility and use of health services among the Romanian Roma ethnicity. These content essays are interspersed with short anecdotes about family doctors serving Roma communities across Romania. In other words, the document is well put together, with compelling sources (popular, such as family doctors and Roma villagers, scholarly, and NGOs, such as Council of Europe materials and the Universal Declaration of Human Rights) and detailed case studies. In contrast, the MP is a how-to manual for training health mediators put together by a physician trainer and a training consultant, both of the JSI Research and Training Institute. It attempts to introduce health topics in simple language, easy to understand by a reader not trained in medicine and easy to reproduce for other untrained audiences. Such topics are (1) basic reproductive health and family planning information and methods; (2) human reproduction; (3) pregnancy, prenatal, and postnatal care; (4) newborn and infant care and breastfeeding; (5) sexually transmitted diseases; (6) ovarian and breast cancer; (7) group health education; and, significantly, (8) communication and behavior change notably, a transmission model of communication, focused on sender, receiver, message, channel, code, and feedback (Carey,

INTERVENTION AUDIENCES IN ROMANIA 9 1992). The explicit audience for this document is Roma women to be trained as health mediators but also the wider Roma communities to whom the reproductive health information will be conveyed. (The dual audience construction is an interesting dynamic within the document, which alternates between addressing the two.) The county-level Direction of Public Health poster and brochure have been recently used in health education initiatives, whether in doctors offices, by health mediators, or distributed along other health-related materials (A. Andrioiu, personal communication, March 15, 2008). Both were financed by Phare funds, a European Union program of assistance for countries that have been candidates to EU membership (Phare, 2008). The poster (about 27x19) is a large, blue-tinted black-and-white photograph of (presumably) a father holding, and smiling down on, his infant son (see Appendix A). It can be inferred the two are Roma, not so much because of their simple clothing (the father is casually dressed, wearing a turtleneck, vest, and baseball cap; the infant draws more attention because of his bear arms and chest wearing only a loose vest); rather, the superimposed text in Romanian and translated into Romany indicates a Romanyspeaking audience. The poster conveys candor and parental attachment through the fathers affection towards his son (displayed on his face and in the embrace) and especially because of the endearing, big-eyed smile the little boy shows the camera and therefore the texts audience. The caption Your children can have a better life, IF YOU ALSO TAKE CARE that they are clean, that they eat well, that they are vaccinated, to get to the doctor when they are sick3 is significantly positioned within green and blue text boxes and the word emphasis is highlighted with red; the colors green, blue, and red are also the colors of the internationally approved Roma

Copiii ti pot avea o via mai bun, DAC I TU AI GRIJ s fie curai, s mnnce bine, s fie vaccinai, s ajung la medic cnd sunt bolnavi. The Romany translation reads Te tre bieti ai jiuven mai mito DACHE TE TUT GRIJA LENDAR te avenle tistai, te chan mito, te avenle vaccinimen, te ghizanlem co doftori cana nine nasfale. Emphasis in the original.

INTERVENTION AUDIENCES IN ROMANIA 10 flag. The sponsors Phare-EU and the countys Foundation Children and Family are identified on the bottom. The brochure titled Family planning and subtitled if you do not wish to have children, do not leave yourselves to chance!4 is a small (about 5x8), sepia-colored information sheet, folded in three (see Appendix B). The cover depicts a photograph of a child in a cart in a seemingly rural area; the child may be a girl, smiling at the camera, sitting near a woven basket; a decrepit house can be seen in the distant background; below, the countys Direction of Public Health is identified. The inside of the brochure contains five pictures and substantial small-font text about family planning; three of the five images are of children, all facing the camera and smiling, presumably Roma, whereas the other two are of a couple and of a woman talking to a medical professional. The back of the brochure exhibits a two-page table of various contraceptive methods, directions for use, their advantages and disadvantages, as well as their efficiency (given in percentages and labeled as small, great, or rather great), as well as contact information for the Direction. Discussion Constructing the Roma audience Overall, the four documents stand as signifiers for two distinct discourses, one that continues and contributes to a patronizing approach to communicating about health and another that relies on a participatory model to improving health behavior. Taken as a whole, the guide to family doctors and the poster of the father and son mark the former, whereas the brochure for Roma women and the training manual symbolize the latter, even though indications of both approaches appear in all four materials. In addition, the construction of the Roma as an audience for family doctors indicates a possible emerging discursive transformation in the Romanian
4

Planificarea familial; dac nu dorii s avei copii, nu v lsai pe seama ntmplrii!

INTERVENTION AUDIENCES IN ROMANIA 11 cultural landscape the Roma are depicted as a culture in its own right, just the Roma, as suggested below. The disadvantaged Roma audience and the modernity paradigm. The Roma as a disadvantaged, in-need audience is the primary mode of representing the Roma throughout the materials. This discursive strategy confirms Sparks (2007) observation that health education remains a field shaped by the dominant paradigm of development communication, with a strong focus on persuading and changing the behavior of those in need. Contributing to this construction, the Roma are framed as an uneducated group that needs to be addressed simply and needs to be informed about (Romanian that is, Hippocratic) medicine and health services. In the brochure, poster, and the manual for health mediators directly for the Roma the form of address is direct, informal, marked by exclamatory phrases, and illustrated by simplistic metaphors and comparisons (for example, fertility is compared to the patterns of seasonal plant sowing, MP, 2007, p. 16). The lay language is used to explain medical terminology; however, using quotations around common terms and placing them in parentheses following the formal ones draws even more attention to them. Such emphasis highlights the distinction and the superiority of one mode of talking vs. the other. The implication is that the Roma audience (both health mediators and the wider community) speaks simply but, more significantly, they think simply for which reason, a family doctor must arm himself with patience, tact and understanding, and explain to the Roma the importance of the various health topics (CDFD, 2007, pp. 59-60). Lack of vocabulary sophistication is collapsed with illiteracy and further with lack of knowledge. Statistical research from a 2004 study on reproductive health is offered as evidence of the lack of knowledge about, access to, and use of, medical and health services

INTERVENTION AUDIENCES IN ROMANIA 12 (CDFD, 2007). It follows that the Roma need to be explained what is more and / or most important. Again, the Roma need help; they need non-Roma intervention. The disadvantaged Roma are further constructed as a community whose traditions need to be corrected. The health education documents assume that there is an expectation that the Roma families have too many (rather than several or a few) children. Whereas the guide to family doctors heavily relies on the cultural explanation of the centeredness of the family within Roma cultures, the other documents start from the assumption of a large family, without further contextualization. The anecdotes in the CDFD depict Roma families always in the context of poverty that is, the Roma live in villages on the margins of towns, with unpaved, muddy, and inaccessible alleys (not roads), and whose children are not dressed well for the weather (the family planning brochure also includes a picture of a child whose sweater shows a whole on the childs chest, exposing bear skin). Poverty is frequently connected to child abandonment due to reckless (non-existing) family planning. The Roma communities are also constructed to be prone to abandoning the too many children that is, family planning means to bring into the world only expected, wanted and loved children (Family planning, 2001; emphasis in the original). The discourse suggests the ideological deviancy implicit in abandonment. First, in the context of European integration, aborting an unwanted child is cause of maternal mortality that situates Romania in a shameful position among countries in Europe! Second, child abandonment is framed as a guilty appeal to the mothers love (and subsequently implying a womans lack of love and care for a child she abandons), regardless of the economic conditions or traditional modes of interaction that may explain the fact of unsupervised children. Third, an unplanned pregnancy leading to abortion is constructed to be deviant in the eyes of religious

INTERVENTION AUDIENCES IN ROMANIA 13 authorities: Even some priests believe that rather than a big sin (abortion), better a smaller one (contraception)! (Family planning, 2001; emphasis added) Once again, the structure of the sentence highlights a patronizing, guilt-inducing attitude towards the Roma women as audience. Such type of commentary stands in sharp contrast to the formal, research-based language of the medical content for example, there is risk for the mothers health or for the health of the future child when the woman is under 18 or over 40 (Family planning, 2001).5 The non-Roma health services such as health insurance, vaccination, even the fortunate availability of pampers vs. cotton diapers (MP, 2007, p. 46) are presented as modern methods, continually improved throughout the past century, today having maximum advantages and minimum side effects (Family planning, 2001). Modern methods are categorically contrasted with traditional methods, known and used for a long time, without a scientific basis (MP, 2007, p. 18). These descriptors contribute to the representation of the Roma audience as a backward subject in need of help / change / development intervention. Likewise, the family doctor is a local hero. Several anecdotes describe success stories of good communication and partnership between doctors and their Roma patients in terms such as the doctor of the gypsies, true guest of honor, trusted and welcomed at the time of his visits with large meals and festive music (CDFD, 2007, p. 19). The family doctor overcomes intercultural conflict simply through his / her dedication to the profession and the patients and, significantly, he / she does so in a situation of threat by the Roma locals. The modernity paradigm is also evident in the optimist conclusion of one doctors story, who declares himself satisfied that we
5

The statements about the unborn child / fetus or the future child (Family Planning, 2001), which abound throughout the studied materials, especially in the MP, must be understood in the context of Romanian culture. There is no politicized discussion and public religious debate regarding the nature of the fetus / child. Generally, the assumption is that the pregnant woman is carrying an unborn child. This belief is not problematic in Romanian society. The pro-life and pro-choice constructions are not features of health discourses of the country. It follows that, for instance, using the word child to refer to the unborn fetus / baby and defining conception as procreation (MP, 2007, p. 18) do not raise the same attention and concern as they would in materials distributed in the USA.

INTERVENTION AUDIENCES IN ROMANIA 14 manage to do work and maintain normalcy (emphasis added). This normalcy signifies that the Roma audience is discursively constructed to be typically outside normalcy that is, deviant and made normal by the family doctors intervention, having communication as weapon in order to persuade (CDFD, 2007, p. 60). The way changing health behavior is talked about in the studied materials also suggests the top-down discursive construction of the disadvantaged Roma. The CDFD abounds in customary and ritualistic descriptions, yet no bridges are suggested between traditional Roma medicine and non-Roma, Hippocratic medicine. Family doctors are left to themselves to decide and / or judge Roma traditions as superstitions to be dismissed, changed, and / or ignored (in the tradition of the dominant paradigm of development communication), or as avenues for conversation and deeper understanding. The fear is that, in the context of historical sustained discrimination and lack of tolerance between the two groups, the family doctor may comfortably stick to familiar interpretations, such as the former. The document itself identifies that Roma typically accuse doctors of demanding bribe the Roma cannot afford, whereas the doctors accuse the Roma of lack of personal hygiene and lack of discipline inside the practice. What might motivate such accusations to end? In addition, the CDFD and the MP both describe data and offer health information about topics that most likely are sensitive in the Roma culture (the reproductive system, positioned in the lower part of the body, is considered impure and taboo, as explained in the guide for family doctors). The examples are numerous (e.g., sexually transmitted diseases, unwanted pregnancies, maternal and infant mortality, limited use of modern contraception methods, family planning seen to have a beneficial influence on couple relations, etc.), yet they all are offered without an explanation or suggestion of how they may be treated cross-culturally. Certainly, the purpose of

INTERVENTION AUDIENCES IN ROMANIA 15 the studied health documents is to address this specific communication crisis, to be a first step towards better communication doctor-Roma patient and towards improved health of the Roma communities. The question remains, nonetheless, whether this purpose is achieved when the information is only presented and not followed by suggestions to assist intercultural communication. Moreover, one essay explains that approximately 10-15% of the total number of Roma in Romania still lives in accordance to the traditional customs and taboos. The document is at fault for glancing over such important group differences and over-emphasizing a (Romanian) Roma audience (except for the single example of explaining pregnancy restrictions within the Braziers and Bear-Leaders communities). A more useful tool for family doctors would be a detailed contextualization of the specific Roma groups they would each serve and treat, rather than a generalized description of the Roma. There are indicators to suggest group differences, but these would need to be spelled out and highlighted to enhance doctor-patient communication. A similar problem of lack of cross-cultural clarity can be seen in the construction of useful questions suggested to health mediators in order to facilitate group education and as techniques of active listening about reproductive health. Are questions such as, How did you feel about?, What would you like to talk about?, or What does your husband say about the method you are using? culturally significant, relevant, and / or translatable? Are group facilitation strategies such as sitting in a circle, always answer enthusiastically to any answer received, or ask the persons in the group to summarize the most important aspects discussed (MP, 2007, pp. 79-80) culturally appropriate? The training manual does not explain. The MP most explicitly contributes to the construction of the Roma audience within the dominant paradigm. It makes clear statements towards changing the health behavior of the

INTERVENTION AUDIENCES IN ROMANIA 16 Roma. Here are some examples: Communication towards behavior change (the title of one of the final sessions of the training; p. 72); people must believe and accept what they are being told and, later, the message must be targeted to those habits that can be most easily influenced in order to determine the person to make the suggested change (p. 76); it is important to find out peoples opinions and better understand their attitudes, concerns, and convictions, in order to adapt the messages about reproductive health to their needs and preoccupations (p. 74); the couple is taught to avoid sexual contact (p. 25). Such examples (emphases added) suggest that behavior change is the ultimate goal; the training teaches mediators how to be strategic about achieving that goal, regardless of whether the change is appropriate and / or desired. The manual visibly avoids mention of how the mediator might go about facilitating an understanding between Roma traditional practices and Hippocratic medicine, although its declared purpose is communicating with the Roma and training mediators to translate and facilitate communication. The Roma audience to be helped is constructed to be a special-needs group, under-privileged, and isolated (in its access to, and understanding of, health services). Finally, changing behavior is assumed to occur out of fear and guilt. Strong language accompanies medical recommendations against smoking, alcohol and drug use, and exposure to chemical substances during pregnancy (for instance, when the mother smokes, drinks alcohol, consumes drugs, her child smokes with her, drinks at the same time as she does, will be using drugs, MP, 2007, p. 37) without necessary research support. The use of this discursive strategy (i.e., fear-based persuasive strategies in health communication) also suggests the assumed simplicity and lack of sophistication of the Roma culture. In sum, the linguistic mode of address and vocabulary choices, the suggested superiority of non-Roma traditions over the Roma customs, framed as backward and pre-modern, the

INTERVENTION AUDIENCES IN ROMANIA 17 deviancy implicit in Roma family structures (which stands in sharp contradiction with the traditional family-centeredness of the minority groups), along with an absence of intercultural communication bridges all such discursive strategies indicate and support a modernity paradigmatic approach to health communication. They also reveal a political commitment to a long-standing attempt to control the Roma other (Charnon-Deutsch, 2002). The assumption is that, by controlling (and changing) its uncivilized health behavior, the Roma community is modernized and easier integrated into the majority population one of the explicit goals both of the Romanian government and of the European Unions integration procedures and funding opportunities in developing Romania. Keeping with tradition and the participatory paradigm. Starks (2007) discusses the participatory paradigm as a more inclusive model of communicating development that actively seeks the involvement and contribution of those whose lives can be improved. This paradigm still draws from the dominant one because of its ultimate commitment to change a group of people perceived to need it; the focus, however, is on the cooperation towards change between the developed and the developing. The poster depicting the Roma father and son illustrates the participatory approach; the photograph and Romany translation signify inclusion of, and attention to the cultural and linguistic needs of, the Roma audience. In other words, the poster is constructed to be more respectful of the worldview and context of the beneficiary of the health communication effort (Hornik, 1988, p. 159) than is the brochure for family planning (not translated and heavy in medical terms). On the whole, the health mediators program is an instance of participatory communication towards development identified as such in the CDFD: The program has emerged in response to the needs of the communities with Roma members [characterized by

INTERVENTION AUDIENCES IN ROMANIA 18 an absence of] communication between the Roma community members and the medical personnel (2007, p. 62); and, also, in the MP, which prepares mediators to evaluate group education panels in regards to whether participants [were encouraged] to identify their own problems and suitable solutions (2007, p. 82). The guide for doctors also argues for continuing programs of information and communication imperiously necessary and more beneficial as long as keeping with the tradition and healthy practices of the Roma communities is encouraged (CDFD, 2007, p. 85). That said, it must be noted that the description of the program offered in the CDFD and the MP stands in stark contrast with the specific training outlined in the manual for the mediators. The language in the CDFD rarely alludes to expectation of child abandonment or lack of hygiene (indicators of the modernity paradigm outlined above); it more frequently describes the mediators explaining health information to a Roma audience by framing [the advantages of family planning] in the traditional cultural system of the Roma community (CDFD, 2007, p. 68), uniquely including a quote from a Roma health mediator. To conclude, the participatory paradigm of communication and development is discursively represented in the analyzed health materials through translations into Romany and sensitive references to the Roma community members as participants in changing their health behavior and practices. Just the Roma audience. The two modes of constructing the Roma as an audience described thus far draw from discourses established in the Romanian culture (and in Eastern and Western Europe more generally). Most scholarly literature, political discussion, mediated representation, and activist observations either contribute to or explain and expose such modes of talking. From a health communication perspective, they certainly fit into comfortable paradigms of dealing with the population whose health behavior is thought to need improvement. The

INTERVENTION AUDIENCES IN ROMANIA 19 communication materials analyzed in this study, however, additionally include elements of a different discourse a rather unique audience construction. The Roma aside from being disadvantaged and participatory are also depicted solidly as a culture in their own right. The audience is just The Roma not different, not an other, not criminally inclined, not victim of poverty (even when poor), not romantically bohemian, not appealing and attractive because of its exoticism; rather, the Roma are just as the Romanians are. In this representational mode, the doctors are invited to treat the Roma patients not the complainer Roma, not the dirty Roma, not the stereotypical Roma, and not the superstitious Roma. Several important elements contribute to this construction. To begin, the Roma are a different social audience. They are no longer consistently constructed at the polar extremes between criminals and victims, as illustrated by this example from the CDFD: The fact that, throughout history, the culture of the Roma has been relatively closed and inaccessible to others cannot be denied, development to be expected within a community with a high risk factor. The period of persecutions based on the anti-gypsy laws in Central and Western Europe has consolidated the Roma ethnic community around the victim mentality. However, research has shown that the Roma population prefers to integrate, rather than live separately in society. Today, the Roma fight for equality and social participation, at the same time as they try to preserve their cultural uniqueness (CDFD, 2007, pp. 47-48). The essay continues with a discussion of marginality, attributed both to the non-Roma majority cultures (through institutional, politico-economic, and social discrimination), as well as to the Roma communities perpetuating the victim role. The authors of the CDFD do not dismiss the fact that the Roma are less developed, for lack of a better term, in terms of economic, political, social, and cultural factors (as they are currently defined) used to compare the Roma to nonRoma populations (e.g., documented and acknowledged poverty or illiteracy characterizing Roma groups), and physical self-marginalized (living at the outskirts of towns is also a decision

INTERVENTION AUDIENCES IN ROMANIA 20 of the Roma community). Nonetheless, such factors are contextualized and explained historically, rather than maintained in a frame of guilt and / or blame: Because of their history, the Roma have not had the chance to conserve, develop, perfect a vast, unique culture. The noted oral character of this culture, the absence of a shared living and work space have left a mark upon the life and cultural products of the Roma communities. The absence of a cultivated, written language has negatively influenced the maintenance of a traditional culture and the development of their own culture (CDFD, 2007, pp. 51-52). As seen above, the literature explains that the discursive construction of inferiority occurs by contrasting a majority, stable, sedentarized, lawful, normal non-Roma community (McVeigh, 1997). Here, however, instead of describing the Roma cultures with an emphasis on their distinction or by contrast to the non-Roma, the audience talked about in the CDFD is described as a culture in its own right. They are a different cultural audience. To illustrate, the different Roma subgroups in Romania are described in some detail, often followed by a commentary on the degree of traditionalism or status of transition from tradition to a more integrated cultural model existent within the specific communities, and uniquely a historic / contextual explanation of this degree of traditionalism is further explained. For example, the Roma tribe of the Blacksmiths (including the Farriers / Shoeing-smiths) has been: among the first sedentarized Roma, because they used to make weapons and light mail, knives, needles, scissors and surgery instruments, tools for farmers and carpenters. Later, many managed to buy land, becoming farmers or blacksmiths, workers in constructions and in industries. Their descendants turned to professional schools, secondary and university studies. They were among the first to lose their language, and many of them do not see themselves today as Roma (CDFD, 2007, p. 14). Related, the authors of the CDFD go to great lengths to explain the intergroup differences among the over 40 Romanian Roma tribes, to caution against a homogeneous Roma group, and to explicate this diversity in light of modernization and urbanization processes.

INTERVENTION AUDIENCES IN ROMANIA 21 The choice of including a rich discussion of the pure-impure distinction that characterizes the whole philosophy of life of the traditional Roma culture (p. 23) in the CDFD (pp. 23-28) is a telling communication development. This information is included with the purpose of explaining the potential cultural and social disagreements between the family doctors and their audience their Roma patients. The division refers to the purity of the top half of the body vs. the impurity of the bottom part, not to be touched or exposed in public. (This rule also explains nursing in public as a pure, celebrated individual and community display and not an inappropriate, private act, as is seen in other non- Roma communities in Romania and in other countries.) It has significant implications for the perception of the human body (especially the female body, as it relates to pregnancy and birth) and for taboos about food and nutrition. Delineating the pure-impure distinction has as central goals to offer family doctors an insight into Roma traditions and to improve their service to their patients. It may further clarify intercultural exchanges and misunderstandings. However, the guide stops short of making any such (useful) recommendation. In what some might see as an example of Western-style political correctness (the guide is funded by a US-based NGO, after all), the JSI program coordinator opens her introductory statement by claiming the solutions are in each and every one of us! (p. 5). How might the family doctor (especially a male one) talk about menstruation, for example, when the taboos about the womans isolation and impurity at that time of the month are a feature of the (traditional) Roma cultures? How might the doctor address a newborns lanugo (body hair) or miscarriage, when the traditional Roma interpretation would associate them with the mothers gestures during pregnancy or with how well her family satisfies her cravings, respectively? From a health communication perspective, the recommendations would be useful, practical, and probably

INTERVENTION AUDIENCES IN ROMANIA 22 needed given the historic misunderstanding and mishandling of Roma issues. From a critical cultural stance, however, this absence places the Roma as a culture (and audience for the health materials) outside of a predetermined, to-be-modernized, to-be-helped category. (The same cannot be said about the constructed audience of the MP or about the family planning brochure.) Conclusion In this study, we applied the concept of analytic audience to assess four examples of health communication efforts developed in Romania, with external funding, to address the health education and behavior of the (problematic) Romanian Roma population. The focus was on how practitioners conceptualized the Roma as an audience to be communicated with and about in order to affect their behavior. The analysis suggests that the Romanian health communication projects chiefly continue the traditional modernity approach to health and development by constructing a disadvantaged and under-privileged Roma audience. Second, the projects attempt to support a participatory approach to health education that calls for keeping the tradition of the (target) audience alive, while at the same time implementing change. Given the Western source of the funding and the education of the staff creating the communication documents, a discursive commitment to the participatory approach is not surprising. Finally, the health education documents show evidence of progressive thinking in describing a Roma audience talked about as a culture in its own right. The thick description of the Roma culture the historical context as well as the detailed review of Roma taboos and customs emphasizes the sophisticated system of beliefs at the basis of the perceived and often stereotyped difference. In other words, it contributes to describing the workings of a culture. Clearly, by acknowledging the complexity of the lives of Roma in characterizing them as an audience, health communicators have taken an

INTERVENTION AUDIENCES IN ROMANIA 23 important step toward bridging cultural divides, instead of simply constructing the Roma as a target for influence. How might these conceptualizations of audience relate to larger political dynamics in Romania and Europe? By assessing how intervention planners and practitioners (as opposed to academic theorists) discuss audiences for recent health education efforts in Romania, we found evidence to validate concern some might have regarding the political agenda of health communication projects funded by the United States and the European Union. That we can find such evidence in the early 21st century as so many structural dynamics face the country is noteworthy; it suggests that health communication projects certainly are not immune from politics. At the same time, such an analysis also revealed linguistic acknowledgement of the right of the Roma to hold values and beliefs that might differ from preferred perspectives, evidence of the growing sophistication and sensitivity of contemporary intervention specialists that is often overlooked by critics. Advancing behavior change is undoubtedly an underlying goal of many health communication projects in contemporary Romania; analysis here highlights the diversity of approaches that might be used in conceptualizing audiences for such efforts. Future work in this vein is potentially valuable as an organizing tool for discussion, as such analytic audience constructions should have actual consequences for practice.

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INTERVENTION AUDIENCES IN ROMANIA 28 Appendix A Your children can have a better life Poster produced by the foundation Children and family Bistria

INTERVENTION AUDIENCES IN ROMANIA 29 Appendix B Family planning Brochure produced by the Direction of Public Health Bistria-Nsud