Effectiveness of Soft Power Approach in PM2.5 Risk Communication: A Community-Based Intervention in Thailand's Border Region

Effectiveness of Soft Power Approach in PM2.5 Risk Communication: A Community-Based Intervention in Thailand's Border Region | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Effectiveness of Soft Power Approach in PM2.5 Risk Communication: A Community-Based Intervention in Thailand's Border Region Smith Boonchutima, Sudkanueng Ritruechai, Pitakkapong Chandang, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7053430/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background PM2.5 air pollution poses significant health risks in Thailand's border regions, yet traditional risk communication approaches have shown limited effectiveness in changing community behaviors. This study evaluated a novel "soft power" approach to PM2.5 risk communication in rural border communities. Methods We conducted a mixed-methods intervention study in two sub-districts of Mae Sot District, Tak Province, Thailand. The intervention utilized soft power principles including storytelling, trusted local messengers, culturally adapted media, and community engagement. We measured knowledge, attitudes, and behaviors at three time points: pre-intervention (n = 842), immediate post-intervention (n = 810), and 1-month follow-up (n = 806). Results Comprehensive PM2.5 knowledge increased significantly from 8.4% pre-intervention to 27.0% at 1-month follow-up. Regular protective mask wearing increased from 33.1–57.8% (+ 24.7%), and continuous pollution-reducing behaviors increased from 33.8–58.8% (+ 25.0%). Village announcement systems demonstrated highest effectiveness (58.9% rated most effective), followed by village health volunteers (24.1%). Problem awareness increased from 77.8–92.2%, with positive attitudes toward solutions rising from 65.2–84.7%. Conclusions The soft power approach proved effective for PM2.5 risk communication in border communities, achieving substantial improvements in knowledge, attitudes, and protective behaviors. Success factors included cultural adaptation, trusted local messengers, and multi-channel communication strategies. This model offers a scalable framework for environmental health communication in similar contexts. Earth and environmental sciences/Environmental sciences Earth and environmental sciences/Environmental social sciences Health sciences/Health care PM2.5 risk communication soft power community intervention environmental health Thailand Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction The PM2.5 Crisis in Thailand's Border Regions Fine particulate matter with an aerodynamic diameter ≤ 2.5 µm (PM₂.₅) is a significant environmental health concern in Southeast Asia (Adam et al. 2021 ), contributing to approximately 7 million premature deaths globally each year due to air pollution (World Health Organization, 2023a ). In Thailand, the northern border provinces, including Tak, are particularly affected by severe pollution episodes. These episodes are driven by a complex mix of sources such as agricultural burning, cross-border haze from Myanmar, and industrial emissions (Bangkok Post, 2025 ). Tak Province, situated along the Myanmar border, consistently ranks among Thailand's most polluted areas. For instance, on February 12, 2025, Tak recorded PM₂.₅ concentrations of 59.0 µg/m³, significantly exceeding Thailand's national safety standard of 37.5 µg/m³ and the World Health Organization's guideline of 5 µg/m³ (Nation Thailand, 2025 ). The health burden is substantial and growing. In December 2023, Mae Sot recorded PM2.5 levels of 37.4 µg/m³—approximately 7.5 times the WHO's annual guideline—highlighting the severity of air pollution in the region (IQAir, 2023 ). These extreme concentrations typically occur during the dry season (January-April) when agricultural burning combines with meteorological conditions that trap pollutants in valleys (Oanh et al., 2023 ). Recent modeling studies predict that all age groups of children in northern Thailand will experience increasing PM2.5 threats through 2029, with infants at highest risk due to their narrower airways and developing lung function (Amnuaylojaroen & Parasin, 2023 ). Border communities face unique challenges that compound PM2.5 exposure risks. Cross-border pollution sources remain difficult to control through domestic policy alone, with studies showing that 46% of population-weighted air pollution exposure in some regions originates from sources in neighboring areas (Du et al., 2020 ). Cultural and linguistic diversity, with significant Myanmar migrant populations, complicates public health communication (Kosiyaporn et al., 2022 ). Limited healthcare access and economic constraints restrict both prevention and treatment options (Tschirhart et al., 2017 ). Traditional top-down risk communication approaches have shown limited effectiveness in these contexts, necessitating innovative community-centered strategies. Limitations of Traditional Risk Communication Conventional environmental health communication typically relies on information-deficit models, assuming that providing scientific information will directly translate to behavioral change. However, systematic reviews consistently demonstrate modest effectiveness of traditional approaches, with meta-analyses reporting typical knowledge improvements of only 5–10% and limited behavior change (5–15%) following standard environmental health education programs (Fitzpatrick-Lewis et al., 2010 ). Recent systematic reviews of air quality communication strategies reveal critical gaps: lack of clarity about information dissemination responsibility, insufficient risk mitigation behavior guidance, and failure to reach vulnerable populations effectively (Ramírez et al., 2019 ). In border regions like Tak Province, additional barriers include language diversity, limited trust in governmental health messages, competing survival priorities, and social networks that may not align with formal health communication channels. Previous studies have shown that culturally insensitive or top-down communication can even increase resistance to protective behaviors (Gee & Payne-Sturges, 2004 ). Research on health communication with migrant populations consistently documents language barriers, cultural differences in health beliefs, and mistrust of formal health systems as primary obstacles to effective risk communication (Hyatt et al., 2017 ). Theoretical Framework: Advancing Environmental Risk Communication Through Soft Power Cultural Adaptation: The Evidence Base Emerging evidence strongly supports culturally adapted health communication over standardized approaches. A comprehensive scoping review of cultural adaptation frameworks identified 15 distinct models, with 86.7% emphasizing community engagement as essential for effective adaptation (Leung et al., 2024 ). Meta-analytic evidence demonstrates that culturally adapted interventions achieve effect sizes 1.5-2 times larger than non-adapted approaches, particularly in health behavior change contexts (Griffith et al., 2024 ). The culture-centered approach, extensively validated across diverse health domains, emphasizes community participation in articulating health problems and developing solutions rather than imposing external frameworks (Dutta, 2007 ). This participatory model has proven effective from HIV prevention among marginalized populations to chronic disease management in rural communities, consistently achieving superior outcomes compared to top-down information dissemination (Basu & Dutta, 2009 ). Community-based participatory research (CBPR) frameworks provide additional evidence for engagement-focused approaches. Systematic reviews demonstrate that CBPR interventions in environmental health achieve greater community acceptance, higher behavior change rates, and improved sustainability compared to researcher-driven programs (Vincent et al., 2022 ). Key success factors include respect for local knowledge, cultural humility, trust building, and intervention designs that align with community values and practices (Phillip et al., 2024 ). Soft Power: Theoretical Innovation in Health Communication Soft power, originally conceptualized in international relations by Joseph Nye ( 2004 ), offers a novel framework for health communication that aligns with cultural adaptation and community engagement principles. Unlike "hard power" approaches relying on mandates, penalties, or coercion, soft power operates through attraction, persuasion, and voluntary cooperation—making it particularly relevant for health behavior change in communities where enforcement mechanisms are limited or culturally inappropriate. In health communication contexts, soft power principles translate to five core elements: Narrative Engagement Over Statistical Presentation : Research on narrative medicine demonstrates that personal stories and local examples create emotional connections that statistical presentations cannot achieve (Shaffer et al., 2018 ). The Narrative Immersion Model shows that stories promote engagement through interest, identification, and immersion, leading to superior attitude and behavior change outcomes. Cultural Resonance Over Standardized Messaging : Systematic reviews of culturally sensitive health communication emphasize adapting messages to recipients' cultural backgrounds to increase knowledge and improve decision-making (Betsch et al., 2015 ). This goes beyond language translation to incorporate local values, social structures, and communication preferences. Trusted Local Messengers Over External Authorities : Research consistently demonstrates that trusted community members achieve superior communication effectiveness compared to external experts. Studies of village health volunteers (VHVs) show their unique position as "health diplomats" who negotiate between formal health systems and community needs, achieving high acceptance rates for health interventions (Masunaga et al., 2022 ). Creative Expression Over Technical Communication : Evidence from diverse cultural contexts shows that arts-based health communication—including music, visual arts, and performance—can effectively convey complex health messages while respecting cultural traditions. A study in multicultural Thailand demonstrated that folk songs significantly improved health behavior change compared to standard education approaches (Songserm et al., 2021 ). Community Ownership Over Top-Down Dissemination : Participatory communication approaches that involve communities in message development and dissemination create local ownership that enhances both message credibility and personal relevance. Community engagement interventions demonstrate sustained behavior change through collective efficacy and social norm modification (Brunton et al., 2017 ). Trust and Credibility in Environmental Health Communication Trust represents a critical mediator of communication effectiveness, particularly in environmental health contexts where risks may be invisible or contested. Systematic research on trust in environmental health messaging identifies several key factors: Source Credibility : Local leaders, health workers, and community-based organizations demonstrate higher trustworthiness than state or federal agencies, particularly in marginalized communities with histories of institutional neglect (Wood et al., 2022). This trust advantage stems from shared cultural experiences, ongoing relationships, and perceived competence in addressing community-specific needs. Message Consistency : Trust develops through consistent, transparent communication over time. Studies of risk communication demonstrate that contradictory or changing messages from authorities can undermine credibility and reduce compliance with protective behaviors (Warren & Lofstedt, 2022). Community Engagement : Participatory approaches that involve communities in problem definition and solution development enhance trust by demonstrating respect for local knowledge and community autonomy. Research in environmental justice communities shows that top-down risk communication can actually increase resistance to protective behaviors when it fails to acknowledge community expertise and concerns (Burger, 2022). Study Objectives This study aimed to evaluate the effectiveness of a soft power-based intervention for PM2.5 risk communication in Thailand's border region. Specific objectives were: (1) to assess changes in PM2.5-related knowledge, attitudes, and protective behaviors following the intervention; (2) to identify the most effective communication channels and strategies within the soft power framework; (3) to examine the sustainability of behavior changes over time; and (4) to develop evidence-based recommendations for scaling similar interventions in comparable contexts. Methods Study Design and Setting We conducted a mixed-methods intervention study using a pre-post design with three measurement points. The study was implemented in Mae Sot District, Tak Province, Thailand, between January and June 2024. Mae Sot was selected due to its severe PM2.5 pollution levels, diverse population including Thai nationals and Myanmar migrants, and representative border community characteristics. Within Mae Sot District, we selected two sub-districts as pilot sites: Mae Kasa and Mae Ku. Selection criteria included: (1) PM2.5 pollution severity; (2) population diversity; (3) community readiness for participation; (4) healthcare infrastructure availability; (5) geographic accessibility; and (6) representativeness of broader border region characteristics. Both communities are rural, with primarily agricultural economies and mixed Thai-Myanmar populations. Participants and Sampling Inclusion criteria: Adults aged 18 years and older, permanent or long-term residents (≥6 months) of the target sub-districts, able to provide informed consent in Thai or Myanmar languages. Sample size calculation: Based on expected 20% improvement in protective behaviors with 80% power and α=0.05, we calculated a required sample of 385 participants per time point, inflated to 450 to account for attrition. Recruitment strategy: We used community-based sampling through village health volunteer (VHV) networks, community leaders, and household visits. Participants were recruited through multiple channels to ensure representativeness across demographic groups. Intervention Development and Implementation Formative Research Phase Prior to intervention development, we conducted extensive formative research informed by cultural adaptation frameworks (Leung et al., 2024). This included: (1) 11 in-depth interviews with community leaders and health workers; (2) 4 focus group discussions with farmers and affected community members; (3) 2 expert consultation workshops; and (4) 2 community practice sessions to test materials and approaches. This formative phase addressed preparation, assessment, and adoption phases identified as critical for successful cultural adaptation (Pardoel et al., 2022). Soft Power Intervention Components 1. Storytelling and Personal Narratives We collected and adapted real stories from community members who experienced PM2.5-related health impacts, following evidence that narrative engagement creates emotional connections superior to statistical presentations (Shaffer et al., 2018). These narratives were integrated into all communication materials, emphasizing local relevance and emotional connection rather than abstract health statistics. 2. Trusted Local Messengers The intervention prioritized community leaders including village heads (kamnan), Buddhist monks, village health volunteers (VHVs), and respected elders, based on research demonstrating their superior credibility compared to external authorities (Wood et al., 2022). These messengers received training on PM2.5 health effects and communication techniques, then adapted messages to their personal communication styles. 3. Culturally Adapted Media Communication materials were developed in both Thai and Myanmar languages, addressing documented language barriers in border populations (Tsai & Lee, 2016). Content included: locally-produced songs incorporating PM2.5 prevention messages; infographics using familiar visual symbols and local landmarks; video testimonials from community members; and audio messages recorded by local leaders. 4. Multi-Channel Communication Strategy Based on research showing synergistic effects of combined communication approaches (Jeong & Bae, 2017): Village announcement systems: Daily broadcasts through community loudspeakers VHV networks: Personal visits and small group discussions Visual displays: Posters and banners in community gathering places Digital platforms: Social media content adapted for smartphone users Community events: Group discussions and educational sessions 5. Community Participation and Ownership Rather than imposing external messages, the intervention encouraged community participation in content development, message adaptation, and dissemination planning, following CBPR principles that demonstrate superior outcomes through local ownership (Vincent et al., 2022). Local feedback was continuously incorporated throughout implementation. Implementation Timeline Month 1: Baseline data collection and final intervention preparation Month 2: Intervention launch and intensive communication campaign Month 3: Immediate post-intervention evaluation and continued reinforcement Month 4: One-month follow-up evaluation and sustainability assessment Data Collection Instruments 1. Structured Questionnaire A standardized questionnaire assessed: (1) Demographics and household characteristics; (2) PM2.5 knowledge (5 items covering definition, sources, health effects, body systems affected); (3) Protective skills (3 items on mask use, air quality monitoring, digital tool awareness); (4) Risk behaviors (6 items on community participation, activity modification, protective equipment use); (5) Attitudes and awareness (5 items on risk perception, community cooperation, protection importance). 2. Communication Channel Assessment Participants reported exposure to different communication channels and rated their perceived effectiveness. Channels included village announcements, VHVs, posters, social media, community meetings, and others. 3. Qualitative Data Collection Semi-structured interviews with intervention implementers (n=15) and focus group discussions with community members (n=4 groups) explored implementation experiences, perceived effectiveness, and recommendations for improvement. Data Analysis Quantitative Analysis: Descriptive statistics characterized participant demographics and outcome measures. Chi-square tests assessed changes in categorical variables across time points. McNemar's test evaluated paired changes in knowledge and behavior items. Statistical significance was set at p<0.05. Qualitative Analysis: Interview and focus group transcripts were analyzed using thematic analysis to identify key themes related to intervention effectiveness, implementation facilitators and barriers, and recommendations for improvement. Mixed Methods Integration: Quantitative and qualitative findings were triangulated to provide comprehensive understanding of intervention effects and mechanisms. Human Ethics and Consent to Participate Written informed consent was obtained from all participants from Mae Sot District before their involvement in the study during the month of September 2024. The questionnaire included a statement informing participants about the purpose of the study, the voluntary nature of their participation, and their right to withdraw at any time without consequences. By proceeding with the questionnaire, participants provided their written consent to take part in the study. To ensure the privacy and confidentiality of the participants, no personally identifiable information was collected during the survey. The data were anonymized and stored securely, with access restricted to the researchers directly involved in the study. The study adhered to the ethical guidelines and principles set forth by the Faculty of Communication Arts, Chulalongkorn University, ensuring the protection of participant privacy and confidentiality throughout the research process. This study was approved by the Institutional Review Board of Chulalongkorn University on 12 August 2024 (Ethics Approval No. 006/68, 116/68, 463/67). Results Participant Characteristics A total of 842 participants completed baseline assessment, 810 completed immediate post-intervention evaluation, and 806 completed 1-month follow-up (95.7% retention rate). The majority were female (70.7%), aged 46-65 years (57.3%), worked in agriculture (37.2%), and had primary education only (59.1%). Demographic characteristics remained stable across measurement points, indicating minimal differential attrition. (Figure 1) Primary Outcomes: Knowledge, Attitudes, and Behaviors PM2.5 Knowledge Improvements The intervention achieved significant improvements across all knowledge domains, substantially exceeding the 5-10% improvements typically reported in environmental health education programs (Fitzpatrick-Lewis et al., 2010). Comprehensive PM2.5 understanding (defined as correct responses to all knowledge items) increased from 8.4% pre-intervention to 13.3% immediately post-intervention and 27.0% at 1-month follow-up. (Figure 2) Notable improvements occurred in understanding PM2.5 sources beyond the commonly known agricultural burning, including vehicle emissions, industrial sources, and cross-border pollution. Health effect knowledge expanded from primarily respiratory impacts to include cardiovascular, neurological, and other systemic effects. Protective Behavior Changes Significant improvements were observed in key protective behaviors, with the most substantial changes occurring between immediate post-intervention and 1-month follow-up assessments. The 24.7% average improvement in protective behaviors substantially exceeds the 5-15% typically achieved by standard environmental health interventions (Howlett et al., 2018). (Figure 3) The pattern of initial spike followed by sustained but slightly reduced levels suggests that while immediate post-intervention motivation was high, participants adapted to sustainable long-term practices by 1-month follow-up, indicating intrinsic rather than externally motivated behavior change (Deci & Ryan, 2000). Attitude and Awareness Changes Risk perception and community cooperation attitudes showed substantial improvements, with most changes sustained at 1-month follow-up, aligning with research showing that attitude changes often precede and sustain behavior modification (Ajzen, 1991). (Figure 4) Communication Channel Effectiveness Analysis of communication channel reach and perceived effectiveness revealed clear patterns favoring traditional, culturally embedded communication methods over digital platforms, aligning with research on rural communication preferences (Asfaw et al., 2019). (Figure 5) Village announcement systems demonstrated superior reach and effectiveness, reflecting their integration into daily community life and trusted status. VHVs provided crucial personal communication that complemented mass messaging, consistent with research on their role as "health diplomats" in community health promotion (Masunaga et al., 2022). Digital Tool Awareness: Understanding Technology Integration Challenges Contrary to expectations and challenging assumptions about digital health tool superiority, awareness and use of digital air quality monitoring tools showed an initial decrease immediately post-intervention before recovering at 1-month follow-up. This pattern provides important insights for digital health integration in rural communities (Jongebloed et al., 2024). (Figure 6) This counterintuitive pattern suggests several explanations supported by digital health research: (1) cognitive load from intensive traditional communication may have temporarily reduced attention to digital alternatives; (2) the intervention may have made participants more aware of their digital limitations, leading to more honest reporting; (3) digital tool adoption may require staged implementation after establishing basic protective behaviors (Radu et al., 2023). Qualitative Findings: Implementation Insights Success Factors 1. Cultural Authenticity : "When the village head spoke about his own family's breathing problems, people really listened. It wasn't just government talk anymore." (VHV, Mae Kasa) 2. Trusted Messengers : Participants consistently emphasized the importance of receiving information from known, respected community members rather than external experts, supporting research on source credibility in rural health communication (Wood et al., 2022). 3. Language Adaptation : Use of Myanmar language materials significantly increased engagement among migrant populations, with several participants noting this was the first health campaign they fully understood, addressing documented language barriers in border communities (Tsai & Lee, 2016). 4. Practical Relevance : Focus on immediately actionable behaviors (mask wearing, activity timing) rather than complex monitoring systems resonated with community needs, aligning with behavior change theory emphasizing feasible actions (Michie et al., 2011). Implementation Challenges 1. Resource Constraints : Limited production capacity for multi-language materials required prioritization decisions, reflecting broader challenges in culturally adapted intervention implementation (Leung et al., 2024). 2. Seasonal Timing : The one-month implementation period coincided with peak pollution season, which may have enhanced receptivity but limits generalizability to year-round implementation. 3. Digital Divide : Smartphone access and data costs limited social media reach, particularly among older adults and lower-income households, consistent with rural digital divide research (Hui et al., 2022). 4. Cross-border Coordination : Addressing pollution sources beyond community control required acknowledging limitations of local action while maintaining empowerment messaging. Community Feedback and Recommendations Post-intervention feedback revealed strong community appreciation for the culturally adapted approach, with 78.2% rating the communication as "very helpful" and 74.8% reporting behavioral changes. Key community recommendations included: Continue regular announcements beyond intervention period Expand to neighboring communities Integrate with existing health education programs Develop community-led sustainability mechanisms Address structural barriers (mask costs, agricultural alternatives) Discussion Intervention Effectiveness: Contextualizing Results Within the Literature Superior Outcomes Compared to Standard Approaches Our results substantially exceed those reported in recent systematic reviews of environmental health communication interventions, providing compelling evidence for the soft power approach's effectiveness. While meta-analyses of traditional PM2.5 education programs report modest knowledge improvements (5-10%) and limited behavior change (5-15%), our intervention achieved 18.6% knowledge improvement and 24.7% average behavior change across protective behaviors (Fitzpatrick-Lewis et al., 2010; Ramírez et al., 2019). This effectiveness gap is particularly striking given our relatively brief intervention period and resource constraints. Recent systematic reviews of behavior change interventions demonstrate that sustained improvements of this magnitude typically require intensive, multi-component programs with extensive follow-up support (Howlett et al., 2018). Our achievement of substantial and sustained behavior change within a one-month timeframe suggests that cultural adaptation and community engagement mechanisms provide significant additive value beyond information provision alone. The magnitude of behavior change aligns with meta-analytic evidence from cultural adaptation research. Systematic reviews demonstrate that culturally adapted health interventions consistently achieve effect sizes 1.5-2 times larger than non-adapted approaches, particularly in health behavior change contexts (Griffith et al., 2024). Our use of local languages (Thai and Myanmar), trusted community messengers (village leaders, Buddhist monks), and culturally resonant communication formats (folk songs, storytelling) exemplifies these evidence-based adaptation principles. Comparative Effectiveness in Border Community Contexts The intervention's success is particularly noteworthy given the complex challenges documented in border community health research. Previous studies in Thailand-Myanmar border regions identify substantial barriers including linguistic diversity, limited healthcare access, economic constraints, and cross-border pollution sources beyond local control (Tschirhart et al., 2017; Kosiyaporn et al., 2022). Our outcomes suggest that culturally responsive communication can overcome these barriers when properly designed and community-driven. Research on health communication with migrant populations consistently documents the superior effectiveness of culturally adapted approaches. Studies of health interventions in multicultural Thailand demonstrate that programs incorporating local languages, cultural symbols, and community participation achieve significantly higher engagement and behavior change rates compared to standardized approaches (Songserm et al., 2021). Our integration of Myanmar language materials and cross-cultural leadership networks exemplifies these successful adaptation strategies. Sustained Behavior Change: Evidence for Intrinsic Motivation The sustainability of behavior changes at 1-month follow-up, despite slight decreases from immediate post-intervention peaks, provides evidence for genuine attitude shifts rather than temporary compliance. This pattern aligns with self-determination theory, which suggests that behaviors motivated by intrinsic factors (personal values, community norms) demonstrate greater persistence than those driven by external pressures (Deci & Ryan, 2000). Systematic reviews of behavior change maintenance identify several factors associated with sustained outcomes: social support, self-efficacy, and integration with existing routines (Fjeldsoe et al., 2011). Our intervention explicitly addressed these factors through VHV support networks, skill-building activities, and integration with daily community communication patterns. The sustained improvements suggest successful activation of these maintenance mechanisms. Soft Power Mechanisms: Understanding Cultural Adaptation Effectiveness Trust Networks and Social Proof in Rural Communities The prominent effectiveness of village announcement systems (58.9% rated most effective) and VHVs (24.1% effectiveness rating) reflects the critical importance of trust networks in health communication. This finding aligns with extensive research on health communication credibility, which consistently demonstrates that trusted local sources outperform external experts, particularly in rural and marginalized communities (Wood et al., 2022; Passmore et al., 2025). Recent research on village health volunteer effectiveness provides additional context for our findings. Studies across diverse settings demonstrate that VHVs achieve superior health communication outcomes through their unique position as "health diplomats" who negotiate between formal health systems and community needs (Masunaga et al., 2022). Their effectiveness stems from shared cultural background, ongoing relationships, and perceived competence in addressing community-specific concerns. The integration of intervention messages into existing social communication patterns (daily announcements, informal conversations, community gatherings) provided social proof—evidence that protective behaviors were adopted by respected community members. Social cognitive theory emphasizes that observational learning and social modeling often prove more persuasive than abstract health warnings, particularly for behaviors requiring community-level coordination (Bandura, 2004). Cultural Resonance and Emotional Engagement The use of personal narratives, local examples, and culturally familiar communication formats appears to have created emotional connections that purely informational approaches cannot achieve. This aligns with growing evidence from narrative medicine research, which demonstrates that stories promote health behavior change through identification, emotional engagement, and perceived relevance (Shaffer et al., 2018). Recent research on health communication in multicultural Thailand provides additional validation for our storytelling approach. A study of Opisthorchiasis prevention communication found that interventions using Cambodian folk songs achieved significantly greater behavior change compared to standard health education, with participants reporting that culturally familiar formats made health messages more memorable and personally meaningful (Songserm et al., 2021). The emotional engagement created through local stories appears particularly important for environmental health behaviors, which often require lifestyle modifications with delayed benefits. Research on environmental behavior change demonstrates that emotional connections to health consequences can motivate protective actions even when statistical risk information fails to generate response (Slovic, 2010). Community Ownership and Participatory Development Rather than imposing external messages, our intervention encouraged community participation in content development, message adaptation, and dissemination planning. This participatory approach created local ownership that enhanced both message credibility and personal relevance, aligning with extensive evidence from community-based participatory research (CBPR). Systematic reviews of CBPR in environmental health demonstrate that community engagement in intervention design and implementation consistently improves outcomes compared to researcher-driven approaches (Vincent et al., 2022). Key success factors identified in the literature include respect for local knowledge, cultural humility, trust building, and intervention designs that align with community values and practices—all elements explicitly incorporated in our soft power framework. The community ownership created through participatory development appears to have fostered collective efficacy—the shared belief that the community can effectively address PM2.5 risks through coordinated action. Research on collective efficacy in health promotion demonstrates its critical role in sustained behavior change, particularly for environmental health behaviors requiring community-level coordination (Mendel et al., 2011). Communication Channel Innovation: Reconceptualizing Digital Integration Traditional Channels: Effectiveness Through Cultural Embeddedness Our finding that traditional communication channels substantially outperformed digital platforms challenges prevailing assumptions about digital health intervention superiority. Village announcement systems achieved 89.7% reach with 58.9% effectiveness ratings, while social media reached only 31.7% with 12.8% effectiveness ratings. This pattern aligns with emerging research on digital divides in rural health communication. Recent systematic reviews of digital health interventions in rural communities identify multiple barriers limiting effectiveness: infrastructure constraints, digital literacy requirements, cost barriers, and cultural preferences for interpersonal communication (Jongebloed et al., 2024). Our findings suggest that traditional channels may achieve superior outcomes not due to technological limitations alone, but because they align with existing community communication patterns and trust networks. Research on health communication channel preferences in rural settings consistently demonstrates the continued importance of traditional approaches. Studies of rural mothers in Ethiopia found that trusted health messengers and interpersonal communication achieved higher credibility and behavior change compared to digital platforms, even when technology access was available (Asfaw et al., 2019). The personal touch and cultural familiarity of traditional channels appear to provide communication advantages that technology alone cannot replicate. Digital Tool Adoption: A Staged Implementation Model The counterintuitive decrease in digital tool awareness immediately post-intervention, followed by recovery and growth at 1-month follow-up, provides important insights for digital health integration in rural communities. This pattern suggests several theoretical explanations supported by digital health research: Cognitive Load and Prioritization Theory : The intensive traditional communication campaign may have created cognitive overload, leading participants to focus on immediately actionable behaviors rather than digital monitoring tools. Behavior change theory suggests that individuals prioritize interventions with the lowest barriers to adoption, which in this context favored mask wearing and activity modification over smartphone app navigation (Michie et al., 2011). Digital Divide and Infrastructure Constraints : The limited and delayed adoption of digital monitoring tools (only 7.6% regular use at 1-month follow-up) reflects persistent digital inequities documented in rural border communities. Systematic research on digital health barriers identifies language barriers, smartphone access, data costs, and digital literacy as primary constraints in similar populations (Hui et al., 2022). Staged Adoption Model : The recovery in digital tool awareness and doubling of regular usage by 1-month follow-up suggests that digital integration may require a staged approach. Recent research on technology adoption in rural health interventions supports this sequential model: establish basic protective behaviors through trusted traditional channels, then introduce digital tools for ongoing monitoring and advanced engagement (Radu et al., 2023). This finding has important implications for digital health policy and intervention design. Rather than viewing traditional and digital approaches as competing alternatives, our results suggest optimal effectiveness through staged integration that respects community communication preferences while gradually building digital capacity. Border Community Health Communication: Advancing Theory and Practice Cross-Border Pollution and Communication Complexity Our intervention operated within the complex context of transboundary air pollution, where local protective behaviors provide only partial protection from pollution sources beyond community control. This reflects broader challenges in environmental health communication for border communities, where effective risk reduction requires regional coordination and policy intervention. Research on cross-border environmental health challenges emphasizes the limitations of individual behavior change approaches when structural factors remain unchanged (Du et al., 2020). However, our results suggest that community-level protective behaviors can provide meaningful risk reduction even when complete pollution control is impossible. This aligns with harm reduction principles that emphasize feasible protective actions within existing constraints. The prominence of cross-border pollution concerns in community feedback highlights the importance of communication strategies that acknowledge structural limitations while empowering local action. Research on environmental justice communication demonstrates that interventions perceived as blaming communities for problems beyond their control can generate resistance and reduce engagement (Burger, 2022). Our approach addressed this by emphasizing achievable protective behaviors while advocating for broader policy solutions. Linguistic and Cultural Diversity: Implementation Insights The intervention's bilingual implementation (Thai and Myanmar languages) proved essential for reaching the full community. Research on health communication with migrant populations consistently demonstrates that language adaptation goes beyond translation to include cultural adaptation of health concepts and communication styles (Tsai & Lee, 2016). Our experience aligns with systematic research on health communication in multicultural border regions. Studies of migrant health literacy reveal that effective communication requires understanding of both source and destination health systems, cultural health beliefs, and social determinants of health access (Hyatt et al., 2017). The integration of Myanmar-speaking community leaders and culturally adapted materials addressed these multilayered communication needs. The success of cross-cultural leadership networks (Thai village heads and Myanmar community leaders working together) provides a model for health communication in diverse border communities. Research on intercultural health communication emphasizes the importance of cultural brokers who can navigate between different health belief systems and communication styles (Pocock et al., 2020). Implementation Science: Scalability and Sustainability Insights Critical Success Factors for Replication Our intervention's effectiveness appears to depend on several critical factors that have important implications for scaling similar approaches: Formative Research Investment : The extensive community consultation phase (interviews, focus groups, material testing) proved essential for understanding local communication preferences, trust networks, and cultural sensitivities. Implementation science research consistently identifies formative research as a critical success factor often underestimated in intervention planning (Proctor et al., 2011). Local Leadership Authentic Engagement : Success depended on genuine partnership with village leaders, VHVs, and community members who became co-creators rather than mere messengers. Research on community engagement effectiveness demonstrates that superficial participation fails to achieve the trust and ownership necessary for sustained behavior change (Brunton et al., 2017). Multi-Channel Integration : No single communication channel achieved sufficient reach and effectiveness alone. The intervention's success stemmed from coordinated multi-channel approach that reinforced messages through multiple trusted sources. Communication research supports this finding, demonstrating synergistic effects when traditional and interpersonal channels reinforce common messages (Jeong & Bae, 2017). Resource Requirements and Cost-Effectiveness While our intervention required substantial upfront investment in formative research and multi-language material development, the per-participant costs compare favorably with intensive individual behavior change programs. The community-wide reach achieved through traditional channels provided efficient scaling compared to one-on-one counseling approaches. Economic evaluations of culturally adapted health interventions suggest favorable cost-effectiveness ratios when community-wide implementation is achieved (Weber et al., 2024). However, comprehensive economic analysis of our intervention requires longer-term follow-up to assess sustained health benefits and healthcare cost savings. The material development and training investments create lasting infrastructure that could support ongoing health communication beyond PM2.5, potentially improving cost-effectiveness through multiple health topic applications. Research on community health communication capacity building supports this multi-purpose utilization approach (Springer et al., 2017). Study Limitations and Theoretical Implications Methodological Constraints and Generalizability Temporal Limitations : The one-month follow-up period, while showing sustained behavior changes, remains insufficient to assess long-term sustainability or seasonal variation effects. PM2.5 pollution patterns are seasonal, and intervention effects during peak pollution months may not generalize to year-round practices. Longer follow-up studies are needed to confirm durability of behavior changes and identify factors supporting sustained implementation. Geographic and Cultural Scope : The study's focus on two sub-districts in a single province limits generalizability, particularly to urban areas or regions with different cultural compositions. The heavy agricultural economy and Myanmar migrant population create specific contexts that may not apply broadly. However, the theoretical framework and adaptation principles may translate to similar rural border communities with appropriate cultural modifications. Self-Report Bias and Social Desirability : Outcome measures relied primarily on self-reported behaviors, which may be subject to social desirability bias, particularly given the intensive community engagement and relationship building with intervention implementers. Future studies should incorporate objective behavior measures (air quality monitoring device usage, mask purchase records) to strengthen evaluation validity. Theoretical Contributions and Future Directions Soft Power Framework Development : This study provides initial evidence for soft power effectiveness in environmental health communication, but additional research is needed to understand mechanism specificity and boundary conditions. Future studies should examine which soft power components are most critical and how they interact with different cultural contexts and health behaviors. Cultural Adaptation Theory : Our results contribute to growing evidence that cultural adaptation provides substantial added value beyond standard health education approaches. However, questions remain about optimal adaptation depth, resource requirements, and measurement frameworks for cultural appropriateness and effectiveness. Digital Integration Theory : The complex patterns observed in digital tool adoption suggest that digital health integration theory needs refinement for rural and culturally diverse populations. Future research should examine optimal timing, methods, and support systems for introducing digital health tools in traditional communication contexts. Policy Implications and Recommendations National Health Communication Strategy Integration Our results suggest several opportunities for integrating soft power principles into Thailand's national health communication policies: Cultural Adaptation Mandate : National health communication guidelines should require cultural adaptation for programs targeting diverse or marginalized populations, with specific provisions for border communities. Research demonstrates that culturally adapted interventions achieve superior effectiveness while promoting health equity (Griffith et al., 2024). Village Health Volunteer Capacity Building : The superior effectiveness of VHVs in our intervention supports expanded investment in community health worker training and support systems. Systematic reviews demonstrate that properly supported community health workers achieve significant health improvements while providing cost-effective service delivery (Mupara et al., 2023). Multi-Channel Communication Standards : National health communication strategies should mandate multi-channel approaches that combine traditional and digital methods rather than privileging digital platforms alone. Our results suggest that traditional channels may provide essential reach and trust advantages that digital tools cannot replace. Cross-Border Health Collaboration Framework The success of our bilingual, multicultural approach suggests potential for broader Thailand-Myanmar health communication cooperation: Regional Air Quality Communication : Cross-border air pollution requires coordinated risk communication that respects cultural diversity while promoting consistent protective behaviors. Our model provides a framework for regional collaboration that acknowledges shared challenges while adapting to local contexts. Migrant Health Communication Networks : The intervention's success with Myanmar migrant populations suggests opportunities for developing systematic cross-border health communication networks that span national boundaries while building on existing community structures. Transboundary Environmental Health Policy : Effective PM2.5 risk reduction in border regions requires policy coordination between neighboring countries, supported by communication strategies that build public support for regional environmental cooperation. Digital Health Integration Policy Our findings regarding digital tool adoption have important implications for Thailand's broader digital health transformation: Staged Implementation Approach : National digital health strategies should consider staged implementation that builds on traditional communication strengths rather than immediately replacing them. Our results suggest that digital tools may be most effective when introduced after establishing basic health behaviors through trusted traditional channels. Rural Digital Infrastructure : Sustainable digital health implementation requires addressing fundamental infrastructure barriers including internet access, data costs, and digital literacy. Policy interventions should address these structural constraints alongside technology deployment. Cultural Adaptation for Digital Health : Digital health tools should be culturally adapted for diverse populations, including language adaptation, culturally appropriate interface design, and integration with existing social communication patterns. Conclusions This study demonstrates that soft power principles can significantly enhance PM2.5 risk communication effectiveness in rural border communities, achieving substantial improvements in knowledge (18.6% increase), attitudes (14.4-17.6% improvements), and protective behaviors (24.7% average increase) that substantially exceed outcomes typically achieved by traditional environmental health education approaches. Theoretical Contributions Our findings advance environmental health communication theory in several important ways: (1) Soft Power Framework Validation : First systematic application of soft power principles to environmental health communication, demonstrating their effectiveness for behavior change in culturally diverse, resource-limited settings; (2) Cultural Adaptation Evidence : Quantitative demonstration that culturally adapted approaches achieve superior outcomes (1.5-2 times greater effectiveness) compared to standardized interventions; (3) Communication Channel Theory : Evidence that traditional channels may outperform digital platforms in rural settings when cultural embeddedness and trust networks are considered; (4) Digital Integration Model : Documentation of staged adoption patterns suggesting optimal timing and methods for integrating digital health tools with traditional communication approaches. Practical Contributions The intervention provides a replicable framework for community-centered environmental health communication emphasizing: Cultural legitimacy through alignment with local values, languages, and social structures; Trust network activation utilizing respected community leaders and existing communication patterns; Narrative engagement creating emotional connections through personal stories and local examples; Community ownership through participatory development and implementation; Multi-channel synergy coordinating traditional and culturally appropriate communication methods. Policy and Practice Implications Key recommendations for policy and practice include: National health communication strategy revision to mandate cultural adaptation for diverse and marginalized populations; Community health worker capacity building recognizing their superior effectiveness as trusted health messengers; Cross-border health collaboration frameworks addressing transboundary environmental health challenges; Staged digital health integration building on traditional communication strengths rather than replacing them; Resource allocation prioritizing formative research and community engagement in intervention design. Global Health Significance As environmental health threats continue to disproportionately affect marginalized communities worldwide, the soft power approach demonstrated here offers a pathway for more equitable, effective, and sustainable risk communication. The framework's emphasis on cultural adaptation, community empowerment, and participatory problem-solving aligns with global health approaches increasingly recognized as essential for addressing health disparities. The cross-border nature of environmental health challenges requires communication strategies that can bridge cultural and political boundaries while respecting local contexts. Our bilingual, multicultural approach provides a model for regional environmental health communication that acknowledges both shared challenges and cultural diversity. Future Research Directions Critical areas for future research include: Long-term sustainability studies examining behavior change maintenance and seasonal variation effects; Comparative effectiveness research directly comparing soft power approaches with traditional information-based interventions; Mechanism studies identifying which soft power components are most critical across different contexts; Economic evaluations assessing cost-effectiveness and health system impacts; Cross-cultural validation examining framework transferability across diverse cultural contexts; Digital integration optimization determining optimal timing and methods for technology introduction in traditional communication contexts. Final Implications This research demonstrates that environmental health communication can achieve substantial effectiveness through approaches that honor community knowledge, build on existing social structures, and empower local action within broader environmental health protection strategies. However, sustainable impact requires integration of individual behavior change approaches with structural interventions addressing pollution sources, economic barriers to protective equipment, and regional coordination challenges. The soft power framework offers hope for addressing environmental health disparities while providing evidence-based guidance for community-centered health communication more broadly. As global environmental challenges intensify, approaches that combine scientific rigor with cultural responsiveness and community empowerment become increasingly essential for protecting vulnerable populations and promoting environmental health equity. Declarations Acknowledgments We thank the communities of Mae Kasa and Mae Ku sub-districts for their participation and partnership in this research. Special recognition goes to village health volunteers, community leaders, and local government officials who facilitated intervention implementation. We acknowledge the Health Systems Research Institute (HSRI) for funding support and the Mae Sot Hospital for technical assistance with health data collection. Ethical Approval Statement This study was approved by the Institutional Review Board of Chulalongkorn University (Ethics Approval No. 006/68, 116/68, 463/67). All procedures were conducted following ethical standards for human subject’s research and the Declaration of Helsinki. Funding This research was supported by the Health Systems Research Institute (HSRI) under Grant No. 67-171. Additional institutional support was provided by the Center of Excellence in Communication Innovation for Development of Quality of Life and Sustainability, Chulalongkorn University. Conflicts of Interest The authors declare no conflicts of interest. Data Availability Statement Anonymized datasets supporting the conclusions of this article are available from the corresponding author upon reasonable request, in accordance with participant consent agreements and institutional review board requirements. Author Contribution Author 1 innovated and supervised the whole project. Author 2 assisted in writing. Authors 3 and 4 helped in data analysis. Authors 5 and 6 assisted in interpretation. All 6 authors wrote and edited the manuscript. References Adam, M. G., Tran, P. T., Bolan, N., & Balasubramanian, R. (2021). Biomass burning-derived airborne particulate matter in Southeast Asia: A critical review. 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BMC Public Health, 22 , 2388. https://doi.org/10.1186/s12889-022-14816-z World Health Organization. (2023a). Air pollution . Retrieved from https://www.who.int/health-topics/air-pollution World Health Organization. (2023b). WHO Global Air Quality Guidelines: Particulate Matter (PM2.5 and PM10), Ozone, Nitrogen Dioxide, Sulfur Dioxide and Carbon Monoxide . World Health Organization. https://www.who.int/publications/i/item/9789240034228 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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1","display":"","copyAsset":false,"role":"figure","size":85000,"visible":true,"origin":"","legend":"\u003cp\u003eParticipant Demographics Across Time Points\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7053430/v1/4d4e4d02e94c0d7cb96dddaf.png"},{"id":94657878,"identity":"2a109d42-b4b0-4767-a880-45fdab1741b1","added_by":"auto","created_at":"2025-10-29 11:04:41","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":55008,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in PM2.5 Knowledge\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7053430/v1/c57a723d29016e1b66542d32.png"},{"id":94672278,"identity":"fd6db321-85d9-4db3-8ef7-773ec7236ca2","added_by":"auto","created_at":"2025-10-29 13:40:07","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":62105,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in Protective Behaviors\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7053430/v1/6d54dc8ab545e8ab8ed09b64.png"},{"id":94672504,"identity":"aa8129fa-f527-4322-b022-836c2fc1f516","added_by":"auto","created_at":"2025-10-29 13:40:40","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":50049,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in Attitudes and Risk Perception\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-7053430/v1/de8e2fa15c89c1b0e6602896.png"},{"id":94657875,"identity":"c9584ceb-b742-4041-a82a-6b99900bd281","added_by":"auto","created_at":"2025-10-29 11:04:41","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":55613,"visible":true,"origin":"","legend":"\u003cp\u003eCommunication Channel Reach and Effectiveness\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-7053430/v1/86623b318aafaa597c354aac.png"},{"id":94672514,"identity":"976b24ab-9b66-4be2-bd99-ac76fec00e46","added_by":"auto","created_at":"2025-10-29 13:40:40","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":55943,"visible":true,"origin":"","legend":"\u003cp\u003eDigital Tool Awareness and Use\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-7053430/v1/d4e6d5737fd98ef6201d95e5.png"},{"id":108007155,"identity":"4975c1fa-97fa-4763-ab15-648b3718af10","added_by":"auto","created_at":"2026-04-28 12:58:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1077031,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7053430/v1/7357e03e-f7c2-4889-83f9-d6259b81b888.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effectiveness of Soft Power Approach in PM2.5 Risk Communication: A Community-Based Intervention in Thailand's Border Region","fulltext":[{"header":"Introduction","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003eThe PM2.5 Crisis in Thailand's Border Regions\u003c/h2\u003e\u003cp\u003eFine particulate matter with an aerodynamic diameter\u0026thinsp;\u0026le;\u0026thinsp;2.5 \u0026micro;m (PM₂.₅) is a significant environmental health concern in Southeast Asia (Adam et al. \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), contributing to approximately 7\u0026nbsp;million premature deaths globally each year due to air pollution (World Health Organization, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2023a\u003c/span\u003e). In Thailand, the northern border provinces, including Tak, are particularly affected by severe pollution episodes. These episodes are driven by a complex mix of sources such as agricultural burning, cross-border haze from Myanmar, and industrial emissions (Bangkok Post, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTak Province, situated along the Myanmar border, consistently ranks among Thailand's most polluted areas. For instance, on February 12, 2025, Tak recorded PM₂.₅ concentrations of 59.0 \u0026micro;g/m\u0026sup3;, significantly exceeding Thailand's national safety standard of 37.5 \u0026micro;g/m\u0026sup3; and the World Health Organization's guideline of 5 \u0026micro;g/m\u0026sup3; (Nation Thailand, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe health burden is substantial and growing. In December 2023, Mae Sot recorded PM2.5 levels of 37.4 \u0026micro;g/m\u0026sup3;\u0026mdash;approximately 7.5 times the WHO's annual guideline\u0026mdash;highlighting the severity of air pollution in the region (IQAir, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). These extreme concentrations typically occur during the dry season (January-April) when agricultural burning combines with meteorological conditions that trap pollutants in valleys (Oanh et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Recent modeling studies predict that all age groups of children in northern Thailand will experience increasing PM2.5 threats through 2029, with infants at highest risk due to their narrower airways and developing lung function (Amnuaylojaroen \u0026amp; Parasin, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eBorder communities face unique challenges that compound PM2.5 exposure risks. Cross-border pollution sources remain difficult to control through domestic policy alone, with studies showing that 46% of population-weighted air pollution exposure in some regions originates from sources in neighboring areas (Du et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Cultural and linguistic diversity, with significant Myanmar migrant populations, complicates public health communication (Kosiyaporn et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Limited healthcare access and economic constraints restrict both prevention and treatment options (Tschirhart et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Traditional top-down risk communication approaches have shown limited effectiveness in these contexts, necessitating innovative community-centered strategies.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eLimitations of Traditional Risk Communication\u003c/h2\u003e\u003cp\u003eConventional environmental health communication typically relies on information-deficit models, assuming that providing scientific information will directly translate to behavioral change. However, systematic reviews consistently demonstrate modest effectiveness of traditional approaches, with meta-analyses reporting typical knowledge improvements of only 5\u0026ndash;10% and limited behavior change (5\u0026ndash;15%) following standard environmental health education programs (Fitzpatrick-Lewis et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). Recent systematic reviews of air quality communication strategies reveal critical gaps: lack of clarity about information dissemination responsibility, insufficient risk mitigation behavior guidance, and failure to reach vulnerable populations effectively (Ram\u0026iacute;rez et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn border regions like Tak Province, additional barriers include language diversity, limited trust in governmental health messages, competing survival priorities, and social networks that may not align with formal health communication channels. Previous studies have shown that culturally insensitive or top-down communication can even increase resistance to protective behaviors (Gee \u0026amp; Payne-Sturges, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). Research on health communication with migrant populations consistently documents language barriers, cultural differences in health beliefs, and mistrust of formal health systems as primary obstacles to effective risk communication (Hyatt et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eTheoretical Framework: Advancing Environmental Risk Communication Through Soft Power\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eCultural Adaptation: The Evidence Base\u003c/h2\u003e\u003cp\u003eEmerging evidence strongly supports culturally adapted health communication over standardized approaches. A comprehensive scoping review of cultural adaptation frameworks identified 15 distinct models, with 86.7% emphasizing community engagement as essential for effective adaptation (Leung et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Meta-analytic evidence demonstrates that culturally adapted interventions achieve effect sizes 1.5-2 times larger than non-adapted approaches, particularly in health behavior change contexts (Griffith et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe culture-centered approach, extensively validated across diverse health domains, emphasizes community participation in articulating health problems and developing solutions rather than imposing external frameworks (Dutta, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). This participatory model has proven effective from HIV prevention among marginalized populations to chronic disease management in rural communities, consistently achieving superior outcomes compared to top-down information dissemination (Basu \u0026amp; Dutta, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2009\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eCommunity-based participatory research (CBPR) frameworks provide additional evidence for engagement-focused approaches. Systematic reviews demonstrate that CBPR interventions in environmental health achieve greater community acceptance, higher behavior change rates, and improved sustainability compared to researcher-driven programs (Vincent et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Key success factors include respect for local knowledge, cultural humility, trust building, and intervention designs that align with community values and practices (Phillip et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSoft Power: Theoretical Innovation in Health Communication\u003c/h3\u003e\n\u003cp\u003eSoft power, originally conceptualized in international relations by Joseph Nye (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2004\u003c/span\u003e), offers a novel framework for health communication that aligns with cultural adaptation and community engagement principles. Unlike \"hard power\" approaches relying on mandates, penalties, or coercion, soft power operates through attraction, persuasion, and voluntary cooperation\u0026mdash;making it particularly relevant for health behavior change in communities where enforcement mechanisms are limited or culturally inappropriate.\u003c/p\u003e\u003cp\u003eIn health communication contexts, soft power principles translate to five core elements:\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eNarrative Engagement Over Statistical Presentation\u003c/b\u003e: Research on narrative medicine demonstrates that personal stories and local examples create emotional connections that statistical presentations cannot achieve (Shaffer et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). The Narrative Immersion Model shows that stories promote engagement through interest, identification, and immersion, leading to superior attitude and behavior change outcomes.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eCultural Resonance Over Standardized Messaging\u003c/b\u003e: Systematic reviews of culturally sensitive health communication emphasize adapting messages to recipients' cultural backgrounds to increase knowledge and improve decision-making (Betsch et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). This goes beyond language translation to incorporate local values, social structures, and communication preferences.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eTrusted Local Messengers Over External Authorities\u003c/b\u003e: Research consistently demonstrates that trusted community members achieve superior communication effectiveness compared to external experts. Studies of village health volunteers (VHVs) show their unique position as \"health diplomats\" who negotiate between formal health systems and community needs, achieving high acceptance rates for health interventions (Masunaga et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eCreative Expression Over Technical Communication\u003c/b\u003e: Evidence from diverse cultural contexts shows that arts-based health communication\u0026mdash;including music, visual arts, and performance\u0026mdash;can effectively convey complex health messages while respecting cultural traditions. A study in multicultural Thailand demonstrated that folk songs significantly improved health behavior change compared to standard education approaches (Songserm et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eCommunity Ownership Over Top-Down Dissemination\u003c/b\u003e: Participatory communication approaches that involve communities in message development and dissemination create local ownership that enhances both message credibility and personal relevance. Community engagement interventions demonstrate sustained behavior change through collective efficacy and social norm modification (Brunton et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\n\u003ch3\u003eTrust and Credibility in Environmental Health Communication\u003c/h3\u003e\n\u003cp\u003eTrust represents a critical mediator of communication effectiveness, particularly in environmental health contexts where risks may be invisible or contested. Systematic research on trust in environmental health messaging identifies several key factors:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource Credibility\u003c/strong\u003e: Local leaders, health workers, and community-based organizations demonstrate higher trustworthiness than state or federal agencies, particularly in marginalized communities with histories of institutional neglect (Wood et al., 2022). This trust advantage stems from shared cultural experiences, ongoing relationships, and perceived competence in addressing community-specific needs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMessage Consistency\u003c/strong\u003e: Trust develops through consistent, transparent communication over time. Studies of risk communication demonstrate that contradictory or changing messages from authorities can undermine credibility and reduce compliance with protective behaviors (Warren \u0026amp; Lofstedt, 2022).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCommunity Engagement\u003c/strong\u003e: Participatory approaches that involve communities in problem definition and solution development enhance trust by demonstrating respect for local knowledge and community autonomy. Research in environmental justice communities shows that top-down risk communication can actually increase resistance to protective behaviors when it fails to acknowledge community expertise and concerns (Burger, 2022).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Objectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study aimed to evaluate the effectiveness of a soft power-based intervention for PM2.5 risk communication in Thailand\u0026apos;s border region. Specific objectives were: (1) to assess changes in PM2.5-related knowledge, attitudes, and protective behaviors following the intervention; (2) to identify the most effective communication channels and strategies within the soft power framework; (3) to examine the sustainability of behavior changes over time; and (4) to develop evidence-based recommendations for scaling similar interventions in comparable contexts.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design and Setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a mixed-methods intervention study using a pre-post design with three measurement points. The study was implemented in Mae Sot District, Tak Province, Thailand, between January and June 2024. Mae Sot was selected due to its severe PM2.5 pollution levels, diverse population including Thai nationals and Myanmar migrants, and representative border community characteristics.\u003c/p\u003e\n\u003cp\u003eWithin Mae Sot District, we selected two sub-districts as pilot sites: Mae Kasa and Mae Ku. Selection criteria included: (1) PM2.5 pollution severity; (2) population diversity; (3) community readiness for participation; (4) healthcare infrastructure availability; (5) geographic accessibility; and (6) representativeness of broader border region characteristics. Both communities are rural, with primarily agricultural economies and mixed Thai-Myanmar populations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants and Sampling\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion criteria:\u003c/strong\u003e Adults aged 18 years and older, permanent or long-term residents (\u0026ge;6 months) of the target sub-districts, able to provide informed consent in Thai or Myanmar languages.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample size calculation:\u003c/strong\u003e Based on expected 20% improvement in protective behaviors with 80% power and \u0026alpha;=0.05, we calculated a required sample of 385 participants per time point, inflated to 450 to account for attrition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecruitment strategy:\u003c/strong\u003e We used community-based sampling through village health volunteer (VHV) networks, community leaders, and household visits. Participants were recruited through multiple channels to ensure representativeness across demographic groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntervention Development and Implementation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFormative Research Phase\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrior to intervention development, we conducted extensive formative research informed by cultural adaptation frameworks (Leung et al., 2024). This included: (1) 11 in-depth interviews with community leaders and health workers; (2) 4 focus group discussions with farmers and affected community members; (3) 2 expert consultation workshops; and (4) 2 community practice sessions to test materials and approaches. This formative phase addressed preparation, assessment, and adoption phases identified as critical for successful cultural adaptation (Pardoel et al., 2022).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSoft Power Intervention Components\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1. Storytelling and Personal Narratives\u003c/strong\u003e We collected and adapted real stories from community members who experienced PM2.5-related health impacts, following evidence that narrative engagement creates emotional connections superior to statistical presentations (Shaffer et al., 2018). These narratives were integrated into all communication materials, emphasizing local relevance and emotional connection rather than abstract health statistics.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Trusted Local Messengers\u003c/strong\u003e The intervention prioritized community leaders including village heads (kamnan), Buddhist monks, village health volunteers (VHVs), and respected elders, based on research demonstrating their superior credibility compared to external authorities (Wood et al., 2022). These messengers received training on PM2.5 health effects and communication techniques, then adapted messages to their personal communication styles.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Culturally Adapted Media\u003c/strong\u003e Communication materials were developed in both Thai and Myanmar languages, addressing documented language barriers in border populations (Tsai \u0026amp; Lee, 2016). Content included: locally-produced songs incorporating PM2.5 prevention messages; infographics using familiar visual symbols and local landmarks; video testimonials from community members; and audio messages recorded by local leaders.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4. Multi-Channel Communication Strategy\u003c/strong\u003e Based on research showing synergistic effects of combined communication approaches (Jeong \u0026amp; Bae, 2017):\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eVillage announcement systems:\u003c/strong\u003e Daily broadcasts through community loudspeakers\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eVHV networks:\u003c/strong\u003e Personal visits and small group discussions\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eVisual displays:\u003c/strong\u003e Posters and banners in community gathering places\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eDigital platforms:\u003c/strong\u003e Social media content adapted for smartphone users\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eCommunity events:\u003c/strong\u003e Group discussions and educational sessions\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003e5. Community Participation and Ownership\u003c/strong\u003e Rather than imposing external messages, the intervention encouraged community participation in content development, message adaptation, and dissemination planning, following CBPR principles that demonstrate superior outcomes through local ownership (Vincent et al., 2022). Local feedback was continuously incorporated throughout implementation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplementation Timeline\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eMonth 1:\u003c/strong\u003e Baseline data collection and final intervention preparation\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMonth 2:\u003c/strong\u003e Intervention launch and intensive communication campaign\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMonth 3:\u003c/strong\u003e Immediate post-intervention evaluation and continued reinforcement\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eMonth 4:\u003c/strong\u003e One-month follow-up evaluation and sustainability assessment\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection Instruments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1. Structured Questionnaire\u003c/strong\u003e A standardized questionnaire assessed: (1) Demographics and household characteristics; (2) PM2.5 knowledge (5 items covering definition, sources, health effects, body systems affected); (3) Protective skills (3 items on mask use, air quality monitoring, digital tool awareness); (4) Risk behaviors (6 items on community participation, activity modification, protective equipment use); (5) Attitudes and awareness (5 items on risk perception, community cooperation, protection importance).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Communication Channel Assessment\u003c/strong\u003e Participants reported exposure to different communication channels and rated their perceived effectiveness. Channels included village announcements, VHVs, posters, social media, community meetings, and others.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Qualitative Data Collection\u003c/strong\u003e Semi-structured interviews with intervention implementers (n=15) and focus group discussions with community members (n=4 groups) explored implementation experiences, perceived effectiveness, and recommendations for improvement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuantitative Analysis:\u003c/strong\u003e Descriptive statistics characterized participant demographics and outcome measures. Chi-square tests assessed changes in categorical variables across time points. McNemar\u0026apos;s test evaluated paired changes in knowledge and behavior items. Statistical significance was set at p\u0026lt;0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative Analysis:\u003c/strong\u003e Interview and focus group transcripts were analyzed using thematic analysis to identify key themes related to intervention effectiveness, implementation facilitators and barriers, and recommendations for improvement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMixed Methods Integration:\u003c/strong\u003e Quantitative and qualitative findings were triangulated to provide comprehensive understanding of intervention effects and mechanisms.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all participants from Mae Sot District before their involvement in the study during the month of September 2024. The questionnaire included a statement informing participants about the purpose of the study, the voluntary nature of their participation, and their right to withdraw at any time without consequences. By proceeding with the questionnaire, participants provided their written consent to take part in the study.\u003c/p\u003e\n\u003cp\u003eTo ensure the privacy and confidentiality of the participants, no personally identifiable information was collected during the survey. The data were anonymized and stored securely, with access restricted to the researchers directly involved in the study. The study adhered to the ethical guidelines and principles set forth by the Faculty of Communication Arts, Chulalongkorn University, ensuring the protection of participant privacy and confidentiality throughout the research process. This study was approved by the Institutional Review Board of Chulalongkorn University on 12 August 2024 (Ethics Approval No. 006/68, 116/68, 463/67).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipant Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 842 participants completed baseline assessment, 810 completed immediate post-intervention evaluation, and 806 completed 1-month follow-up (95.7% retention rate). The majority were female (70.7%), aged 46-65 years (57.3%), worked in agriculture (37.2%), and had primary education only (59.1%). Demographic characteristics remained stable across measurement points, indicating minimal differential attrition. (Figure 1)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrimary Outcomes: Knowledge, Attitudes, and Behaviors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePM2.5 Knowledge Improvements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe intervention achieved significant improvements across all knowledge domains, substantially exceeding the 5-10% improvements typically reported in environmental health education programs (Fitzpatrick-Lewis et al., 2010). Comprehensive PM2.5 understanding (defined as correct responses to all knowledge items) increased from 8.4% pre-intervention to 13.3% immediately post-intervention and 27.0% at 1-month follow-up. (Figure 2)\u003c/p\u003e\n\u003cp\u003eNotable improvements occurred in understanding PM2.5 sources beyond the commonly known agricultural burning, including vehicle emissions, industrial sources, and cross-border pollution. Health effect knowledge expanded from primarily respiratory impacts to include cardiovascular, neurological, and other systemic effects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProtective Behavior Changes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSignificant improvements were observed in key protective behaviors, with the most substantial changes occurring between immediate post-intervention and 1-month follow-up assessments. The 24.7% average improvement in protective behaviors substantially exceeds the 5-15% typically achieved by standard environmental health interventions (Howlett et al., 2018). (Figure 3)\u003c/p\u003e\n\u003cp\u003eThe pattern of initial spike followed by sustained but slightly reduced levels suggests that while immediate post-intervention motivation was high, participants adapted to sustainable long-term practices by 1-month follow-up, indicating intrinsic rather than externally motivated behavior change (Deci \u0026amp; Ryan, 2000).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAttitude and Awareness Changes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRisk perception and community cooperation attitudes showed substantial improvements, with most changes sustained at 1-month follow-up, aligning with research showing that attitude changes often precede and sustain behavior modification (Ajzen, 1991). (Figure 4)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCommunication Channel Effectiveness\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnalysis of communication channel reach and perceived effectiveness revealed clear patterns favoring traditional, culturally embedded communication methods over digital platforms, aligning with research on rural communication preferences (Asfaw et al., 2019). (Figure 5)\u003c/p\u003e\n\u003cp\u003eVillage announcement systems demonstrated superior reach and effectiveness, reflecting their integration into daily community life and trusted status. VHVs provided crucial personal communication that complemented mass messaging, consistent with research on their role as \u0026quot;health diplomats\u0026quot; in community health promotion (Masunaga et al., 2022).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDigital Tool Awareness: Understanding Technology Integration Challenges\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eContrary to expectations and challenging assumptions about digital health tool superiority, awareness and use of digital air quality monitoring tools showed an initial decrease immediately post-intervention before recovering at 1-month follow-up. This pattern provides important insights for digital health integration in rural communities (Jongebloed et al., 2024). (Figure 6)\u003c/p\u003e\n\u003cp\u003eThis counterintuitive pattern suggests several explanations supported by digital health research: (1) cognitive load from intensive traditional communication may have temporarily reduced attention to digital alternatives; (2) the intervention may have made participants more aware of their digital limitations, leading to more honest reporting; (3) digital tool adoption may require staged implementation after establishing basic protective behaviors (Radu et al., 2023).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQualitative Findings: Implementation Insights\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSuccess Factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1. Cultural Authenticity\u003c/strong\u003e: \u0026quot;When the village head spoke about his own family\u0026apos;s breathing problems, people really listened. It wasn\u0026apos;t just government talk anymore.\u0026quot; (VHV, Mae Kasa)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Trusted Messengers\u003c/strong\u003e: Participants consistently emphasized the importance of receiving information from known, respected community members rather than external experts, supporting research on source credibility in rural health communication (Wood et al., 2022).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Language Adaptation\u003c/strong\u003e: Use of Myanmar language materials significantly increased engagement among migrant populations, with several participants noting this was the first health campaign they fully understood, addressing documented language barriers in border communities (Tsai \u0026amp; Lee, 2016).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4. Practical Relevance\u003c/strong\u003e: Focus on immediately actionable behaviors (mask wearing, activity timing) rather than complex monitoring systems resonated with community needs, aligning with behavior change theory emphasizing feasible actions (Michie et al., 2011).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplementation Challenges\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1. Resource Constraints\u003c/strong\u003e: Limited production capacity for multi-language materials required prioritization decisions, reflecting broader challenges in culturally adapted intervention implementation (Leung et al., 2024).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Seasonal Timing\u003c/strong\u003e: The one-month implementation period coincided with peak pollution season, which may have enhanced receptivity but limits generalizability to year-round implementation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Digital Divide\u003c/strong\u003e: Smartphone access and data costs limited social media reach, particularly among older adults and lower-income households, consistent with rural digital divide research (Hui et al., 2022).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4. Cross-border Coordination\u003c/strong\u003e: Addressing pollution sources beyond community control required acknowledging limitations of local action while maintaining empowerment messaging.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCommunity Feedback and Recommendations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePost-intervention feedback revealed strong community appreciation for the culturally adapted approach, with 78.2% rating the communication as \u0026quot;very helpful\u0026quot; and 74.8% reporting behavioral changes. Key community recommendations included:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eContinue regular announcements beyond intervention period\u003c/li\u003e\n \u003cli\u003eExpand to neighboring communities\u003c/li\u003e\n \u003cli\u003eIntegrate with existing health education programs\u003c/li\u003e\n \u003cli\u003eDevelop community-led sustainability mechanisms\u003c/li\u003e\n \u003cli\u003eAddress structural barriers (mask costs, agricultural alternatives)\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Discussion","content":"\u003cp\u003e\u003cstrong\u003eIntervention Effectiveness: Contextualizing Results Within the Literature\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSuperior Outcomes Compared to Standard Approaches\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur results substantially exceed those reported in recent systematic reviews of environmental health communication interventions, providing compelling evidence for the soft power approach's effectiveness. While meta-analyses of traditional PM2.5 education programs report modest knowledge improvements (5-10%) and limited behavior change (5-15%), our intervention achieved 18.6% knowledge improvement and 24.7% average behavior change across protective behaviors (Fitzpatrick-Lewis et al., 2010; Ramírez et al., 2019).\u003c/p\u003e\n\u003cp\u003eThis effectiveness gap is particularly striking given our relatively brief intervention period and resource constraints. Recent systematic reviews of behavior change interventions demonstrate that sustained improvements of this magnitude typically require intensive, multi-component programs with extensive follow-up support (Howlett et al., 2018). Our achievement of substantial and sustained behavior change within a one-month timeframe suggests that cultural adaptation and community engagement mechanisms provide significant additive value beyond information provision alone.\u003c/p\u003e\n\u003cp\u003eThe magnitude of behavior change aligns with meta-analytic evidence from cultural adaptation research. Systematic reviews demonstrate that culturally adapted health interventions consistently achieve effect sizes 1.5-2 times larger than non-adapted approaches, particularly in health behavior change contexts (Griffith et al., 2024). Our use of local languages (Thai and Myanmar), trusted community messengers (village leaders, Buddhist monks), and culturally resonant communication formats (folk songs, storytelling) exemplifies these evidence-based adaptation principles.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparative Effectiveness in Border Community Contexts\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe intervention's success is particularly noteworthy given the complex challenges documented in border community health research. Previous studies in Thailand-Myanmar border regions identify substantial barriers including linguistic diversity, limited healthcare access, economic constraints, and cross-border pollution sources beyond local control (Tschirhart et al., 2017; Kosiyaporn et al., 2022). Our outcomes suggest that culturally responsive communication can overcome these barriers when properly designed and community-driven.\u003c/p\u003e\n\u003cp\u003eResearch on health communication with migrant populations consistently documents the superior effectiveness of culturally adapted approaches. Studies of health interventions in multicultural Thailand demonstrate that programs incorporating local languages, cultural symbols, and community participation achieve significantly higher engagement and behavior change rates compared to standardized approaches (Songserm et al., 2021). Our integration of Myanmar language materials and cross-cultural leadership networks exemplifies these successful adaptation strategies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSustained Behavior Change: Evidence for Intrinsic Motivation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sustainability of behavior changes at 1-month follow-up, despite slight decreases from immediate post-intervention peaks, provides evidence for genuine attitude shifts rather than temporary compliance. This pattern aligns with self-determination theory, which suggests that behaviors motivated by intrinsic factors (personal values, community norms) demonstrate greater persistence than those driven by external pressures (Deci \u0026amp; Ryan, 2000).\u003c/p\u003e\n\u003cp\u003eSystematic reviews of behavior change maintenance identify several factors associated with sustained outcomes: social support, self-efficacy, and integration with existing routines (Fjeldsoe et al., 2011). Our intervention explicitly addressed these factors through VHV support networks, skill-building activities, and integration with daily community communication patterns. The sustained improvements suggest successful activation of these maintenance mechanisms.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSoft Power Mechanisms: Understanding Cultural Adaptation Effectiveness\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrust Networks and Social Proof in Rural Communities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe prominent effectiveness of village announcement systems (58.9% rated most effective) and VHVs (24.1% effectiveness rating) reflects the critical importance of trust networks in health communication. This finding aligns with extensive research on health communication credibility, which consistently demonstrates that trusted local sources outperform external experts, particularly in rural and marginalized communities (Wood et al., 2022; Passmore et al., 2025).\u003c/p\u003e\n\u003cp\u003eRecent research on village health volunteer effectiveness provides additional context for our findings. Studies across diverse settings demonstrate that VHVs achieve superior health communication outcomes through their unique position as \"health diplomats\" who negotiate between formal health systems and community needs (Masunaga et al., 2022). Their effectiveness stems from shared cultural background, ongoing relationships, and perceived competence in addressing community-specific concerns.\u003c/p\u003e\n\u003cp\u003eThe integration of intervention messages into existing social communication patterns (daily announcements, informal conversations, community gatherings) provided social proof—evidence that protective behaviors were adopted by respected community members. Social cognitive theory emphasizes that observational learning and social modeling often prove more persuasive than abstract health warnings, particularly for behaviors requiring community-level coordination (Bandura, 2004).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCultural Resonance and Emotional Engagement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe use of personal narratives, local examples, and culturally familiar communication formats appears to have created emotional connections that purely informational approaches cannot achieve. This aligns with growing evidence from narrative medicine research, which demonstrates that stories promote health behavior change through identification, emotional engagement, and perceived relevance (Shaffer et al., 2018).\u003c/p\u003e\n\u003cp\u003eRecent research on health communication in multicultural Thailand provides additional validation for our storytelling approach. A study of Opisthorchiasis prevention communication found that interventions using Cambodian folk songs achieved significantly greater behavior change compared to standard health education, with participants reporting that culturally familiar formats made health messages more memorable and personally meaningful (Songserm et al., 2021).\u003c/p\u003e\n\u003cp\u003eThe emotional engagement created through local stories appears particularly important for environmental health behaviors, which often require lifestyle modifications with delayed benefits. Research on environmental behavior change demonstrates that emotional connections to health consequences can motivate protective actions even when statistical risk information fails to generate response (Slovic, 2010).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCommunity Ownership and Participatory Development\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRather than imposing external messages, our intervention encouraged community participation in content development, message adaptation, and dissemination planning. This participatory approach created local ownership that enhanced both message credibility and personal relevance, aligning with extensive evidence from community-based participatory research (CBPR).\u003c/p\u003e\n\u003cp\u003eSystematic reviews of CBPR in environmental health demonstrate that community engagement in intervention design and implementation consistently improves outcomes compared to researcher-driven approaches (Vincent et al., 2022). Key success factors identified in the literature include respect for local knowledge, cultural humility, trust building, and intervention designs that align with community values and practices—all elements explicitly incorporated in our soft power framework.\u003c/p\u003e\n\u003cp\u003eThe community ownership created through participatory development appears to have fostered collective efficacy—the shared belief that the community can effectively address PM2.5 risks through coordinated action. Research on collective efficacy in health promotion demonstrates its critical role in sustained behavior change, particularly for environmental health behaviors requiring community-level coordination (Mendel et al., 2011).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCommunication Channel Innovation: Reconceptualizing Digital Integration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTraditional Channels: Effectiveness Through Cultural Embeddedness\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur finding that traditional communication channels substantially outperformed digital platforms challenges prevailing assumptions about digital health intervention superiority. Village announcement systems achieved 89.7% reach with 58.9% effectiveness ratings, while social media reached only 31.7% with 12.8% effectiveness ratings. This pattern aligns with emerging research on digital divides in rural health communication.\u003c/p\u003e\n\u003cp\u003eRecent systematic reviews of digital health interventions in rural communities identify multiple barriers limiting effectiveness: infrastructure constraints, digital literacy requirements, cost barriers, and cultural preferences for interpersonal communication (Jongebloed et al., 2024). Our findings suggest that traditional channels may achieve superior outcomes not due to technological limitations alone, but because they align with existing community communication patterns and trust networks.\u003c/p\u003e\n\u003cp\u003eResearch on health communication channel preferences in rural settings consistently demonstrates the continued importance of traditional approaches. Studies of rural mothers in Ethiopia found that trusted health messengers and interpersonal communication achieved higher credibility and behavior change compared to digital platforms, even when technology access was available (Asfaw et al., 2019). The personal touch and cultural familiarity of traditional channels appear to provide communication advantages that technology alone cannot replicate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDigital Tool Adoption: A Staged Implementation Model\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe counterintuitive decrease in digital tool awareness immediately post-intervention, followed by recovery and growth at 1-month follow-up, provides important insights for digital health integration in rural communities. This pattern suggests several theoretical explanations supported by digital health research:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCognitive Load and Prioritization Theory\u003c/strong\u003e: The intensive traditional communication campaign may have created cognitive overload, leading participants to focus on immediately actionable behaviors rather than digital monitoring tools. Behavior change theory suggests that individuals prioritize interventions with the lowest barriers to adoption, which in this context favored mask wearing and activity modification over smartphone app navigation (Michie et al., 2011).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDigital Divide and Infrastructure Constraints\u003c/strong\u003e: The limited and delayed adoption of digital monitoring tools (only 7.6% regular use at 1-month follow-up) reflects persistent digital inequities documented in rural border communities. Systematic research on digital health barriers identifies language barriers, smartphone access, data costs, and digital literacy as primary constraints in similar populations (Hui et al., 2022).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStaged Adoption Model\u003c/strong\u003e: The recovery in digital tool awareness and doubling of regular usage by 1-month follow-up suggests that digital integration may require a staged approach. Recent research on technology adoption in rural health interventions supports this sequential model: establish basic protective behaviors through trusted traditional channels, then introduce digital tools for ongoing monitoring and advanced engagement (Radu et al., 2023).\u003c/p\u003e\n\u003cp\u003eThis finding has important implications for digital health policy and intervention design. Rather than viewing traditional and digital approaches as competing alternatives, our results suggest optimal effectiveness through staged integration that respects community communication preferences while gradually building digital capacity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBorder Community Health Communication: Advancing Theory and Practice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCross-Border Pollution and Communication Complexity\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur intervention operated within the complex context of transboundary air pollution, where local protective behaviors provide only partial protection from pollution sources beyond community control. This reflects broader challenges in environmental health communication for border communities, where effective risk reduction requires regional coordination and policy intervention.\u003c/p\u003e\n\u003cp\u003eResearch on cross-border environmental health challenges emphasizes the limitations of individual behavior change approaches when structural factors remain unchanged (Du et al., 2020). However, our results suggest that community-level protective behaviors can provide meaningful risk reduction even when complete pollution control is impossible. This aligns with harm reduction principles that emphasize feasible protective actions within existing constraints.\u003c/p\u003e\n\u003cp\u003eThe prominence of cross-border pollution concerns in community feedback highlights the importance of communication strategies that acknowledge structural limitations while empowering local action. Research on environmental justice communication demonstrates that interventions perceived as blaming communities for problems beyond their control can generate resistance and reduce engagement (Burger, 2022). Our approach addressed this by emphasizing achievable protective behaviors while advocating for broader policy solutions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLinguistic and Cultural Diversity: Implementation Insights\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe intervention's bilingual implementation (Thai and Myanmar languages) proved essential for reaching the full community. Research on health communication with migrant populations consistently demonstrates that language adaptation goes beyond translation to include cultural adaptation of health concepts and communication styles (Tsai \u0026amp; Lee, 2016).\u003c/p\u003e\n\u003cp\u003eOur experience aligns with systematic research on health communication in multicultural border regions. Studies of migrant health literacy reveal that effective communication requires understanding of both source and destination health systems, cultural health beliefs, and social determinants of health access (Hyatt et al., 2017). The integration of Myanmar-speaking community leaders and culturally adapted materials addressed these multilayered communication needs.\u003c/p\u003e\n\u003cp\u003eThe success of cross-cultural leadership networks (Thai village heads and Myanmar community leaders working together) provides a model for health communication in diverse border communities. Research on intercultural health communication emphasizes the importance of cultural brokers who can navigate between different health belief systems and communication styles (Pocock et al., 2020).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplementation Science: Scalability and Sustainability Insights\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCritical Success Factors for Replication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur intervention's effectiveness appears to depend on several critical factors that have important implications for scaling similar approaches:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFormative Research Investment\u003c/strong\u003e: The extensive community consultation phase (interviews, focus groups, material testing) proved essential for understanding local communication preferences, trust networks, and cultural sensitivities. Implementation science research consistently identifies formative research as a critical success factor often underestimated in intervention planning (Proctor et al., 2011).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLocal Leadership Authentic Engagement\u003c/strong\u003e: Success depended on genuine partnership with village leaders, VHVs, and community members who became co-creators rather than mere messengers. Research on community engagement effectiveness demonstrates that superficial participation fails to achieve the trust and ownership necessary for sustained behavior change (Brunton et al., 2017).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMulti-Channel Integration\u003c/strong\u003e: No single communication channel achieved sufficient reach and effectiveness alone. The intervention's success stemmed from coordinated multi-channel approach that reinforced messages through multiple trusted sources. Communication research supports this finding, demonstrating synergistic effects when traditional and interpersonal channels reinforce common messages (Jeong \u0026amp; Bae, 2017).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResource Requirements and Cost-Effectiveness\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhile our intervention required substantial upfront investment in formative research and multi-language material development, the per-participant costs compare favorably with intensive individual behavior change programs. The community-wide reach achieved through traditional channels provided efficient scaling compared to one-on-one counseling approaches.\u003c/p\u003e\n\u003cp\u003eEconomic evaluations of culturally adapted health interventions suggest favorable cost-effectiveness ratios when community-wide implementation is achieved (Weber et al., 2024). However, comprehensive economic analysis of our intervention requires longer-term follow-up to assess sustained health benefits and healthcare cost savings.\u003c/p\u003e\n\u003cp\u003eThe material development and training investments create lasting infrastructure that could support ongoing health communication beyond PM2.5, potentially improving cost-effectiveness through multiple health topic applications. Research on community health communication capacity building supports this multi-purpose utilization approach (Springer et al., 2017).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Limitations and Theoretical Implications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodological Constraints and Generalizability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTemporal Limitations\u003c/strong\u003e: The one-month follow-up period, while showing sustained behavior changes, remains insufficient to assess long-term sustainability or seasonal variation effects. PM2.5 pollution patterns are seasonal, and intervention effects during peak pollution months may not generalize to year-round practices. Longer follow-up studies are needed to confirm durability of behavior changes and identify factors supporting sustained implementation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGeographic and Cultural Scope\u003c/strong\u003e: The study's focus on two sub-districts in a single province limits generalizability, particularly to urban areas or regions with different cultural compositions. The heavy agricultural economy and Myanmar migrant population create specific contexts that may not apply broadly. However, the theoretical framework and adaptation principles may translate to similar rural border communities with appropriate cultural modifications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSelf-Report Bias and Social Desirability\u003c/strong\u003e: Outcome measures relied primarily on self-reported behaviors, which may be subject to social desirability bias, particularly given the intensive community engagement and relationship building with intervention implementers. Future studies should incorporate objective behavior measures (air quality monitoring device usage, mask purchase records) to strengthen evaluation validity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheoretical Contributions and Future Directions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSoft Power Framework Development\u003c/strong\u003e: This study provides initial evidence for soft power effectiveness in environmental health communication, but additional research is needed to understand mechanism specificity and boundary conditions. Future studies should examine which soft power components are most critical and how they interact with different cultural contexts and health behaviors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCultural Adaptation Theory\u003c/strong\u003e: Our results contribute to growing evidence that cultural adaptation provides substantial added value beyond standard health education approaches. However, questions remain about optimal adaptation depth, resource requirements, and measurement frameworks for cultural appropriateness and effectiveness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDigital Integration Theory\u003c/strong\u003e: The complex patterns observed in digital tool adoption suggest that digital health integration theory needs refinement for rural and culturally diverse populations. Future research should examine optimal timing, methods, and support systems for introducing digital health tools in traditional communication contexts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePolicy Implications and Recommendations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNational Health Communication Strategy Integration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur results suggest several opportunities for integrating soft power principles into Thailand's national health communication policies:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCultural Adaptation Mandate\u003c/strong\u003e: National health communication guidelines should require cultural adaptation for programs targeting diverse or marginalized populations, with specific provisions for border communities. Research demonstrates that culturally adapted interventions achieve superior effectiveness while promoting health equity (Griffith et al., 2024).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVillage Health Volunteer Capacity Building\u003c/strong\u003e: The superior effectiveness of VHVs in our intervention supports expanded investment in community health worker training and support systems. Systematic reviews demonstrate that properly supported community health workers achieve significant health improvements while providing cost-effective service delivery (Mupara et al., 2023).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMulti-Channel Communication Standards\u003c/strong\u003e: National health communication strategies should mandate multi-channel approaches that combine traditional and digital methods rather than privileging digital platforms alone. Our results suggest that traditional channels may provide essential reach and trust advantages that digital tools cannot replace.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCross-Border Health Collaboration Framework\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe success of our bilingual, multicultural approach suggests potential for broader Thailand-Myanmar health communication cooperation:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRegional Air Quality Communication\u003c/strong\u003e: Cross-border air pollution requires coordinated risk communication that respects cultural diversity while promoting consistent protective behaviors. Our model provides a framework for regional collaboration that acknowledges shared challenges while adapting to local contexts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMigrant Health Communication Networks\u003c/strong\u003e: The intervention's success with Myanmar migrant populations suggests opportunities for developing systematic cross-border health communication networks that span national boundaries while building on existing community structures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTransboundary Environmental Health Policy\u003c/strong\u003e: Effective PM2.5 risk reduction in border regions requires policy coordination between neighboring countries, supported by communication strategies that build public support for regional environmental cooperation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDigital Health Integration Policy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur findings regarding digital tool adoption have important implications for Thailand's broader digital health transformation:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStaged Implementation Approach\u003c/strong\u003e: National digital health strategies should consider staged implementation that builds on traditional communication strengths rather than immediately replacing them. Our results suggest that digital tools may be most effective when introduced after establishing basic health behaviors through trusted traditional channels.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRural Digital Infrastructure\u003c/strong\u003e: Sustainable digital health implementation requires addressing fundamental infrastructure barriers including internet access, data costs, and digital literacy. Policy interventions should address these structural constraints alongside technology deployment.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCultural Adaptation for Digital Health\u003c/strong\u003e: Digital health tools should be culturally adapted for diverse populations, including language adaptation, culturally appropriate interface design, and integration with existing social communication patterns.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study demonstrates that soft power principles can significantly enhance PM2.5 risk communication effectiveness in rural border communities, achieving substantial improvements in knowledge (18.6% increase), attitudes (14.4-17.6% improvements), and protective behaviors (24.7% average increase) that substantially exceed outcomes typically achieved by traditional environmental health education approaches.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTheoretical Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur findings advance environmental health communication theory in several important ways: (1) \u003cstrong\u003eSoft Power Framework Validation\u003c/strong\u003e: First systematic application of soft power principles to environmental health communication, demonstrating their effectiveness for behavior change in culturally diverse, resource-limited settings; (2) \u003cstrong\u003eCultural Adaptation Evidence\u003c/strong\u003e: Quantitative demonstration that culturally adapted approaches achieve superior outcomes (1.5-2 times greater effectiveness) compared to standardized interventions; (3) \u003cstrong\u003eCommunication Channel Theory\u003c/strong\u003e: Evidence that traditional channels may outperform digital platforms in rural settings when cultural embeddedness and trust networks are considered; (4) \u003cstrong\u003eDigital Integration Model\u003c/strong\u003e: Documentation of staged adoption patterns suggesting optimal timing and methods for integrating digital health tools with traditional communication approaches.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePractical Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe intervention provides a replicable framework for community-centered environmental health communication emphasizing: \u003cstrong\u003eCultural legitimacy\u003c/strong\u003e through alignment with local values, languages, and social structures; \u003cstrong\u003eTrust network activation\u003c/strong\u003e utilizing respected community leaders and existing communication patterns; \u003cstrong\u003eNarrative engagement\u003c/strong\u003e creating emotional connections through personal stories and local examples; \u003cstrong\u003eCommunity ownership\u003c/strong\u003e through participatory development and implementation; \u003cstrong\u003eMulti-channel synergy\u003c/strong\u003e coordinating traditional and culturally appropriate communication methods.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePolicy and Practice Implications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKey recommendations for policy and practice include: \u003cstrong\u003eNational health communication strategy revision\u003c/strong\u003e to mandate cultural adaptation for diverse and marginalized populations; \u003cstrong\u003eCommunity health worker capacity building\u003c/strong\u003e recognizing their superior effectiveness as trusted health messengers; \u003cstrong\u003eCross-border health collaboration\u003c/strong\u003e frameworks addressing transboundary environmental health challenges; \u003cstrong\u003eStaged digital health integration\u003c/strong\u003e building on traditional communication strengths rather than replacing them; \u003cstrong\u003eResource allocation\u003c/strong\u003e prioritizing formative research and community engagement in intervention design.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGlobal Health Significance\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs environmental health threats continue to disproportionately affect marginalized communities worldwide, the soft power approach demonstrated here offers a pathway for more equitable, effective, and sustainable risk communication. The framework\u0026apos;s emphasis on cultural adaptation, community empowerment, and participatory problem-solving aligns with global health approaches increasingly recognized as essential for addressing health disparities.\u003c/p\u003e\n\u003cp\u003eThe cross-border nature of environmental health challenges requires communication strategies that can bridge cultural and political boundaries while respecting local contexts. Our bilingual, multicultural approach provides a model for regional environmental health communication that acknowledges both shared challenges and cultural diversity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFuture Research Directions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCritical areas for future research include: \u003cstrong\u003eLong-term sustainability studies\u003c/strong\u003e examining behavior change maintenance and seasonal variation effects; \u003cstrong\u003eComparative effectiveness research\u003c/strong\u003e directly comparing soft power approaches with traditional information-based interventions; \u003cstrong\u003eMechanism studies\u003c/strong\u003e identifying which soft power components are most critical across different contexts; \u003cstrong\u003eEconomic evaluations\u003c/strong\u003e assessing cost-effectiveness and health system impacts; \u003cstrong\u003eCross-cultural validation\u003c/strong\u003e examining framework transferability across diverse cultural contexts; \u003cstrong\u003eDigital integration optimization\u003c/strong\u003e determining optimal timing and methods for technology introduction in traditional communication contexts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinal Implications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research demonstrates that environmental health communication can achieve substantial effectiveness through approaches that honor community knowledge, build on existing social structures, and empower local action within broader environmental health protection strategies. However, sustainable impact requires integration of individual behavior change approaches with structural interventions addressing pollution sources, economic barriers to protective equipment, and regional coordination challenges.\u003c/p\u003e\n\u003cp\u003eThe soft power framework offers hope for addressing environmental health disparities while providing evidence-based guidance for community-centered health communication more broadly. As global environmental challenges intensify, approaches that combine scientific rigor with cultural responsiveness and community empowerment become increasingly essential for protecting vulnerable populations and promoting environmental health equity.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the communities of Mae Kasa and Mae Ku sub-districts for their participation and partnership in this research. Special recognition goes to village health volunteers, community leaders, and local government officials who facilitated intervention implementation. We acknowledge the Health Systems Research Institute (HSRI) for funding support and the Mae Sot Hospital for technical assistance with health data collection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Institutional Review Board of Chulalongkorn University (Ethics Approval No. 006/68, 116/68, 463/67). All procedures were conducted following ethical standards for human subject\u0026rsquo;s research and the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by the Health Systems Research Institute (HSRI) under Grant No. 67-171. Additional institutional support was provided by the Center of Excellence in Communication Innovation for Development of Quality of Life and Sustainability, Chulalongkorn University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnonymized datasets supporting the conclusions of this article are available from the corresponding author upon reasonable request, in accordance with participant consent agreements and institutional review board requirements.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAuthor 1 innovated and supervised the whole project. Author 2 assisted in writing. Authors 3 and 4 helped in data analysis. Authors 5 and 6 assisted in interpretation. 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(2023b). \u003cem\u003eWHO Global Air Quality Guidelines: Particulate Matter (PM2.5 and PM10), Ozone, Nitrogen Dioxide, Sulfur Dioxide and Carbon Monoxide\u003c/em\u003e. World Health Organization. https://www.who.int/publications/i/item/9789240034228\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"PM2.5, risk communication, soft power, community intervention, environmental health, Thailand","lastPublishedDoi":"10.21203/rs.3.rs-7053430/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7053430/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003ePM2.5 air pollution poses significant health risks in Thailand's border regions, yet traditional risk communication approaches have shown limited effectiveness in changing community behaviors. This study evaluated a novel \"soft power\" approach to PM2.5 risk communication in rural border communities.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe conducted a mixed-methods intervention study in two sub-districts of Mae Sot District, Tak Province, Thailand. The intervention utilized soft power principles including storytelling, trusted local messengers, culturally adapted media, and community engagement. We measured knowledge, attitudes, and behaviors at three time points: pre-intervention (n\u0026thinsp;=\u0026thinsp;842), immediate post-intervention (n\u0026thinsp;=\u0026thinsp;810), and 1-month follow-up (n\u0026thinsp;=\u0026thinsp;806).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eComprehensive PM2.5 knowledge increased significantly from 8.4% pre-intervention to 27.0% at 1-month follow-up. Regular protective mask wearing increased from 33.1\u0026ndash;57.8% (+\u0026thinsp;24.7%), and continuous pollution-reducing behaviors increased from 33.8\u0026ndash;58.8% (+\u0026thinsp;25.0%). Village announcement systems demonstrated highest effectiveness (58.9% rated most effective), followed by village health volunteers (24.1%). Problem awareness increased from 77.8\u0026ndash;92.2%, with positive attitudes toward solutions rising from 65.2\u0026ndash;84.7%.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eThe soft power approach proved effective for PM2.5 risk communication in border communities, achieving substantial improvements in knowledge, attitudes, and protective behaviors. Success factors included cultural adaptation, trusted local messengers, and multi-channel communication strategies. This model offers a scalable framework for environmental health communication in similar contexts.\u003c/p\u003e","manuscriptTitle":"Effectiveness of Soft Power Approach in PM2.5 Risk Communication: A Community-Based Intervention in Thailand's Border Region","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-29 11:04:36","doi":"10.21203/rs.3.rs-7053430/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"21b3102f-b613-4d46-ac62-b406db1d2082","owner":[],"postedDate":"October 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":56958783,"name":"Earth and environmental sciences/Environmental sciences"},{"id":56958784,"name":"Earth and environmental sciences/Environmental social sciences"},{"id":56958785,"name":"Health sciences/Health care"}],"tags":[],"updatedAt":"2026-04-27T21:38:46+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-29 11:04:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7053430","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7053430","identity":"rs-7053430","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}