Health behavior lies at the core of any successful public health intervention. While we will examine the behavior of individual in depth in this course, we also recognize by way of the Ecological Model that individual behavior is encouraged or constrained by the behavior of families, social groups, communities, organizations and policy makers. We recognize that behavior change is not a simplistic process but requires an understanding of dimensions like frequency, complexity and cultural congruity. Such behavioral analysis is strengthened through the use of a toolkit of theoretical models and practical frameworks. While many of such models and frameworks exist, in this course we will review the Health Belief Model, Social Learning Theory, Theory of Reasoned Action, the Trans-Theoretical Model and the PRECEDE Framework. After building your behavioral analysis toolkit with these examples, you will see that actual behavior change program planning uses a combination of ideas and variables from different models, theories and frameworks. Ultimately we aim to encourage course participants to apply the idea that successful programs are theory based as they go about involving people in improving their health.
Explanatory Models: Learning From Local Perspectives
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Do curso por Johns Hopkins University
Diagnosing Health Behaviors for Global Health Programs
11 classificações
Johns Hopkins University
11 classificações
Curso 4 de 6 em Specialization Foundations of Global Health
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Individual Behavior, Perspectives, and Interpretations
We continue with theories and models, understanding human behavior, and understanding perspectives. We'll also examine an example of meanings and interpretations using malaria and river blindness as well as an introduction to force field theory and an explanation of using and making models and theories.
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William Brieger, DrPHProfessor, Health Systems Program of the Department of International Health
Bloomberg School of Public Health
It's important to consider the models, the types of models, together.
The explanatory models provide important background understanding and
interpretation of the theoretical concepts.
Talked about perceptions.
What are the cultural perceptions?
So if these models are combined and used to provide information,
to analyze information, to plan, and to evaluate programs, it is
hoped that health education will be more culturally appropriate and more effective.
At this point, we will go into more detail on the concept of explanatory models.
Reality is the question.
Reality is socially and culturally constructed from the experiences
of people living in a particular social physical environment.
People interpret these experiences within that environment, and
interpret it through dialogue and discussion with each other.
Their own subjective experiences, the efforts they make to solve problems.
The results arising therefrom are validated over time.
The concept of objectivity does not
really exist because one cannot step outside oneself.
But within a given culture, through common experiences,
people can agree on a common subjectivity that become the beliefs and
norms of their particular culture.
It's important for us in health, education, and public health to understand
how each culture and subculture views the world.
How they explain the events and respond to the events that occur.
Therefore, explanatory models define reality in a local context.
In the next slide, I have a simple picture of a tree.
But, again, the explanatory model helps us realize that
what this tree means is in the eye of the beholder.
One person may see that the tree is good for shade.
Another person may associate the tree with certain ancestors or
local deities, and believe it should be worshipped for fertility.
Some people may see the tree as a source of food.
The fruit is very good.
Some people may see the tree as a source of medicine and cut up the bark or
roots or leaves and use it for that.
This, in short, shows us that not just individual people, but different cultures.
There is a very beautiful tree in Western Nigeria, throughout much of Africa.
The flamboyant tree with bright red flowers.
The name of course in English emphasizes the beauty of the flowers.
Whereas the name in a local language emphasizes
the noise that the seed pods make.
So the same tree, but given different names because different characteristics of
that tree have different meanings to people.
So we need to recognize this,
simply from the standpoint of different illness experiences have different
meanings to Western-trained health workers than they do to community members.
And if we don't understand these differences, it's like the blind men and
the elephant, they're all of the same elephant but they don't realize it.
The example of Guinea Worm disease is provided in the next few slides.
Guinea Worm, as we noted in the previous module,
from the biomedical point of view, is a disease that is waterborne.
But the illness that people in southwestern Nigeria
experience is called sobia.
There are different kinds of sobia depending on the stage that
Guinea Worm is in.
People may initially experience systemic illnesses.
Sobia awoka is the kind of Guinea Worm where there are pains in the joints and
around the body.
It's been explained as if guinea worm was a snake moving here and
there in the body, and wherever it's touching the pains occur.
Egbesin sobia are rashes all over the body.
A person may wake up and discover that he or she has rashes.
And that is seen as the sign or the herald of guinea worm,
which may emerge any time in the near future once these rashes are experienced.
Or again, it may not.
But the important thing is through focus group discussions,
through in-depth interviews, getting people to talk about their own personal
experiences with the disease, they define an experience that is different
from what western medicine would call Guinea Worm disease.
But to them they respond to it and are interpreting any solutions or
programs we offer in the light of these perceptions.
Guinea Worm may progress in the local context.
Sobia may have a localized manifestation.
The condition Akukudidi are hardened patches on the skin and
people believe Guinea worm may be under that.
Clinically, we may say that, well, this is the rough lichenified onchodermatitis,
part of onchocerciasis, onchocircle skin disease.
But local people believe it has something to do with Guinea worm.
Another stage that they recognize is local swelling.
True, guinea worm before it's going to erupt will form a blister.
But people believe that any swelling or nodules on the skin harbor a guinea worm,
whether it comes out or whether it doesn't.
They call these things by different names.
There may be wiwu which is swelling in a particular point.
Koko ara are specific nodules.
Sobia eleta is a blister that only blood comes out of.
But these are considered as local manifestations of sobia.
Whereas in fact, the nodules may harbor the adult worms of [INAUDIBLE],
they maybe.
We don't know clinically what all of these things are, but people do recognize it and
respond to it.
At a point,
people recognize that guinea worm does emerge from a blister under the skin.
And they have no problem distinguishing this as Sobia.
This, in fact, from the epidemiological point of view,
is the condition of concern because once the worm emerges, it can deposit
its larvae in the pond whenever people wade into the pond to collect water.
And so here is a point where indigenous views, local illness perceptions and
Western views, Western scientific views of illness and disease correspond.
Finally, people believe that there may be post-emergent conditions of guinea worm.
The guinea worm may go back inside the body and continue the aches and pains.
Much of health education in guinea worm has been spent on trying to convince
people to adopt the scientific explanation.
For guinea worm and abandon their own explanatory model.
The following slide shows the official life-cycle type of drawing
that appears in textbooks for training health workers
where the person is swallowing the water that contains the cyclops.
The passage of time is difficult to show in drawings like this.
And that may be a reason that local people are sometimes confused by our efforts to
provide scientific knowledge.
But the person is standing in water.
The worm is emerging from the leg.
Larvae are expelled, cyclops swallow the larvae, larvae develop in the cyclops,
and then eventually the person swallows the infected larvae and
the cycle starts again.
So this is a completely different idea of what it is to have guinea
worm from what local people believe.
As we indicated before, local people believe guinea worm is part of their body.
It's a tendon, it's a vein that may come loose and eventually come out of the body.
So the idea of simply telling local people, this is the way the disease
spreads without understanding their local beliefs and
explanations, will often fall on deaf ears or seem completely incredulous.
The next slide shows a drawing on the front of a Nigerian news magazine
that was used to try to draw attention of policymakers and politicians, etc.
To the plight of people with Guinea worm.
Because this is a disease that affects people in remote,
rural areas it doesn't get the attention it deserves.
And often, the main educational efforts are needed at the policy level,
not at the community level.
We will talk more about this in module 6.
The next slide we had done surveys in many of the communities in Southwest Nigeria.
The intention of the survey by UNICEF was to identify villages that were endemic so
these could be targeted for wells.
In the process, we use the opportunity
to determine how local people responded to the guinea worm experience.
People were asked first,
did you have guinea worm during the last transmission season?
Which in the case of Southwestern Nigeria would have been in the dry season from
about October through about March or April.
Then after hearing if they said,
yes, they were asked well what kind of guinea worm did you have?
What kind of sobia did you have?
And this way it was possible to distinguish between guinea worm that
emerged, and the other cultural manifestations of the illness experience.
As can be seen from the chart that is people's first response, yes,
I had a guinea worm was taken for granted then there would have been
an overestimation 35% of the responses
were cultural illnesses, cultural manifestations of guinea worm.
Only 65% were actual emergent worms.
If programs do not take into account local beliefs and
perceptions, in this particular case,
there may be an overestimation If villages are going to be targeted for
interventions, one or two cases of Sobia Awoka or Sobia Wiwu in a village.
Without proper clarification could result in efforts to distribute filters, etc.
A lot of resources being expended on villages where the disease doesn't pose
a public health threat.
Because there's no emergent worm.
So this is important how culture anthropology and
epidemiology need to work together.
Explanatory models involve providing meaning and interpretation.
And it's not just how people interpret or understand the disease or illness itself.
But there's also the process of interpreting, or
giving meaning, to the control technologies that we have to offer.
We've already noted that people experience different
presentations of sobia, or guinea worm.
They are aware of what part of the body the worm can come out.
Mostly, in the lower limbs that come in contact with water.
And they believe it cannot be prevented because it's part of the body.
So with that in mind, recognize that many of our interventions,
such as specific protection measures, the use of filters.
Other measures such as chemical application to the pond to
kill the cyclops may not be perceived as reasonable or helpful to people if they
believe guinea worm is already in the body and cannot be prevented.
Ironically, we found the people have no problem accepting a reliable clean source
of water from a hand-dug well or a pump because it has intrinsic value of its own.
But they tend to be very skeptical
about the concept of filtering to prevent the worm.
How can we filter out something that's already in our body?
Or if the worm is so big, how did it get in our body in the first place?
Without our seeing it?
We need to look closely at people's interpretations of the control measures
that are offered.
In the case containment phase of guinea worm eradication, the village health
worker, and the district health staff are encouraged to dress the ulcer.
This has a positive effect in terms of cleaning the ulcer, and
preventing secondary infections, but
it's also designed to prevent contact with the worm and water.
Unfortunately, people believe that dressing the ulcer makes the worm angry.
That the worm will go back inside and cause more trouble.
And people tend to remove the dressing as soon as they leave the clinic.
As we've mentioned, people are used to filtering, dealing with food items.
They see the benefit of filtering to clean out debris and
dirt from the water they may collect from the pond.
But they don't connect filtering with disease prevention.
And as mentioned on the other hand,
wells are quite acceptable, regardless of people's beliefs.
And so, ironically, if we try to promote
well construction as part of a major intervention for guinea worm control.
People will accept the wells for their own benefit,
regardless of whether they changed their beliefs about guinea worm.
And we have to be careful as health workers not to be so
stubborn that we have to convince everyone to believe what we believe
in order to make a successful program.
If we understand how local people think,
then we'll be in a better position to adapt our promotional efforts
to be congruent with what they believe and expect.
Another example of the interpretation of interventions is in condom promotion.
At least three issues need to be analyzed.
What do people think about the condoms themselves?
Focus groups, both male and female, think that it's unnatural to use a condom.
Females are particularly afraid that the condom might tear and get stuck inside.
And both males and females talk about introducing the topic
of condom may cause conflict in their relationship.
So condoms themselves may be controversial just within the relationship.
One must analyze what people think about STDs.
In some countries, people believe AIDS is a foreigner's disease.
It won't happen to them.
It's not really endemic to their country.
Their beliefs that AIDS is not common in younger people.
And so older men would have sex with younger women thinking that they're safe.
In some places, STDs are believed to be a sign right of passage.
In Western Nigeria, the literal translation of one of the names for
gonorrhea is disease of enjoyment.
And then of course, if people are enjoying themselves and
condoms are unnatural, again looking at the two interpretations together show why
it might be difficult to promote condom use.
Especially they don't feel at risk or threatened by the disease.
Finally, condoms are generally viewed in connection with family planning and
pregnancy prevention.
So that the idea of them as an STD prevention is not common.
People consider things that it's not possible to get pregnant the first time
they have sex so they wouldn't wear condoms.
Pregnancy may actually be desired in a relationship.
In some situations, a woman feels she must get pregnant before
marriage to demonstrate to her husband that she's fertile.
So all of these factors need to be taken into consideration.
So it's not simply a matter of a person using a condom as a behavior.
But a person is interpreting the condom itself as an artifact or technology,
interpreting the condom in relation to their own relationship with each other.
In terms of what sexually transmitted diseases are, and
how condoms relate to that.
And in terms of pregnancy itself, and condoms' relation to that.
So all of these local interpretations affect how people will see condoms and
whether they'll use them.
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