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.
