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.
Malaria, River Blindness: Meanings and Interpretations
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Do curso por Johns Hopkins University
Diagnosing Health Behaviors for Global Health Programs
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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
Efforts to control malaria disease provide another example of explanatory models and
interpretations.
In a project promoting bed nets treated with insecticide in Nsukka,
Nigeria, in the eastern part of Nigeria.
Baseline studies were done to find out how people perceived of bed nets and malaria.
Well, first people identified several different types of malaria.
There was the common, or ordinary malaria,
that most people recognize clinically with fever, pain, weakness.
Some people noted dizziness, tiredness, chills, headache.
And when asked what causes this, majority of people in the focus group discussions
and also in interviews, talked about fever malaria being caused by too much sun,
too much work, and some people did mention mosquito bites.
We found that mention of mosquito was associated with education.
Those who had been to school were more likely to mention this.
Another type of malaria is called yellow, or colored, malaria.
People recognize this with some of the other symptoms of ordinary malaria,
but also the eyes and the urine turn yellow, stronger headache and fever.
And what is this caused by?
Again, too much sun and heat, too much oil in the diet, oily food,
dirty water, overwork.
And again some people mentioned mosquitoes.
A third type of malaria that's described is dry malaria.
People become slim, they shrink.
They dry up, lose weight, become emaciated.
This again is caused by much work, exposure to the sun and
poor feeding habits, poor quality or inadequate food.
Wet malaria is recognized as swelling of the body,
weight gain, dull feeling, weakness, edema, cold.
And this is caused by the cold or rain in the rainy season and also poor feeding.
Then have heavy or strong malaria.
The person may be talking senselessly, madness, very high fever,
serious headache, quick onset of the fever.
And then we have shaking malaria.
Again the person may be behaving abnormally,
talking abnormally, strong headache, restlessness and tremors.
This is caused, they say, by too much thinking, charms, or
curses by other people, drinking too much alcohol, or taking drugs.
So all of these still fall under the same illness name as malaria.
But they are recognized as being slightly different and
having slightly different causes.
So, if someone comes in with a control technology and
say we're going to prevent malaria, people in the village would rightly question,
what kind of malaria are you going to prevent?
And if, in fact, the bed nets do prevent malaria,
that we know of, as a disease caused by plasmodium then we
may be preventing what people see as ordinary malaria.
But then they may say well, the interventions not successful because
people are still getting other kinds of malaria.
We've just talked about several different types of malaria that people perceive
locally, and
that information was shared with us during some focus groups in the community.
Another method that we use to get people to give us their ideas about what
kinds of malaria, and what malaria look like in their community,
was a qualitative research method called Pile Sorts.
During various surveys and community discussions, we had heard people describe
all the different things you can have when you are experiencing malaria illness.
And some of the many things included convulsions, hot body, dizziness,
headache, vomiting, cold and chills, loss of appetite,
sleepiness, lack of blood, yellow urine, yellow eyes, weakness, body aches.
There are so many different things that would make it very difficult to determine
what really is a particular illness condition.
How can you differentiate?
How do you communicate with people with all these different symptoms which ones
really are malaria?
So the Pile Sort process, was to write all these down on little pieces of paper and
have people take the symptoms that they thought in their own mind went together
and put them in little piles.
And we had a computer program that helped analyze the most common piles,
and what we came up with is mapping, as it's called,
of four different clusters of symptoms.
We took those clusters of symptoms and went back to some of our key informants.
Some of the local medicine people and community members, elders in the community
and say okay, if somebody has these cluster of symptoms what do they have?
So one of the things that we found is if they had complained of dizziness and
lack of blood, that cluster of symptoms, people said that's Oyii.
That means dizziness, literally your head is turning.
So that's not malaria that's a condition called dizziness.
Okay, if they complained of having hot body and chills.
So, well that's ordinary malaria, that's Iba.
Now, when they looked at the cluster of symptoms called yellow eyes, headache and
yellow urine, they say that's Iba Ponju.
Yellow malaria.
And finally, when someone said they had strong body aches and
weakness, that's Ako Iba, the male malaria, the real strong one.
So this was another method of sorting out and
finding out how people classified the different kinds of diseases they had, and
explain them so that when you're listening to someone and talking about it, you
can understand from their point of view what they think they're suffering from.
Another concern that we had arose from a clinical experience.
A mother was explaining that she had brought her child in,
the child had just had convulsions that morning.
She said, well yesterday my child was having a little temperature wherever,
it was just only malaria.
But this morning I knew it was another disease because the child started shaking.
So again we used in depth interviews to talk to people, case studies,
to find out well, what are these things about?
And people made an interesting contrast between Iba malaria, which has some of
the symptoms we've already discussed, and the idea that it comes in the hot season.
Because it may be exposure to heat and sun, it's not so
serious, everybody gets it like the common cold.
And this other thing, now clinically people say yes, febrile convulsions.
But, people locally don't consider convulsions to be arising from cold,
they have another name for it, this Ile Tutu,
which is cold earth disease and Uri is the actual convulsion.
Okay, so the contrast is very distinct in local people's mind
between these two conditions.
OKay, one you have hot body, the other you have cold and shivering.
One comes in the hot dry season, the other, people perceive, or believe,
comes in the cold wet season.
One is extremely serious.
In fact, they rush all kinds of medicines,
as you'll see in one of the case studies we'll look at later, and
pour them down the child's mouth, to try to get them to get over the convulsions.
But, the cause, again, is leaving the child on the ground in cold weather,
where the cold can seep into the child's body.
So the convulsion is the slow building up of the cold, and
the progression of chills into a convulsion.
Which is a completely different, again, perception from, clinically what we would
know would be a febrile convulsion caused by a disease like malaria.
To what people believe is inappropriate child care,
leaving the child on the ground in the cold weather.
And so therefore when some of the health workers suggested in those days said, yes
you should tepid sponge your child with cool water to bring down the temperature.
The mothers said, Heaven forbid, that will cause Ile tutu.
A number of these issues if we're not aware how local people perceive and
define some of these conditions.
The information that we share with them from our Western scientific point of view,
may make no sense at all,
they may think we're actually we trying to threaten their lives.
Interpreting the control technologies, we might start with looking at treatment.
Prompt treatment is an important measure in control, and
also in preventing mortality especially in children.
Traditionally, people use various kinds of herbal medicines.
These are bitter, and
it's believed that the medicines work by making the person sweat out the illness.
The medicine can be drunk, people can inhale it, people can even bathe with it,
the herbal medicine.
People believe that anti malarial drugs in the shop or
in the clinic do not have this effect of making people sweat out the disease, so
they don't think it's as effective.
And, in a fair proportion of people there's side effects of itching.
Their existing treatment technologies are seen as,
preferable to what we may have to offer.
When we talk about encouraging bed net use,
we have to think of how do people interpret what a bed net is.
In fact, people like having nets for
their own sake they believe the nets beautify the home.
In fact, the nets can even become a status symbol because we identify that
people who are able to hang curtains in their homes,
in these villages around Ansuka, were of higher socio and economic status and
the people with no curtains at their doors and windows.
And so getting a bed net, and the bed nets were given free in that particular
project, was seen as a status symbol by people, to make their home nicer.
Another positive thing they saw about the net was it kept them warm
in the cool nights, during the rainy season.
On the other hand, people complained about heat, lack of air during the dry season.
Even though mosquitoes were still around, they would go out and
sleep outside at night.
In terms of making sense out of efforts to
promote bed net use as a way to prevent malaria people can't see the connection.
Since malaria is caused by the sun,
how can sleeping under nets at night, prevent it?
And therefore, we find that people logically say,
well, if it's caused by much work under the sun, but we're farmers,
we can't stop working to prevent the disease.
Therefore, we take herbs prophylactically.
People's interpretation and responses have an internal logic.
And we need to understand that logic because our
promotional efforts of giving them the facts, the empirical, rational approach
often falls on deaf ears because what we have to say doesn't make sense
because we haven't taken our time to learn about these local explanatory models.
In the following pictures,
we can see a group of high school students performing a drama, trying to encourage
mothers to provide prompt treatment with antimalarials.
We've found that more and more mothers are adopting these because they
fear that maybe herbs are too strong for small children.
The picture also shows some packets of antimalarial drugs, and
the local herbs together.
One way that we used during training to convince people
that chloroquine was a valid antimalarial drug was to have them chew the leaves and
see how bitter they are, and taste the chloroquine tablets.
And so we're able to bridge the gap a bit.
The next slide shows a person sleeping under a bed net
as a malaria control measure.
One way to learn about local interpretations of illnesses,
is to listen to poetry, stories, songs in the village.
The next couple of slides, show a praise song, as it were, for onchocerciasis.
It's common for individuals to have what is called, oriki or
a praise song and name for themselves that talk about their family history, and
in this case, diseases or serious events are also given their own oriki.
In this case, to describe onchocerciasis, it's called, Narun, Narun,
with spots all over the body.
Who is entering?
Please don't step on me.
That stops a child from hoeing.
That kills the penis.
That spoils the body with rashes.
Groping about with hands on the ground.
These different phrases, joined together, describe the different characteristics of
onchocerciasis, or river blindness, that people in the community perceive.
Obviously if someone is asking who entered, don't step on me.
It's implying that the person is a blind person.
Onchocerciasis causes body pains and aches and weakens the person.
They can't hoe in their farm.
It's believed that onchocerciasis causes impotence and infertility.
It kills the penis, body rashes,
all the onchodermatitis is seen as a very stigmatizing experience.
People don't know if these rashes could eventually lead to a more serious disease
like leprosy.
They don't know if the rashes are contagious.
There's a belief that any of the puss or
water coming from any kind of a rash is dangerous.
And finally again, the groping about with the hands on the ground implying
the blindness that results from onchocerciasis.
These local, cultural manifestations show how people view a condition and
provide a good ground to begin our health education.
By recognizing these, by using them in our education we can show that as
health workers we are familiar with, we are respectful of the local culture.
Explanatory models or local beliefs are not just disease oriented, they also cover
issues such as acceptable or normative behavior under certain conditions.
One thing that's common in many societies are prescriptive or
proscriptive behaviors during pregnancy.
For example one of our students who was who was looking at the issue
of health promotion or health seeking behaviors of pregnant women look
at the question of what foods were appropriate for them to eat.
Because during clinic sessions for ante or prenatal care, the nurses and
midwife talk quite a lot about eating to stay healthy during pregnancy and
produce a healthy baby.
The question arose in her mind were what is actually
acceptable food during pregnancy for the women in the community, and
how does this relate to what the nurses tell them?
She found an interesting thing that quite a number of women have said that
you shouldn't eat green vegetables, green leafy vegetables during pregnancy.
They explain this that the vegetables may cause indigestion,
stomach upset, and that may lead to miscarriage.
In fact found that there were some important associations with that.
That the women who had this belief were more likely to be uneducated,
not having formal education.
We were able to identify certain groups that have these beliefs.
One other belief they had is one shouldn't eat bush meat or game.
For example if you eat a monkey or you eat a snake,
it could affect the appearance of the child.
There were interesting beliefs that some of the heavier starchy foods.
Again the food is cooked up into a big lump of starch.
And there were some concerns that eating too much of the heavy starchy foods
may again fill up the stomach, make the upset stomach but
also cause something that is known as hot stomach.
And this hot stomach.
The people believe it's not necessarily you can put a thermometer there and
tell it's hot.
But there's a concept that something called hot stomach also causes
miscarriage.
Other eating concerns were that if a mother eats
plantain during pregnancy, the child will later suffer from sunken fontanel.
Interestingly enough,
this gets back into some of the things we've talked about, diarrhoeal diseases.
People do not see a connection between dehydration.
And there's many languages, there's no word specifically for dehydration and
diarrhea.
So the symptom of sunken fontanel in infants
is thought to be caused by the fact that the mother ate plantain.
The little ridges on the plantain are synonymous with the sunken area
in the child's head.
So, you want to avoid eating these things during pregnancy so
your child won't have that problem.
Other eating that may have effect on the child ultimately is
eating snails during pregnancy may cause the child to salivate too much.
And in a number of cultures, there's a concern that
if a pregnant woman eats eggs, she'll have a difficult delivery.
Because it's seen that baby chicks have a difficult time getting their way out of
the egg and the baby may likewise have difficulty coming out of the womb.
So some of these may be observational things that people have interpreted
over time.
And some of these may be through experience of symptoms that have caused
people to come up with these believes.
The important thing through is that how do these beliefs influence a person's diet.
Well, not eating monkey meat during pregnancy is probably not a big deal.
Because how many people are going to go out and catch monkeys?
And there are other sources of protein, cow meat, that's available.
So that's not a major concern.
So as long as there are some variety and some substitutes, and
if the nurse or midwife is sensitive to these local beliefs, then she can
adjust her nutritional discussions and nutritional education to fit in with local
beliefs without necessarily sacrificing the nutritional status of the mother.
So it's important not only to gather this information but
to use it in a culturally sensitive way.
The next slide shows that people's perception of illness
influences their treatment behavior.
A longitudinal study was done by one of our own NPH students in Nigeria.
And she visited mothers over a period of six months.
And asked them weekly, had the child had any illness?
We had found previously through formative research that
there were different kinds of diarrhoeal diseases.
And this has been reported in India, in Guatemala, Honduras,
many countries people classify different kinds of diarrhoeal,
just like we talked about different kinds of Malaria.
Broadly speaking, there were diarrhea that were recognized as more watery in nature.
This was often attributed to teething.
And there was diarrhea that was more the dysentery nature that also had blood and
mucus.
What was interesting to the student was to find out how mother's
classified the diarrhoeal illness the child had.
And then whether the mother used the nationally promoted oral rehydration
therapy, in particular, a homemade salt-sugar solution.
And when she compared the mother's own classification of the illness with whether
or not the salt-sugar solution was used, she found a strong relationship between
a classification of watery diarrhea and use of salt-sugar solution.
Mothers had interpreted the national educational messages that
diarrhea is dangerous because a child loses water.
And so, if they perceive the diarrhea as being watery, they wanted to replace it.
But if the diarrhea was more complicated and more like dysentery,
then they chose other solutions, such as herbs, and wanted to get medicines.
So, clearly, people's perceptions influence their actions,
their explanatory models,
their interpretations are necessary to know to understand their illness behavior.
In particular, the local name for dysentery like illnesses is jedi jedi.
Literally that means something eating at someone's rear end.
And this disease, or local cultural illness,
is more feared because it's believed that the lower back
contains the power for sexual drive.
And especially in male children, if they suffer from this jedi jedi or
there's dysentery, rectal prolapse, lower back pain,
all of these fall under the same heading, the same name as jedi jedi.
And so this is something that requires more serious solution than just homemade
rehydration drinks, because it could damage the child from future reproduction.
Interestingly enough, people believed that this jedi jedi is caused by sugar.
Too much sugar, too many sweet things.
And they're very skeptical about homemade salt-sugar solution.
Fearing that if you give a child with dysentery salt-sugar solution,
you'll be causing the dysentery or jedi jedi to get worse.
We've tried to use our greater understanding of local health beliefs and
explanations to come up with a process called health belief synthesis.
Trying to identify common points between a scientific world view,
and a local cultural, or indigenous world view.
Are there points of common explanation
that can be used to enhance health education?
This health belief synthesis is shown on a table in the next slide.
On the left column are indigenous ideas about diarrhea.
On the right-hand are scientific ideas.
And in the center are some common points that could be used to start dialogue,
interchange, exchange of ideas and mutual learning about the condition.
Indigenous ideas include some of the things we've mentioned.
That teething causes diarrhea.
Mother's say something like dirty stomach causes diarrhea.
And so the diarrhea's washing out the dirt.
There's a belief that a heavy infant has diarrhea in order to shed weight and
be able to stand up and start walking.
Even dietary factors,
there are beliefs that giving the child too much beans can cause diarrhea.
Obviously, this contrasts with the idea of different kinds of organisms, bacteria,
virus-causing diarrhea in the scientific world view.
The idea that many of these organisms are spread through a fecal oral route.
And it's recognized, of course,
that certain foods could irritate the stomach and lead to diarrhea.
But that diarrhea itself is not a disease but is a symptom of specific infections.
Now where is there any common ground on these two perspectives on diarrhea?
When we talk to mothers we ask them to think about their children.
Prior to the time they're having diarrhea, what did they see?
Children crawling around?
Children chewing on things, teething, putting objects in their mouth?
Okay, we agree, that yes, all children do this, it's very common.
And that in fact when they pick up these objects and put them in their mouth,
these objects may be dirty.
And this is possibly how the child gets dirty stomach.
And based on that agreement, then we can talk about
what can be done in terms of preventing the dirt getting into the stomach.
What can be done in terms of how we respond to the resulting diarrhea.
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