1. BLOOMBERG JOHNS HOPKINS SCHOOL of PUBLIC HEALTH
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JOHNS HOPKINS
BLOOMBERG
SCHOOL of PUBLIC HEALTH
Copyright 2006, The Johns Hopkins University and William Brieger. All rights reserved. Use of these materials permitted only in accordance with license rights granted. Materials provided “AS IS”; no representations or warranties provided. User assumes all responsibility for use, and all liability related thereto, and must independently review all materials for accuracy and efficacy. May contain materials owned by others. User is responsible for obtaining permissions for use from third parties as needed.

2. and the Ecological Model William R. Brieger, MPH, CHES, DrPH
JOHNS HOPKINS
BLOOMBERG
SCHOOL of PUBLIC HEALTH
Health Behavior
and the Ecological Model
William R. Brieger, MPH, CHES, DrPH
Johns Hopkins University 1

3. Section A
Dimensions of Health Behavior 2

4. Disease, Ecology, and Behavior
 Diseases occur within
ecological settings and are
thus context dependent
 Cultural practices can directly alter
ecological relationships between hosts
and agents of disease
 Biological and cultural traits with
adaptive value against disease will
generally be selected
Continued 3

5. Disease, Ecology, and Behavior
 Human behavior plays a
significant role in the etiology of
every major category of disease
 The understanding of the influence of
human behavior on disease requires a
sociological perspective 4

6. Behavior Analysis Filtering behavior to prevent guinea worm
Image Courtesy of the Carter Center
Filtering behavior to prevent guinea worm 5

7. Dimensions of Behavior
 Frequency
– Every time drinking water is
collected from the pond, which
could range from daily to a few
times a week
Continued 6

8. Dimensions of Behavior
 Duration
– Each individual filtering session
may take 10–15 minutes; filtering as
a health habit needs to be
practiced for several years until
guinea worm is eliminated from the
village
Continued 7

9. Dimensions of Behavior
 Timing
– Filtering must be done immediately
after one reaches home
– with a bucket of pond water
– in order not to give anyone the
opportunity to drink unsafe water 8

10. Image courtesy of the Carter Center9

11. Filtering Behavior Involves Steps
Form
Filtering Behavior Involves Steps
 Inspect the filter for holes
 Place it right-side-up over the mouth of
the pot
 Attach the filter
 Pour the water slowly into the center of
the filter
 Remove the filter carefully so as not to
allow dirt and cyclops to fall into the pot
 Rinse the filter with “clean” water
Continued 10

12. Filtering Behavior Involves Steps
Form
Filtering Behavior Involves Steps
 Dry the filter
 Store the filter in a safe place
 Wash the filter with soap when it’s dirty
 Replace the filter annually or when
holes develop
 Continue all steps until the guinea
worm is eliminated from the village 11

13. More Dimensions  There are alternatives for managing
Competition
 There are alternatives for managing
domestic water supplies to make these
appear acceptable for consumption
 Most often, people simply allow water to
settle before drinking
 They may also apply a small amount of
alum (inexpensive) to precipitate
suspended matter in the water 12

14. More Dimensions  Compared to allowing the water to
Competition
 Compared to allowing the water to
settle, filtering is a more complex
behavior
 The skills needed to attach the filter to
the pot depend on the design
 Other steps in “correct” filtering add to
the complexity 13

15. More Dimensions  Within the culture, there is precedent
Congruence
 Within the culture, there is precedent
for making water appear more clear
before drinking
 The process of filtering or sieving
exists as in the making of maize starch
porridge
 The concept of filtering to prevent
diseases, particularly guinea worm,
which is thought to be a natural part of
the body, like a vein, is unknown 14

16. More Dimensions  Behaviors are not isolated events
Linkage
 Behaviors are not isolated events
 They are linked with and influence
other behaviors and social norms in
water collection, water consumption,
and other domestic chores 15

17. Levels of Health Behavior
(Preventive) health behavior
– Actions people take to remain well
and to prevent illness
 Illness behavior
– Actions taken when people feel
indisposed to determine the nature
of their problem and to seek
solution
Continued 16

18. Levels of Health Behavior
 Sick-role behavior
– Actions taken by people to recover
from illness (once such illness has
been established by a
“gatekeeper”)
 At-risk behavior
– Actions taken by people with a
chronic condition to maintain health
and prevent death 17

19. The Social Construction of Illness and Disease
 Patients suffer “illnesses”
 Physicians diagnose and treat
diseases”
 Behavior is influenced by people’s
perception of their illness experiences
or the illnesses they wish to avoid
Continued 18

20. The Social Construction of Illness and Disease
 Illnesses are experiences of dis-valued
changes in states of being and in
social function
 Diseases, in the scientific paradigm or
modern medicine, are abnormalities in
the structure and function of body
organs and systems
 Illness and disease, so defined, don’t
stand in a one-to-one relationship 19

21. An Example of Guinea Worm
 Disease
– Dracunculiasis medinensis: A
meter-long subcutaneous
waterborne helminthic infection
 Illness
– Sobia: Part of the body that moves
around to cause pains and rashes,
and later may come out of the body 20

22. No: 14.3% of 481 Nearby Dengue Case? YES: 40.2% of 316 YES:
Determinants of Dengus to Infection Among Residents of
Charters Towers, Queens Land, Australia
Overall Prevalence: 24.6% of 797
Nearby
Dengue
Case?
No:
14.3% of 481
YES: 40.2% of 316
YES:
27.7% of 83
House Screened?
No:
44.6% of 233
NO:
20% of 60
YES:
47.8%
of 22
Water Tank Nearby?
NO:
34.6% of 81
YES:
50% of
152
Use of Knockdown Spray? 21

23. Section B
Units of Identity and Change 22

24. Units of Identity, Practice,
and Solution
 Individual
 Family
 Group/association
 Neighborhood
 Organization/institution
 City/county/district
 State/ethnic group/nation/continent, etc 23

25. Defining the Units  Units of identity are determined by the
people themselves—they identity their
own sense of “belonging” which
expands over life time
Continued 24

26. Defining the Units  Units of practice are those units of
identity that helping professionals
chose to work with
Continued 25

27. Defining the Units  Units of solution are those units of
identity that have the skills and
resources to solve the problems
experienced by the units of practice 26

28. Types and Nature of Change
Natural Change
 Changes that occur due to normal
biological and physical processes and
people’s adaptation to those changes
 Changes brought about by the aging
process—an increase in motor skills
as a child grows and a
decrease among the elderly
 Changes in activity brought on by
seasonal-weather changes 27

29. Types and Nature of Change
Planned Change
 The intentional effort of human beings
to bring about changes in their
physical and social environments to
achieve their goals
 Can also be referred to as
interventions; includes efforts to “help”
others 28

30. Different Approaches to
Planned Change
 Power-coercive
 Empirical-rational
 Normative-reeducative 29

31. Power-Coercive  The perspective that change occurs
primarily when force is applied
 This may be physical or legalistic
 It may also occur because of the
power struggle between haves and
have nots
Continued 30

32. Power-Coercive  Strategies can be non-violent
but involve confrontation
 One may also work within the political
system and through the power elite
 The basic philosophical assumption
about change is that people will not
change unless pushed 31

33. Empirical-Rational  The perspective that human beings
are rational decision makers and will
act in their best interest when
appropriate information is presented to
them by experts
 Changed strategies draw on basic
research and rely on dissemination of
knowledge, personnel management,
systems analysis, etc
Continued 32

34. Empirical-Rational  The basic philosophical assumption
about change is that people, once
provided with scientifically correct
information, will rationally chose the
“best” course of action 33

35. 34

36. Normative-Reeducative
 A view that people are self-actualizing
and capable of diagnosing and solving
their own problems
 The change agent facilitates self-
examination and commitment to action
 These strategies stress dialogue
 There is a collaborative approach
between client and change agent
Continued 35

37. Normative-Reeducative
 Behavioral and social science methods
are particularly important
 There is an emphasis on developing
problem-solving capacities and
personal/system growth
 The basic philosophical assumption is
that people are self-actualizing 36

38. Chin & Benne Kellman Schaller Rothman Comparison of Approaches Author
Empirical-
Rational
Normative-
Reeducative
Power-Coercive
Kellman
Compliance
Internatization
Externally
Motivated
Externally
Motivated
Internally
Motivated
Schaller
Locality
Development
Social
Planning
Rothman
Social Action 37

39. Order of Change  First order – Changing from one way of
behaving to another (substituting);
for example, change from smoking
cigarettes to chewing nicotine gum
Continued 38

40. Order of Change  Second order – Change in ways of doing things,
ways of living; for example,
cigarette smoker changes lifestyle
to reduce stress and pressure to
smoke 39

41. Section C
Examples and Links 40

42. An Example Micro The health worker Change substitutes a video for
In the
Clinic
First Order Change
Second Order Change
Micro
Change
The health worker
substitutes a video for
providing health
information to patients
instead of individual
instruction
The health worker involves the
patient through counseling in
identifying his/her own
problems and finding
solutions
Macro
Change
Administrators design a
new record keeping that
format that is substituted
for the old forms
The clinic institutes home-
based records 41

43. A Malaria Example Macro Change First Order Change Second Order Change
Treatment
First Order
Change
Second Order Change
Micro Change
Substitute herbs for
‘modern’ anti-
malarial drugs
Mothers raking initiative to seek
prompt treatment from village
health worker instead of waiting
passively for illness to progress
Macro
Change
Provision of Clinics
by government as
an alternative to
Indigenous
Practitioners
Community participation in
organization and management of
local drug revolving fund to
ensure supplies of anti-malarial
drugs 42

44. More Links among Theories
Bienens Model
ORDER of CHANGE
TYPE of CHANGE
Modernization
First Order Change
Planned Change
Second Order
Change
Transformation
Planned Change
Survival
Adaptation
Natural Change 43

45. Levels of Prevention  What health technologies are available
to prevent of ameliorate problems? 44

46. Prevention/intervention
Levels of
Prevention/intervention
 Health promotion
– Developmental, a wide impact on
health
 Specific protection
– Preventive specific diseases—for
example, polio immunization
 Early detection
– Identify asymptomatic stage
treated more effectively
Continued 45

47. Prevention/intervention
Levels of
Prevention/intervention
 Limitation of disability
– Prompt treatment to prevent
complications
 Rehabilitation
– Interventions to ameliorate
complications, disability
 Maintenance
– Chronic conditions, prevent crises
and premature death 46

48. Comparing Levels of Health Behavior and Levels of Prevention/Intervention
Promotion
Specific
Protection
Early
Detection
Limitation
Of Disability
Rehabilitation
Maintenance
Preventive health
behavior
Illness
behavior
Sick-role
behavior
At-risk
behavior
Modernization 47

49. Measuring Health Behaviors at the Different Levels
From CDC’s Behavior Risk
Factor Surveillance System 48

50. Health Promotion Behaviors
Eating 5+ servings of fruits & vegetables daily 35 30 25 20 15 10 5 28 29 19
Male Female < HIGH
School
HS/GED Some
Post
College
Source: CDC – Behavior Risk
Factor Surveillance System
Education Gender

51. Specific Protection Behaviors
Flu Vaccine Past Year 40 35 30 25 20 15 10 5
White
Black
Other
Hispanic
College
<HighSchool
HS/GED
SomePost
Source: CDC – Behavior Risk
Factor Surveillance System
Ethnic Group Education

52. Early Detection Behaviors
Having a BP check in the past year
100 80 60 40 20
Male Female White
Black Hispanic
Other
Source: CDC – Behavior Risk
Factor Surveillance System
Sex Ethnic Group

53. Limitation of Disability Behavior
Did Cost Prohibit Health Service Seeking?
(percent who said yes) 17
11 10 9 6
White
Black
Other
Hispanic
College
<HighSchool
HS/GED
SomePost
Source: CDC – Behavior Risk
Factor Surveillance System
Ethnic Group Education

54. Section D
The Ecological Model: Avoiding Blaming the Victim by Identifying the Locus of Needed Change 53

55. Ecological Model  Intrapersonal factors
– Characteristics of the individual
 Interpersonal processes and
primary groups
– Formal and informal social
networks and support
 Institutional factors
– Organizational characteristics and
rules
Continued 54

56. Ecological Model  Community factors
– Relationships among organizations
and networks
 Public policy and laws
– At local, regional, and
national levels 55

57. Example: Adolescent Sexual Behavior
 Intrapersonal
– Beliefs about vulnerability; gender
differences in sexual initiation and
attitudes
 Interpersonal
– Peers validate sexual behavior;
families may influence sexual
initiation
Continued 56

58. Example: Adolescent Sexual Behavior
 Institutional
– Poor access to reproductive health
services; clinics not “youth friendly”
 Community norms
– Double standards for male and female
 Public policy
– Punitive instead of educational
approach; public avoidance of
information sharing 57

59. Example: Teenage Drinking
Policy
88% US Senators accepted alcohol PAC
money in 1998; drinking age restriction laws;
laws viz drunk driving-all focus on individual
Institutional
$700 million/yr in beer
advertising; how much
speed on drug education
In schools?
Interpersonal
10 million teens drink,
1/3 binged in past month, risk beliefs, etc.
Interpersonal
Only 3% parents think their
teen drinks; others help buy
the drinks as underage
Community
Alcohol easily available;
norms for alcohol drinking-
Social, stress, etc. 58

60. Example: Insecticide-Treated Nets
 Intrapersonal
– Net use, beliefs,
perceptions
 Interpersonal
– Household
power issues
 Community
– Ability to
organize
Photo: CDC
Continued 59

61. Example: Insecticide-Treated Nets
 Organizational
– Public
resources,
private sector
role
 Policy
– Taxes, tariffs,
priorities on
prevention
Photo: CDC 60

62. ITNs in Context  Nets come in various sizes and cost $3.00
 Insecticide treatment with deltamethrin
takes place every six months and
costs $0.50 per net each time
Continued 61

63. ITNs in Context  Community-based distribution
programs take many forms including
local distributors, local production,
community involvement
 Cultural contrast—Herbs are the best
prevention since one cannot avoid
“causes” of hard work in the hot sun 62

64. Intrapersonal-Level Questions
 What are the perceived benefits?
– Beautify home
– Keep warm
– Give privacy
– Kills other insects
Continued 63

65. Intrapersonal-Level Questions
 What are perceived constraints?
– Costs, continual
– Heat in dry season
– Perceived need lower when
mosquitoes few
– Prefer alternatives: Window
screens, aerosols
Continued 64

66. Interpersonal-Level Questions
 What is the family structure?
– Decision making
– Allocation of resources
– How many nets needed?
– Can we re-treat all nets?
Continued 65

67. Interpersonal-Level Questions
 Small children are most at risk, but do
they get priority in the household?
 What social groups in community
promote nets and other health
innovations? 66

68. Community-Level Questions
 Are there local marketing mechanisms?
 Are there associations that could take
responsibility?
 Is there a history of participation and
organization?
 How will overall leadership structure
impact on programs?
 Are there sub-group or ethnic tensions? 67

69. Re-treatment Can Be a Community Affair If One Accounts For …
 Subsections and neighborhoods
 Locations where there is water and a
place to dry
 Ethnic groups
 Gender roles
 Leadership 68

70. Organizational-Level Questions
 Is malaria (and prevention) a priority
for the health services?
– Will nets be free, subsidized, or at
cost?
– Will distribution be house-to-house or
central?
 What funds and staffing are allocated to
malaria control?
Continued 69

71. Organizational-Level Questions
 Is there planning and
monitoring capacity?
 What is the potential role of the private
and NGO sectors?
 What of other development sectors—
finance, education, commerce,
development, etc.? 70

72. How Health System Organizes Delivery Mechanism Affects Re- treatment
H2H free Central free Fee Charged
Kilifi District, Kenya: Snow et al., 1999 71

73. Policy-Level Questions
 Is there a national malaria policy?
 Is provision of nets and insecticides part
of government policy, including pricing
issues?
 Is the private sector included?
 What are customs regulations concerning
import of net materials—taxes, tariffs?
 Who makes these decisions—what
vested interests?
Copyright 2005, The Johns Hopkins University and Bill Brieger. All rights reserved. Use of these materials permitted only in accordance with license rights granted. Materials provided “AS IS”; no representations or warranties provided. User assumes all responsibility for use, and all liability related thereto, and must independently review all materials for accuracy and efficacy. May contain materials owned by others. User is responsible for obtaining permissions for use from third parties as needed. 72