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1 This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike License. Your use of this material constitutes acceptance of that license and the conditions of use of materials on this site. 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. JOHNS HOPKINS BLOOMBERG SCHOOL of PUBLIC HEALTH

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

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 4 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

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

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 Continued 7 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

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 9 Image courtesy of the Carter Center

11 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 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 12 More Dimensions 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

14 13 More Dimensions 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

15 14 More Dimensions 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

16 15 More Dimensions 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

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 17 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

19 Continued 18 The Social Construction of Illness and Disease Patients suffer illnesses Physicians diagnose and treat diseases Behavior is influenced by peoples perception of their illness experiences or the illnesses they wish to avoid

20 19 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, dont stand in a one-to-one relationship

21 20 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

22 21 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 House Screened? Water Tank Nearby? YES: 27.7% of 83 No: 44.6% of 233 NO: 34.6% of 81 YES: 50% of 152 Use of Knockdown Spray? NO: 20% of 60 YES: 47.8% of 22

23 22 Section B Units of Identity and Change

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

25 Defining the Units Units of identity are determined by the people themselvesthey 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 26 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

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

29 28 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

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

31 Continued 30 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

32 31 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

33 Continued 32 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

34 33 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

35 34

36 Continued 35 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

37 36 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

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

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 39 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

41 40 Section C Examples and Links

42 41 An Example In the Clinic Micro Change First Order ChangeSecond Order Change Macro 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 Administrators design a new record keeping that format that is substituted for the old forms The clinic institutes home- based records

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

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

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

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

47 46 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

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

49 48 Measuring Health Behaviors at the Different Levels From CDCs Behavior Risk Factor Surveillance System

50 Health Promotion Behaviors Eating 5+ servings of fruits & vegetables daily Male Female < HIGH School College HS/GED Some Post Source: CDC – Behavior Risk Factor Surveillance System Education Gender

51 Ethnic Group Education Specific Protection Behaviors Flu Vaccine Past Year White Black Hispanic Other { "@context": "http://schema.org", "@type": "ImageObject", "contentUrl": "http://images.slideplayer.com/730259/2/slides/slide_50.jpg", "name": "Ethnic Group Education Specific Protection Behaviors Flu Vaccine Past Year 31 25 24 27 35 29 27 30 White Black Hispanic Other

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

53 Limitation of Disability Behavior Did Cost Prohibit Health Service Seeking? (percent who said yes) White Black Hispanic Other { "@context": "http://schema.org", "@type": "ImageObject", "contentUrl": "http://images.slideplayer.com/730259/2/slides/slide_52.jpg", "name": "Limitation of Disability Behavior Did Cost Prohibit Health Service Seeking.", "description": "(percent who said yes) 9 13 16 14 17 11 10 6060 White Black Hispanic Other

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

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

57 Continued 56 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

58 57 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

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

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

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

62 Continued 61 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

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

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

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

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

67 66 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?

68 67 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?

69 68 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

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 70 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.?

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

73 72 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 materialstaxes, tariffs? Who makes these decisionswhat 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.


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