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This is the second part of module one, dealing with the ecological model.

In the previous lecture, we've outlined how the social and

behavioral sciences are important for not only understanding, but planning and

delivering primary healthcare and public health programs.

In this lecture we'll look at the underlying conceptual framework for

the course which is the ecological model.

This will begin by looking at human behavior

as the core of the model and understanding why people behave the way they do.

How behavior relates to health.

Section A, Dimensions of Health Behavior.

It's important to recognize that disease occurs in an ecological context.

Its context dependent disease is related not only to

the presence of causative agents, but has very much to do with

the way people behave and expose themselves to these agents or

prevent themselves from coming in contact with these agents or situations.

In particular, as we mentioned before, this ecology relates to the social and

cultural practices of a particular community, which in turn have been defined

by the physical and social environment in which people find themselves.

So cultural practices, as we said,

efforts to prevent mosquitoes from biting people using burning local herbs.

Or beliefs about worshipping certain divinities

to influences how people do or do not come in contact with agents of disease.

Biological and cultural traits

have been found to be adaptive against disease and maybe selective for.

Human behavior plays a significant role in the etiology of every major

category of disease, not just infectious diseases, but also chronic diseases.

This may seem obvious at first sight, but many times, when we're planning disease

control programs, we're more concerned about technologies that try

to influence the causative agents or the environmental conditions and

forget about the fact that it's human beings who choose to use

the technologies or human beings that put themselves in certain situations are not.

Whether we're talking about issues such as cancers and

people's exposure to certain foods or environmental conditions,

whether we're talking about infectious agents and people's hygiene behaviors.

Whether we're talking about chronic conditions such as hypertension and

diabetes where diet and activity levels are very important in understanding

how some people experience a disease, how people controlled the disease.

So understanding the influence of human behavior is crucial

to planning health and public health programs.

And this requires us to have a social science perspective on health and disease.

In particular, it's important to analyze human health behavior.

As we said,

behavior is not just a small piece of the puzzle that can be removed and changed.

We have to look at it in a broader context of people's

daily life patterns, their belief systems.

The slide with a small cartoon it's taken from a comic book that is used by

the Guinea Worm Eradication Program in Africa, so

the school children can be involved in the control efforts.

The picture shows a young boy filtering pond water through a cloth filter

into a family water pod and is explaining to his friends that

filtration will remove the cyclops which carry the Guinea worm larvae.

Now of course cyclops are minute.

They can barely visible to the human eye.

You can see it with the aid of a hand lens but

obviously most people in the village, especially if the water is muddy,

would not see or know that there are cyclops in the water.

So knowledge alone, of course, is not adequate to influence behavior but.

Here is a specific behavior that could prevent guinea worm,

filtering this water before drinking.

It's important to use this as an example

to understand that behavior is a complex of actions.

Behavior is not simply something that is turned off and on like a light switch.

But it has various dimensions.

The next slide shows that one of the important dimensions is frequency.

Some behaviors can be performed once, some behaviors need to be repeated at certain

specific times of day for a number of days over time.

In particular, filtering water to prevent guinea worm,

unless there is a new well installed in the village.

As long as people are using the pond water,

this filtering has to be done every time the family collects water for drinking.

In contrast, some behaviors, such immunization against measles,

may only have to be done once during the first year of a child's life but

behaviors that are habitual are much more difficult to encourage and influence.

Another dimension of behavior is duration.

How long does it take to perform this behavior?

Each filtering, after having collected the water, may take 10 to 15 minutes,

the process of collecting, putting on the filter,

making sure that it's in the right position, pouring the water slowly.

And again, if this time demand, duration of a particular

behavior is inconvenient, it may influence people's willingness to adopt it.

Okay, another dimension is the question of timing.

When exactly must this be done?

In terms of filtration, this must be done immediately after the person

reaches the home because if the water is allowed to sit, a child may come up and

take a cup of water out of the bucket before it's been properly filtered.

Another dimension is form.

What form the behavior takes?

And the implication here is it involves various steps to be done correctly.

So, what we have is actually, a complex of steps that lead to the specific behavior.

Again, filtering is not a one step deal where you're turning on or

off, putting on or on a filter.

It's a process of one, inspecting the filter for holes.

Even a small pin prick is enough to allow the cyclops to go through.

And if, of course, people having washed the filter, hung it up to dry, if they

hung it on a bush that has thorns, they may wind up with a hole in the filter.

So, these need to be inspected for.

If the filter has holes, it needs to be replaced.

The filter needs to be placed right side up on the mouth of the pot,

we found out that if the filter has been removed and is kept in a damp place or

folded up for even a day, the cyclops could survive in the moisture.

So if the filter is put on one side up One day and

is not properly dry and turned over and put the other side up the next day,

cyclops surviving in the dampness of the filter could be

put into the pot, when new water is poured over it.

Okay, the filter needs to be attached.

There are different ways of doing this.

Some cloth filters are made with drawstrings.

Some you have to take another string and tie it around the filter.

Some are made with elastic or rubber, so that they can be stretched over the pot.

So they are different things, but

definitely the filter has to be strongly attached to the pot, so

that when the water is poured in it won't fall into the pot.

After the filtration, the filter cloth has to be removed carefully.

Again if it flips over,

cyclops that have been collected into the cloth could be turned over into the water.

Ideally afterwords the filter should be rinsed with clean water.

This not only removes the cyclops that would have been collected, but also dirt

particles, which can clog up the filter and make the duration of filtering slower.

Ideally, the filter should be dried in the sun, stored in a safe place, so

that children will not get it and play with it, make holes in it.

From time to time it needs to be washed with soap, if it's dirty.

And it needs to be replaced at least once a year or as often as holes develop.

And of course this depends on how frequently it's used, larger families that

collect drinking water more often may find that their filters wear out sooner.

And all of these steps need to be continued over and over again

as long as water is collected until guinea worm is eliminated from the village or

until the village has been supplied with a proper protected well.

Another issue of dimensions of behavior is the fact that people have alteratives.

There are a competition among behaviors.

This becomes evident when we look at marketing.

The term social marketing has been used for promotional efforts,

to try to get people to use a socially desirable good, such as the oral

rehydration therapy, such as immunization, such as vitamin supplements etc.

One thing that is often overlooked when we do public health based on marketing

is that we assume that because a product is quote, good for people,

unquote, that everyone will want to buy it or use it.

What happens in reality, if we look at something like soft drinks,

is that a company promoting sale of soft drinks recognizes that

they are not the only manufacturer of soft drinks.

A company selling cola drinks recognizes that there are three or

four other companies marketing cola drinks.

They recognize that not everybody likes cola.

Some people may prefer an orange soft drink or a lemon lime soft drink.

They also recognize that soft drinks are not the only beverage that people like.

Some people may prefer iced tea, some people may prefer milk.

So when companies are planning to promote a particular product,

they recognize that there's competition, and

they recognize that if they are lucky, they will get a certain market share.

When we're promoting health related products, we assume that they're good for

everyone and that there will be few people

who will reject the thing that most people will want it or need it.

In fact when we look even at the thing of the example of the guinea worm cloth

filter, we recognize its still there are alternatives that people can choose for

managing their domestic water supply.

Part of this is based on, again, culture,

people's perceptions of what is clean, what is hygienic in many villages,

as long as water appears to be clear, it is acceptable.

People use alum to settle their water.

They can buy little chunks of alum in the market, put this in their water and

it will settle the particulate matter and it will appear to be clean.

It doesn't settle the cyclops, but people would be satisfied with it.

Some people that don't want to afford the alum

can just allow their drinking water to stand for some hours and it will settle.

So, some people were satisfied with that.

And that, in a way, becomes a competition for

the behavior of filtering, because the visible effects to people are the same.

And if they believe the guinea worm is already in their body,

they're born with it, it's like a tendon or a nerve.

And if their perception of what is clean water is that it's clear to the eye,

then filtering may or may not be an acceptable alternative.

Not everyone will filter because they may feel that what they're doing to their

water is adequate.

Another important to mention of behavior is complexity.

As this relates to form, but basically complexity has to do with the steps,

the skills, the difficulty of carrying out a particular behavior.

Taking a piece of alum and swishing it around in the water is relatively simple

compared to the process of attaching a filter.

Pouring the water carefully and caring for the filter.

So, filtering process is more complex

than the process of allowing the water to settle.

And again, this may affect people's choice and their behavioral alternatives.

Another important dimension to be aware of is congruence.

How similar or different is the recommended health-related behavior

to what people are doing already?

What is acceptable and believable in their culture?

Okay, in one way, filtering does meet with community preferences for clear water.

The process of filtering is similar to what people do to sieve corn starch

when they're making porridge.

But on the other hand,

the concept of filtering to prevent disease is an alien concept,

because people believe that disease like guinea worm is already in their body.

People will say well, if the guinea worm is in the water as big as it is,

we could see it.

Finally, the dimension of linkage is to be considered.

Behaviors are not isolated events.

They are linked with and influence other behaviors.

So we are concerned about what are the various, in many communities women and

children but, particularly women are responsible for collecting and

managing domestic water supply.

So their water collection and treatment behaviors must be considered

in broad context of all of the different domestic responsibilities and

behaviors that they must carry out from a day-to-day basis.

How does adding these extra steps of filtering fit in or

conflict with their existing responsibilities.

Does it make sense in terms of what they're used to doing?

Do they have the time for it?

Does it conflict with what they're already doing?

And so here again, in summary, we have various factors that must be considered.

The behavior is not a simple offer on process, but individual behaviors

must be considered in terms of their frequency, how often it's done,

the duration, how long it takes, any specific required timing, medicine for

a good example, taking medicines three times a day before meals.

The form, the steps involved in the specific behavior.

Whether there are alternatives to compete with the recommended health behavior.

How complex or difficult the behavior is to perform?

How congruent or similar it is to what people are used to in their culture?

And in terms of how the behavior is linked with other activities and

behaviors and beliefs that people have.

And engages in sick role behavior.

Sick role concerns all of those actions that people take, so

that they can recover from the illness.

Now, again, the issue of role Draws from our understandings of sociology.

People have roles that they must perform in a society.

We've talked about the roles of a mother in a house,

in terms of collecting and filtering water.

There are roles that people have in families, mothers, fathers,

husbands, wives, children, siblings, other extended family members.

People have economic roles,

that are often reflected in the occupational names given to these.

People have roles as community members, in social groups.

They may be a chairperson or a treasurer of a group.

So in terms of social relationships, people have different roles and

responsibilities.

There are also deviant roles in the society.

To be labelled a thief implies that a person is carrying out a deviant role.

But also, to be labelled as sick is a deviant role.

A social group, a society cannot afford to have many people

occupying a deviant role at once, because that social order would collapse.

Whether it's the deviance of thieving and stealing, or

whether it's the deviance of people being sick.

We've found that, if many people are sick from Guinea worm in a particular

community, there are fewer people able to work, to be able to care for

children, to bring in money for the household.

So when many people are sick at once, the society is threatened.

That's why, in many societies, healthcare has become a social institution.

And there are specific people designated as gatekeepers who can determine

who is allowed to be carrying out the role of sickness.

When someone is sick they require, possibly, extra or

different kinds of food.

They require care that may cost money.

They may need to be relieved from other roles and

responsibilities in the family in order to focus on trying to recover.

So, societies make rules and regulations about who is allowed to be sick.

One very common example is, a person who is sick often

requires a certificate from a physician to present back at school or

back at the workplace to give them permission to have been sick.

So this idea of controlling sickness

is very much an important part of the sick role.

Once a person has been declared by an official gatekeeper as sick,

the role and responsibilities of that sick person is, as we said,

to take all necessary actions to recover, and therefore return to his or

her normal role and responsibility in the society, in the family.

And engages in sick-role behavior.

Sick-role concerns all of those actions that people take so

that they can recover from the illness.

Now again, the issue of role draws from our understandings of sociology.

People have roles that they must perform in a society.

We've talked about the roles of a mother in a house,

in terms of collecting and filtering water.

There are roles that people have in families.

Mothers, fathers, husbands, wives, children,

siblings, other extended family members.

People have economic roles that are often reflected in the occupational names

given to these.

People have roles as community members, in social groups.

They may be a chairperson or a treasurer of a group.

So, in terms of social relationships, people have different roles and

responsibilities.

There are also deviant roles in the society.

To be labeled a thief as a deviant implies that a person

is carrying out a deviant role.

But also, to be labeled as sick is a deviant role.

A social group, a society, cannot afford to have many people

occupying a deviant role at once, because that social order would collapse.

Whether it's the deviance of thieving and stealing, or

whether it's the deviance of people being sick.

We've found that, if many people are sick from guinea worm in a particular

community, there are fewer people able to work, to be able to care for

children, to bring in money for the household.

So when many people are sick at once, the society is threatened.

That's why, in many societies, healthcare has become a social institution, and

there are specific people designated as gatekeepers,

who can determine who is allowed to be carrying out the role of sickness.

When someone is sick, they require, possibly, extra,

or different kinds of food.

They require care that may cost money.

They may need to be relieved from other roles and

responsibilities in the family in order to focus on trying to recover.

So societies make rules and regulations about who is allowed to be sick.

One very common example is: a person who is sick often

requires a certificate from a physician to present back at school, or

back at the workplace, to give them permission to have been sick.

So this idea of controlling sickness

is very much an important part of the sick-role.

Once a person has been declared by an official gatekeeper as sick,

the role responsibilities of that sick person is, as we said,

to take all necessary actions to recover, and therefore return to his or

her normal role and responsibility in the society and the family.

Finally, we have at-risk behavior.

This is something that has become much more common as populations age,

as chronic disease becomes a more common part of life.

We do not have cures for many chronic diseases such as hypertension and

diabetes.

We can control them.

So, even if a person feels ill, they've been having headaches,

they seek healthcare.

The doctor checks their blood pressure,

turns out that they have elevated blood pressure.

They are prescribed certain antihypertensive drugs,

certain dietary restrictions, but the hypertension is not going to go away.

This is the essence of at-risk behavior or

health maintenance behavior, is that the person, throughout the rest of his or

her life, will have to make changes, and maintain those changes

in order to maintain as high a level of health as possible,

knowing that the person will not return to the pre-illness stage.

So what the person is preventing at this level is untimely death.

These changes that are necessary oftentimes separate the person

from friends and relatives, the dietary changes,

things that the person is not allowed to do, additional things that the person

must do in terms of, for example, administering insulin, are all new.

And all are habitual behaviors.

They may not be congruent with what the person's believed before.

And so this presents a particular challenge.

But again, the important part to remember is,

in terms of understanding human behavior and health,

in order to plan health education programs that compliment our public health efforts.

We need to focus not just on preventive actions, but recognizing that there is

human behavior involved in illness and healthcare seeking.

Human behavior issues involved in sick-role,

in terms of disease management, illness management, and recovery.

And also in terms of health maintenance in the long term.

So our health behavioral interventions and

planning need to consider all of these levels.

We've talked about the different types of health behavior,

different levels of health behavior.

And in particular, we mentioned illness behavior.

It's important to realize that there is a difference between illness and disease.

Patients suffer illnesses, but physicians diagnose and treat diseases.

Illnesses are experiences of disvalued changes in states of being and in social

function, whereas diseases, in the scientific paradigm of modern medicine,

are abnormalities in the structure and function of body organs and systems.

So defined, illness and disease do not stand in a one to one relationship.

The example of guinea worm disease is instructive.

As a disease, guinea worm, is known as dracunculiasis medinensis.

It's a meter-long subcutaneous water borne helminthic infection.

As we've mentioned before, people get it by drinking pond water

that contains small crustaceans, cyclops, which have swallowed guinea

worm larvae from other infected people who wade in the pond.

In contrast,

people in southwestern Nigeria experience the illness called Sobia.

People believe that sobia is part of their body.

It can move around, causing pains and aches.

At certain points, rashes may appear and people call this admission sobia,

meaning that it's heralding the onset of the worm.

The aches and pains are called sobia waka.

Now people believe that the worm,

in moving around, eventually, may come out of the body or it may not.

When it comes out of the body, when it's emerged through a blister and

starts depositing larvae when people wade in the stream, this is the point at which

the illness of sobia and the disease of guinea worm merge.

But generally, what we're concerned about is when people experience illness in

a cultural context, it may not have the same definition, seriousness,

concern, as the medical profession would believe in terms of the disease.

In terms of epidemiology, if guinea worm has not come out of the skin,

it is not of public health importance, because it cannot spread.

But the illness, sobia, is believed to be in the body, and causing aches and pains.

Ironically, from the patient's point of view, these exit pains are important.

And x-ray evidence from Saudi Arabia, which has not had guinea worm for many

decades, has shown that people complaining of rheumatism, arthritis, pains and

aches, on x-ray have shown to have calcified guinea worm in their joints.

It did not come out, but it was still there.

So, it's important to be aware of these differences.

When people complain of an illness, it may not be the same thing.

But again, it may harbour some important experiences of discomfort for people.

So, we need to be aware of these experiences of local,

culturally defined illness as the ones that motivate people in illness behavior,

in treatment seeking behavior.

The next slide looks at some issues of behavior and

social ecology in terms of the spread of dengue fever in Australia.

Dengue's carried by a mosquito, it breeds in small collections of water,

such as water pots, whereas the mosquito, the anopheles mosquitos that

carry malaria prefer more open ponds that are clean and get sunlight.

The aedes aegypti that carry dengue prefer dark places,

old broken bottles and cans, poles, and tree trunks, etc.

So, this slide shows that there are certain characteristics of people who were

more likely to have been found to have dengue due to the certain behavioral and

ecological conditions.

Living near another person with dengue was an obvious choice,

because if other people in the environment are getting it,

then you might be likely to be exposed to the same conditions.

One thing that's subsequently distinguished people in that particular

environment was whether they had taken the effort to screen their house.

Did they have windows and door screens?

Okay, another distinguishing factor was whether there

was a water tank nearby in one of the buildings or not.

Another factor was whether or

not people used insecticide sprays to kill mosquitoes.

So, these were some behaviors that distinguish those who were

likely to have the disease or not.

What's also important is that each of these behaviors implies a broader

understanding of the social and economic conditions in which people live.

How many people can afford to screen their house?

How many people can afford to buy the sprays?

How many people know that the mosquitos are at cause and realize that the water

tanks in their houses and apartment buildings are breeding sites or not?

How many people know that mosquitos are actually a cause and

are willing to buy the insecticides?

So, we can, in an epidemiological study,

identify those behaviors that are associated with the spread of disease.

What we need beyond that are the sociological,

anthropological studies to find out why people do the behaviors that they do.

Dimensions of Health Behavior

Diagnosing Health Behaviors for Global Health Programs

Meet the Instructors