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.
Theories in Practice
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The Health Belief Model and Social Learning Theory
In this module you will be introduced to the Health Belief Model as well as the Social Learning Theory, which will allow you to better understand how to complete your Peer Review in this module, as you will be completing one of each with a case study provided.
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William Brieger, DrPH
Professor, Health Systems Program of the Department of International Health
[MUSIC]
In the previous lecture, we looked at the different variables or components that
could be put together in theories or models to help explain health behavior.
In this lecture, we'll start to look at some of the common theories and
models that are used by health educators
to plan programs to help people behave in healthier ways.
The first slide shows the results of a study that reviewed different
health education programs and articles written about them.
And found out that the most common theory of all that's used is the health
belief model.
This is followed by social learning theory.
Subsequent to that is the concept of self efficacy,
which in fact is a major component of social learning theory.
So, in fact, if the two of those were combined,
that would be the most popular model used in health education research.
The third is theory of reasoned action.
And as we mentioned, later we will deal with the transtheoretical,
or non-theoretical models, the stages of change.
While there are many, many theories developed by social psychologists,
by health educators, it’s not possible to deal with all of them in this course.
But what we want to do is to look at those that are very common in the health
education and the public health literature, and understand those.
To examine them carefully to see what each one can contribute to our
understanding of health behavior.
To make comparisons and
to use them as tools to help diagnose or understand health behavior.
The first model we'll look at is the health belief model.
The health belief model has several basic components,
starting with a recommended health action.
So we will see health belief model is really the only major model
that looks at health behavior as a specific outcome or dependent variable.
Of course, health belief model could be adapted in terms of recommended action for
other activities, such as students in primary schools, mastering reading.
Such as agricultural workers planting new kinds of crops or using pesticides.
But in our particular case, we will use it in the way it was developed.
The health belief model was developed in the 1950s by social
psychologists working in the US public health service who were trying to
understand why people would engage in certain preventive activities.
Such as seeking immunization, such as going for
screening tests for tuberculosis and other conditions.
So, the recommended action was focused
clearly on existing public health interventions.
Will people get their child immunized?
Will people attend screening programs?
Another important component is the issue of perceived threat,
that we have talked about.
Is the child susceptible to measles?
If the child gets measles is it a serious condition?
In addition to looking at perceptions of the illness or the disease,
the health believe model also examines people perceptions of
the recommended action itself.
And this comes in a section called perceived benefits barriers,
perceived benefits and constraints to taking the action.
This is very similar to the concept of outcome and value expectancies,
that we've talked about earlier.
They include such concerns as the perceived efficacy of the intervention.
Will this vaccine really work to protect my child?
Issues like perceived costs.
How expensive is seeking vaccine?
Are the vaccines free?
But does it mean I take off time from work and lose money?
The perceived benefits, etc.
Another component of health belief model are modifying factors.
These include social and demographic characteristics.
And structural factors, such as knowledge, personality.
Finally, there is a component known as cues to action.
These are stimuli that may be internal or external that help when
a person perceives a threat of the illness to go ahead and take action.
Health belief model is, in many ways,
a decision making paradigm within the context of modifying factors.
Which means in the context of a particular social, economic, or
ethnic group, people make decisions comparing threat versus benefits.
Thus, it draws heavily on the basic concept of force field.
One does make a cost-benefit analysis.
One does tend to weigh the likelihood that the recommended
action will produce a good effect versus the perceived seriousness of the illness.
Is it worthwhile?
The keyword in health belief model is perception.
We're not talking about threat or risk from an epidemiological sense.
We know that children below a certain age may be
at risk if they have not been immunized.
But then, again, the question of the mother's action or the parent's action
to get the child immunized has to do with their perception, their likelihood.
We use the example of malaria.
Some people do not see a connection between febrile convulsions and malaria.
We know that children are at risk of convulsions when
they do have high temperature.
But since people in some communities believe that convulsions are another
disease caused by cold, and they believe that malaria's caused by heat,
they may not perceive their child at risk when the child has malaria.
So this word, perception, is very important.
We are talking about recommended action to control or prevent or treat a disease.
At the same time,
people are perceiving threat in relation to their cultural perceptions of illness.
We have four examples of health belief model in the slides that follow.
The first slide looks at perceived threat of guinea worm disease.
In the communities in West Africa where I've worked,
people believe that they are highly susceptible.
This is clearly tied in with the notion that guinea worm is part of the body and
that people are born with it.
So it's quite easy for someone to have the manifestation
of the disease of the worm coming out of their body.
Clearly, people see it is a very serious condition.
There are local songs that talk about guinea worm.
People sing and beg guinea worm not to knock them down.
The people that were knocked down last year cannot walk.
So this shows that people do see it in their own community as a serious problem.
Thus, the combination of high susceptibility and
high seriousness results in a high perceived threat from this disease.
And yet, as you can see in the drawing, the likelihood that they will shelter
their pond water to prevent this disease is low.
Again, as we said, the health belief model balances the perception about the illness
or disease itself with people's attitudes toward The recommended action.
People see some benefits of filtering the water.
It can remove visible dirt particles and debris.
It's made easily available by village health workers in every village.
One of the designs that were used included an elastic band sewn around the filter so
it would be easy to put on the pot.
But the constraints are a bit more formidable
because guinea worm is already in the body, according to local beliefs,
it's doubtful whether filtering water could prevent it.
If people want clear water, their inexpensive alternatives,
such as using alarm or simply allowing the water to settle.
And some people take the health workers at their word.
Clean water, safe water is in fact the best solution and
so they consider that when health workers try to distribute filters
that they are only providing them with the second rate alternative.
They would prefer to have the wells.
So the likelihood of them filtering is low because they doubt the value or
efficacy of the filtering.
These perceptions are modified by several factors.
There are people in the community, who because of their contact the trained
village health workers do know believe they're getting worms in the water and
they are more likely to accept the benefits of filtering.
On the other hand, if the filters are costly,
people may not buy them because of their low economic status.
Fortunately, recognizing the usefulness of filters,
the Global 2000 WHO have been able to get
a subsidiary of DuPont to donate the filter cloth to overcome that barrier.
Another factor to consider are household roles.
Who is it that must carry out all this filtering?
Most often is the mother, the woman in the house, and
she has many other responsibilities and filtering may or may not be convenient.
Educational levels are low in many of the rural communities,
or people don't have education at all.
And this influences how they perceive the disease, how they perceive filtering.
Assuming people feel threatened by guinea worm and
are considering the possibility of filtering, cues to action that may come up
include promotional activities via the village health worker.
Who, as a neighbor, can go house to house encouraging people to use it.
People can see their neighbors buy the filter and use it.
They can see people who suffer from getting worm.
And may be stimulated to try to prevent the problem in themselves.
The next slide looks at the issue of purchasing bed nets to prevent malaria.
In terms of perceptions of malaria,
we've talked about our explanatory models in different cultures and
how people believe that malaria is caused by work, heat, sun, dust.
And it's a condition that people believe is quite common, that they're susceptible.
In surveys or group discussions, people say yes,
it's not unlikely that I would have two or three episodes of malaria a year.
But people perceive that malaria itself is a minor condition, an inconvenience.
They can still continue to work.
Or with some herbs or drugs, by the next day, they can resume work.
Their knowledge, as a modifying factor,
often does not include the negative consequences, such as a fever or
convulsions, cerebral malaria in children, prolonged malaria leading to anemia.
So, because of this lack of knowledge or perception
of malaria in their local culture, they don't think of it as a serious condition.
So, the threat is somewhat low.
People would look at it as the common cold.
What do they think of bed nets?
Well, in terms of benefits, we've talked about that when we looked at force field
and here again, we can apply the same principles of constructing force field.
Warm when it rains, privacy, reduced insect nuisance,
beautifying the home, keeping the bed clean.
On the other hand, it's hot in the dry season, it may be expensive.
Pre-treatment, with the insecticide at additional cost.
And some people believe you can't really prevent malaria.
Okay, so the benefits are there but the costs may be high and so
if the threat is not perceived as terribly high, they may be unlikely to buy it.
This may again be modified by economic status, who can afford it,
house hold gender roles, again the finance for the net may be expected to come
from the father but the mother will be expected to take care of it.
She perceives a need but may not be able to convince
the husband to spend that money then the children will not have nets.
Choose to action may be such things as sleepless nights,
seeing their neighbors buy the nets, and promotional activities.
So just as we were looking in force field, if the likelihood
of buying the nets is low, what could we do to increase the positive factors and
to decrease the restraining factors?
What can we do to help people see that malaria is more dangerous?
What could we do to overcome some of the barriers or constraints such as cost?
We can also, of course, use these models to look at treatment behavior,
illness behavior, preventative behavior, rehabilitative behaviors, etc.
The next next slide shows an analysis using health belief to understand whether
parents will provide prompt treatment for their children who have malaria.
When using health belief model to understand illness and
sick role behaviors, it's important to recognize that
the threat of getting the disease- is already passed.
The person is feeling and in disposition, the person is feeling symptoms.
The question of threat then arises from weighing whether
the condition itself is likely to result and complications, including death.
So the threat of malaria complications is considered here.
Similarly, if we were looking at the question of diabetes.
If a person has already been diagnosed as diabetes,
we would not ask the question, do they feel susceptible to getting diabetes.
The question is framed as do they feel susceptible to complications and
crises that result from already having diabetes.
So in this case, we ask people in the community,
do they feel that themselves or their child, in particular,
could be susceptible to complications such as cerebral malaria, anemia, convulsions.
And if those things occur, would they be serious or not.
What happens, of course, when we look at malaria as an illness,
people do not perceive in the local community that there are complications.
These conditions, such as convulsions,
are viewed as another disease entity with a completely different cause,
as is shown in one of our lab work examples or case studies.
People believe that convulsions is caused by something called cold Earth disease,
that the child gets from being left on the ground.
And so people do not perceive that these things could happen and
therefore there is a low threat to malaria.
A low threat associated with malaria.
People still, of course, do not like to be sick and they will take medicine.
The question is will they use an antimalarial drug promptly and
in the right amount.
In particular chloroquine is still effective in West Africa and
it's still cheap, so that's the recommended drug.
What do people think about it, especially in giving their children?
On the positive side, they say yes it's convenient, it's available in all the drug
shops, if it's already prepackaged then mothers believe it's safe.
Some believe that orthodox medicines are faster and
thus save time so that the mother can return to work.
On the other hand if they're not prepackaged,
the mothers find it difficult to measure the dose.
They worry about that.
There are expectations about what an anti malarial medicine should do.
Indigenous medicines, herbal medicines often cause a person to sweat.
And they believe the disease comes out with the sweat.
Taking chloroquine does not do that.
Going to the clinic may be seen as a waste of time.
And some people experience itching as a side effect.
The modifying factors of course have to do with.
The community where they live and the access to alternatives.
Are there other caregivers available?
What is their economic status?
What can they afford?
Is it cheaper to get herbs from the backyard or go to a chemist shop and
buy prepackaged drugs?
Gender roles in care giving are important to consider.
The mother may be the one expected to determine that a child is ill.
She may be expected to administer any kinds of care.
But the father may be expected to come up with the money.
So their communication and
decision making in the household are important modifying factors.
Educational level, in terms of understanding dosages,
in terms of beliefs about the condition are important.
Cues to action in terms of encouraging the use of western antimalarial
drugs could include the fact that village health workers who are selected by
the villagers themselves have been trained to promote and administer chloroquine.
There may be advice from neighbors.
Now this advice could encourage them to use the western drugs.
Accused action can also be negative and
the advice may be to encourage them to use herbs.
Previous experience with medications may be a cue.
What happened the last time they took chloroquine?
Was there itching?
There was not?
The child recover quickly or not?
And mass media advertising drugs would be another cue.
The next slide looks at applying health leaf model to decisions of
pregnant women to attend antenatal care in a timely and consistent manner.
This is somewhat of a complicated behavior in the sense that it involves
one booking or registering for antenatal care relatively early.
And then attending at intervals recommended by the nursing staff.
The question arises,
are there any perceived threats that the mother has during pregnancy?
Often times, people would see pregnancy as a normal condition.
There are any problems such as miscarriages,
etc., people would consider it to be fate.
It's not likely that the average person would have these kind of complications.
Although the consequences would be perceived of as very serious
by the woman and by family members.
But since pregnancy is considered normal for the most part, people who don't feel
susceptible to problems, they may not be able to articulate
eclampsia in their local languages, then there doesn't seem to be much threat.
What do people think about antenatal care itself?
Well, if we look back at our force field analysis
we can see the perceived benefits.
Safe delivery,
healthy baby, good health of the mother, maybe a shorter hospital stay.
On the negative side, the constraints.
If they have to pay fees.
If it takes a lot of time to be attended to.
If the maternity center is far away.
If there are transfer problems.
If they're reluctant to reveal to other people they are pregnant before it shows.
If the attitude of the provider is abusive or not friendly.
But on the whole, women enjoy going to antenatal care in many of the villages and
see the positive aspects.
Even though they consider pregnancy normal, benefit of attending,
meeting other women, getting the medications,
getting the examinations is seen as something positive.
So the likelihood of attending is moderate, assuming it's available.
Modifying factors would include knowledge of pregnancy risks,
economic status of the family whether they can afford the fees, age and parity.
Which are obviously interrelated.
It's possible that after experiencing several pregnancies,
a woman may feel less at risk.
Occupation, whether she has the time.
Educational status, household structure,
who can help her with taking care of other children while she attends.
Finally there are cues to action for previous pregnancy experiences.
Current symptoms or feelings.
Experiences and behavior of friends, whether they're going,
if she would meet them there.
Advice from her mother, her mother in law.
And communication by the health workers over the radio, through home visits.
As we can see in the next slide we do make use of our information,
from explanatory models, to construct our theoretical models.
We take people's own perceptions and tried to interpret that information in terms
of the variables that we know will influence health behavior.
Therefore, before planning any program, these models help
us design questionnaires, design focus groups to ask questions.
We find out about local beliefs and then we use that information to construct our
models and theories to help predict why people will attended antenatal care.
Why they will use bed nets.
And who is more likely to use bed nets than others.
Are there different segments of the population?
In terms of the beliefs about pregnancy,
the existing explanatory model or understanding of how pregnancy works,
can see that it's normal but people want to keep it hidden.
Beliefs about malaria influence the recommended action.
The cause being perceived as sun or heat.
People do not believe nets could prevent sun or heat in the daytime,
if you're sleeping under the net at nighttime.
Beliefs and expectations about what is a good medicine.
Okay, good medicines make one sweat.
Modern medicines cause side effects, so
this influences people's likelihood of using modern medicines.
Beliefs about guinea worm, perceptions that since it's already in the body
the filters would not be able to remove it.
The important issue about using the models is that having put
all the pieces together, identified the variables and put them in the right place,
is that what conclusions, what lessons can we learn from applying that model?
Does it really help us understand behavior?
How do we interpret our findings?
So the next two slides give us some examples.
For example, with health belief model, we've looked at the outcome,
the likelihood of action.
And we can see that while the threat of guinea worm disease is high,
people know they lose work, they know it's painful.
And they also know that they are highly susceptible.
Everyone has it and of course local beliefs that its in your
blood implies of course that everyone is susceptible.
So even in spite of the high level of threat,
people are more concerned about looking at the pros and cons,
the benefits and constraints, of taking the action itself.
Yes, guinea worm is a threat, but we do not believe that this filter
will remove the worm that's already in your body.
So looking at that balance, yes, there's a high threat but it's overridden by
the perception that the filter doesn't work, that it's not efficacious.
So, again, the implication of that for intervention, okay, and
action is low because this intervention,
this technology of filtering is not seen as acceptable to people.
What can we do to modify the filter, what can we do to modify people's perception
of the filter, or what alternatives to filtering are available?
Let's look at the example of threat of complications during pregnancy.
The health belief model showed us that people do not see pregnancy,
generally, as a high risk or threatening situation.
They don't perceive that pregnant women,
normally in the community, are any greater risk of problems.
There may be a few things that the fetus might be subjected to, as we've said,
if the woman gets hot stomach from eating certain things.
Or if the woman goes out at mid day or midnight when witches and
spirits are about it may affect the child.
But pregnancy itself is seen as normal so
there's not a high degree of threat perceived.
But on the other hand, the recommended action going into antenatal
care is seen as having intrinsic benefits to itself.
So people may be motivated to go into antenatal care,
not because they feel that pregnancy is dangerous time for them,
but because they enjoy getting the free medications, getting the check-ups,
meeting their friends, the songs that the nurses teach them to sing.
So that there are important distinctions to be made.
The health belief model helps us to look at both, the illness or
disease, as well as the proposed intervention.
And balancing off the perceptions, so one can see the intervention is good by itself
whether they feel threatened or not.
Or one can feel highly threatened but
see that the proposed technology that we offer is of no use.
So these again are some of the things we have to do.
We have to take our models and say what lessons have we learned?
How can we apply this to developing interventions to
influence health behavior?
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