Welcome to our course in community change and public health. I'm Bill Brieger. Our first lecture is going to be used to guide you through the ecological model to provide some context to community change. In the ecological model, we are looking at five levels of change. One thing that we're concerned about is that we don't look only at individuals, and whether they adopt a new health behavior or not. But, consider the other factors, such as family setting, such as health service availability, such as community leadership and norms. Even the enabling environment of policy, and laws, to see how all of this fits together and influences behavior. Ultimately, again, we will be focusing this course on the community, but we want you to be aware of this broader context. This ecological model, as I said, forms the basis of our course, Social and Behavioral Foundations of Primary Healthcare. The website is there, if you want to look at the overview of that broader course. And you can download the course materials, the slides for free at our open course ware site which is also listed on this slide. So again, you can have access to these broader materials and see how our course and community change fits into the broader context of the ecological model. I'm just going to say a bit more about the ecological model as we go along and use the example of insecticide treated bed nets that help prevent malaria. There's a goal throughout malaria endemic regions of the world that at least 80%, if not more, of people living in those areas will sleep under a bed net every night. These bed nets have insecticide impregnated into the fibers as they are manufactured and last, at least, two or three years in terms of their strength with the insecticide. The nets may actually last longer. But the idea is that these would be replaced. But if the majority of the people in the household sleep under these nets, they will be protected, the nets will kill mosquitoes, so they will have a double benefit. So, the individual is protected, the community is protected. The interpersonal level intrapersonal, the individual is what we're concerned about there is, what do they think about nets? What do they think about malaria? Do they perceive this as a problem? Do they perceive themselves at risk? Do they think the nets are helpful? Do they think the nets are inconvenient? Hot, lack of ventilation. What problems do they see at their own level? How is this influenced at the interpersonal level, at the household power structure? We've seen many examples which we'll talk about in terms of the in the house. Just because nets are there doesn't mean that the vulnerable people, like children under five, or pregnant women or actually using them. We want to look in the community, in the social networks and see how these can influence a distribution and use of nets. Of course, the community we're talking about, how easy it is to organize them? Can they take responsibility for net distribution and monitoring? either disenfranchised segments of the community? What is their history of involvement? Then, the institutional level, of course, the public sector is the largest supplier of these bed nets. But you can also get them through the private sector. There are shops that sell nets. sometimes they're subsidized, sometimes they're at cost. But the question is, are there enough institutional outlets so that people can get the nets? Is there institutional support to follow up for replacement? You may have a big campaign, but then again new people are, come into the community. New children are born. So, we need a constant replacement. So, are the institutions, the antenatal care, prenatal care clinics, the child welfare clinics, schools, like I said, private shops. Are these all set up such that these institutions can support continued bednet acquisition and use? And finally, some policy issues that are extremely important in understanding this. The community may want nets. They may be willing to use nets. But if their are taxes on importing the nets or tariffs. If there are priorities on other areas and their la, or their lack of guidelines and strategy documents to encourage the distribution and use of nets. No matter how much the community, the family, the individual wants these nets, if the policy does not enable their easy distribution, there will be challenges. So, we need to look at the behavior of policy makers, of program managers, of community leaders, of family members, organizational members, as well as the individual who ultimately will sleep under that net. So again, the ITNs themselves, as I said, they are now produced as long-lasting nets. In theory, they could last five years, but in practice we've discovered that in quote normal use where children are running around the house, where people tend to wash them too much, their functional life may be less than half of those five years. Community distribution has been often done through mass campaigns. they're free in those campaigns, but the question is what happens afterwards? We've talked about that. So, we have these three aspects of net distribution catch up. Where we want to make sure that everyone in the community, every household, has enough nets to cover their sleeping spaces, so the campaigns do that. Keep up where we provide nets through services like antenatal care for all pregnant women. And, hang up. There's no point to have a net in your house if you keep it in a trunk under the bed. So, you need to hang it up and actually sleep under it. And again, we need support at all these levels different aspects. For example, the, the catch-up organizing, the national policymakers and program managers are important for that. The hang-up part of it is very important for community groups, family members to encourage and support each other. So, one thing about this ecological model, it gives us different perspectives on where to intervene to bring about community change. So again, we do this all in the context of the local culture where people may think that there are other preventative measures that are better. They may have a tradition of herbal treatment to prevent because they believe the cause may be hard work. And, of course, you can't stop working hard when you're a village farmer. So, it's better to take herbs than to stay home and not feed your family. So, we always have these contrasts within the community to, to look at our interventions and the bid, bed nets in particular. Okay. One of the things at the intrapersonal level, the individual. If you have a bed net or you know bed nets are being distributed, what makes you decide you want one, you hang it up and you will actually use it following all of those steps? One of the things that people say they like about the nets, it beautifies their home keeps them warm in the rainy season. Of course, it keeps them hot in the [LAUGH] in the dry season, they say. Gives some privacy within it because what happens is that the bed is somewhat covered, and in many small rural communities people don't have many rooms in their home. So, the bed net covering the bed is is a good thing for them. other insects, bed bugs are killed by the nets. And certainlyb there are people that believe ma the bed nets will prevent malaria. They believe that mosquitoes carry malaria. Not everybody believes it. And even if they bel, don't believe it, they may have heard it at the clinic. If you ask them, they will tell you what you want to hear but they may not believe it. Some of the constraints, we talk about the lack of ventilation, heat. the idea that if mosquitoes are not visible very much, like in the dry season, maybe there won't be malaria, let's not use the nets. Some people prefer alternatives. There are parts of Western Nigeria that would much prefer to have a simple window screen built by a local carpenter than to sleep under a net. Other people will burn herbs or mosquito coils. So there are different preferences, and this is the thing we learn in from the commercial side of behavior change. People make choices based on their perceptions and preferences. So, there are many different beverages that people can choose from. And, we need to realize there are many different ways of preventing malaria from, or mosquito bites, from the point of view of the community. They may not all be scientific, but it's community preferences. So, we have competition out there. and again, one Of the things that we need to think about, the cost of buying extra nets if there were not enough for in the distribution for everyone. On the interpersonal level, as we mentioned before, even though there are bed nets in the household, the vulnerable groups may not be using them. And the demographic and health surveys that are done on a regular basis in malaria endemic countries have shown as in this chart, that less than the desired proportion, as I mentioned before. 80% of children, of women, and pregnant women are actually really using the nets in their household every night. So, this is a challenge. They may be there but for some reason, and we need to find out what are the dynamics in that family, in that community that may be preventing the individual from using the net. community levels questions. Are nets being marketed? As we can can see there all kinds of nets being sold along the streets in Wagadoogu or Bommacco. these may not be impregnated nets, they may not be the best ones, but they're available. is there, are there local associations that can help with the distribution and encouragement of use of nets? How will the local leadership take a role in making sure that people get their nets? Are there subgroups that have been neglected that we need to make sure they do get nets? So, these are community-level questions. the one thing we want to find out is, how can all these different community group, sections of the community get involved? And I think some of the lectures we'll talk about, different involvement mechanisms, different levels of participation in our subsequent lectures. somebody organizational questions are institutional level questions. Again, the community may want the net, but the, in terms of getting things organised, the health system, may have difficulty getting, enough nets, to the right place, at the right time. sometimes we forgetting about the role of the private sector that could play in providing nets, either at cost or subsidized. So, these are the kind of things we need to look around at these different institutions, and see how they could be appropriately involved. Again, we're, we're concerned about the community in this course, but we have to be aware that there are these other levels that impinge on the ability of the community to, to, solve its health related problems. there are a number of private sector organizations, pharmacy shops in Ghana are selling nets, private foundations, corporations are providing support for vouchers. So, there are a number of things we need to consider. At the policy level, you can have your nets piled up in the storeroom. Do they get out to people? Is there provision for money for logistics? Is the fact that the government's providing free nets affecting people's willingness to use them? Is it affecting the private sector? Which is a problem, because in the long term, it may be the private sector that needs to keep up the supply of nets. Has the government done anything to encourage the local production and manufacture of insecticide treated nets? And if it doesn't, is it removing customs from imported nets so that people can get them? This is one thing the left hand and the right hand, the Ministry of Health may be importing nets. The, the customs officials may be wanting to make money off of nets, and the poor people in the country suffer because of that. So again, the key points in the ecological analysis is that people may want to sleep under nets. But, other family members may take priority. certain sections of the community may be left out. Organizations may not be able to maintain their momentum in a reliable supply of nets. National strategies may neglect community involvement, or charge import duty which slows down access to nets. So, we need to be aware of all of these things before we decide who is at fault if people are not sleeping under nets. hopefully, the ecological model, as you can see, is the background to this and can now see how our course on community change fits into that broader model. For those of you who are interested in learning more about malaria, we have some of the web sites blog, Twitter, things that I work on in malaria, that are a way of doing advocacy to bring about change. again, we see this as a background to the course. We hope you will enjoy Community Change in Public Heath, thank you for joining us. So if you're.
