In bringing about behavior change in public health, we often focus on the individual mother, student, or farmer. We should not forget the community structure and norms constrain for encouraging individual health behaviors. This course examines the community context of the changes needed to promote the public’s health. We begin by examining the various definitions of ‘community’ and the processes by which we ‘diagnose’ or seek to understand the structure and characteristics of different types of communities. An appreciation of community similarities and differences is necessary lest we fall into the trap of designing one-size-fits-all interventions. We need to recognize that no matter that outsiders may view a community as poor or neglected, we can find strengths and capacities for improvement in each community. Identifying community capacities and resources is the first step in facilitating community change. Different practical and philosophical approaches to change and therefore, examined. Specific to the change process is our recognition of the need for communities to participate in the design, implementation and evaluation of any intervention. We examine the concept of participation in an effort to see how different levels of involvement may affect sustainability of community change efforts. Finally a case study of a community participatory approach to onchocerciasis control in Africa is presented. Community Directed Intervention has subsequently been successfully applied to providing other essential primary health care services by and in the community, such as insecticide treated bednets, malaria treatment, vitamin A distribution, deworming medicines, and pneumonia and diarrhea case management.
Lecture 1: Ecological Model
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Del curso dictado por Johns Hopkins University
Community Change in Public Health
74 calificaciones
De la lección
Module 1
This week, we'll get oriented to the course, learn about the ecological model, and learn how to classify communities on the basis of identity, linkages, group orientation, and integration.
Conoce a los instructores
William Brieger, DrPHProfessor, Health Systems Program of the Department of International Health
Bloomberg School of Public Health
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.
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