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Module 8

Good notes and revisions for behavioural science

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16 views17 pages

Module 8

Good notes and revisions for behavioural science

Uploaded by

abdiraufmadey
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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BEHAVIORAL SCIENCE

MODULE 8: HEALTH PROMOTION


Health promotion seeks to improve the health of individuals and
communities through education, behavioral change and environmental
improvement.
WHO (1986) defines health promotion as ‘The process of enabling
people to increase control over the determinants of health and
thereby improve their health.’
WHO (1948) defines health as ‘A state of complete physical, mental,
and social well-being and not merely the absence of disease or
infirmity.’

UNIT 1: HEALTH PROMOTION

Health promotion has evolved from health education. Providing


knowledge alone is not enough and that for people to be able to live a
healthy life, an individual’s motivation, skills and the influence of
social environment are important determinants as well.

Principles of health promotion


a. Empowerment – way of working to enable people to gain
greater control over decisions and actions affecting their health.
b. Participative – where people take an active part in decision
making.
c. Holistic – taking account of the separate influences on health
and the interaction of these dimensions. It involves all the
aspects of the individual that are physical, social, spiritual and
mental health.
d. Equitable – ensuring fairness of outcomes for service users.
e. Intersectoral – working in partnership with other relevant
agencies/organizations.
f. Sustainable – ensuring that the outcomes of health promotion
activities are sustainable in the long term.
g. Multi-strategy – working on a number of strategy areas such as
programmes, policy.
The Ottawa Charter for Health Promotion
The 1st international conference for health promotion was held in
Ottawa in November 1986. The Ottawa Charter presents a
CHARTER for action to achieve health for all by the year 2000 and
beyond. Health promotion is seen to have the following
characteristics:
1. It is a process.
2. It is enabling – there is need to achieve equity in health, and so
health promotion focuses on achieving this equity. This also
means that actions are to be done by, with and for people, not
imposing anything upon them.

The Ottawa charter has identified a set of 5 mechanisms of health


promotion:
1. Building a healthy public policy.
2. Creating a supportive environment.
3. Strengthening community action.
4. Developing personal skills.
5. Re-orientating health services.

These mechanisms were however updated in the Jakarta


Declaration (WHO, 1997), which focused on creating partnerships
between sectors, including private-public partnerships. The priorities
for the 21st century were to:
1. Promote social responsibility for health
2. Increase investment in health development
3. Consolidate and expand partnerships for health
4. Increase community capacity and empower the individual
5. Secure an infrastructure for health promotion

Recently, through the Bangkok Charter (2005), WHO has reviewed


the strategies for health promotion.
Priorities for health promotion in the 21st century have been outlined
as follows:
1. Promote social responsibility for health- both public and
private sectors should promote health by pursuing policies and
practices that:
• Avoid harming the health of individuals
• Protect the environment and ensure sustainable use of
resources
• Restrict production of and trade in inherently harmful
goods and substances such as tobacco and armaments as
well as discourage unhealthy marketing practices
• Safeguard both the citizen in the marketplace and the
individual in the workplace
• Include equity focused health impact assessments as an
integral part of policy development
2. Increase investment for health development- increasing
investment for health development requires a multi-sectoral
approach including, for example, additional resources for
education and housing as well as for the health sector.
Investments for health should reflect the needs of particular
groups such as women, children, older people, and indigenous,
poor and marginalized populations.
3. Consolidate and expand partnerships for health- health
promotion requires partnerships for health and social
development between the different sectors at all levels of
governance and society. WHO guidelines should be adhered to.
4. Increase community capacity and empower the individual-
health promotion is carried out by and with people, NOT on or
to people. It improves both the ability of individuals to take
action, and the capacity of groups, organizations or communities
to influence the determinants of health. This requires practical
education, leadership training, and access to resources.
Empowering individuals demands more consistent, reliable
access to the decision-making process and the skills and
knowledge essential to effect change.
5. Secure an infrastructure for health promotion- to secure an
infrastructure for health promotion, new mechanisms for
funding it locally, nationally and globally must be found.
Incentives should be developed to influence the actions of
governments, NGOs, educational institutions and the private
sector to make sure that resource mobilization for health
promotion is maximized. Training in and Practice of local
leadership skills should be encouraged in order to support health
promotion activities.

SECTION 2: HEALTH BELIEF MODEL

HBM is a psychological model that explains and predicts health


behaviors. Focuses on attitudes and beliefs of individuals towards
health. HBM was developed in 1950s by social psychologists
Hochbaum, Rosenstock and Kegels. They were working at the U.S.
Public Health Service and wanted to explain why many people did not
participate in public health programs such as TB or cervical cancer
screening.
It was extended by Leventhal, Rosenstock, Becker and others to
explain differing reactions to symptoms and to explain variations in
adherence to treatment. It has been adapted to explore a variety of
long and short term health behaviors, including sexual risk behaviors
and the transmission of HIV/AIDS.
In the HBM, the likelihood that a person will follow a preventive
behavior is influenced by their subjective weighing of the costs and
benefits of the action; the perception involves the following elements:
1. Perceived susceptibility- person’s judgement of his or her risk
of contracting the condition. This may be measured by questions
such as “Taking all factors into account, what do you thing are
your chances of getting the disease?”
2. Perceived seriousness of the condition- the severity of the
condition and its impact on lifestyle. Questions may include “if
you got [the disease], how serious would that be?”
Combination of perceived susceptibility and seriousness is
termed perceived threat. Perceived threat is influenced by
information and it creates a pressure to act, but does NOT
determine how the person will act. How the person will act is
influenced by the balance between the perceived efficacy and
cost of alternative courses of action:
• Perceived benefits of an action- will the proposed action
be effective in reducing the health risk? Does this course
of action have other benefits? The beliefs will reflect
social and cultural influences. Questions may include “Do
you think there is anything that could be done to prevent
this condition? How effective would that be?”
• Perceived barriers to action- How do these benefits
compare to the perceived costs of action? Are there
barriers to action? Will it involve expense, pain, or
embarrassment? Questions may include “What difficulties
do you see in undertaking this action?”
• A stimulus or cue to action- When a person is motivated
and can perceive a beneficial action to take, actual change
often occurs when some external or internal cue (e.g., a
change in health, the physician's advice, or a friend's
death) triggers action. As cues may be fleeting events they
are elusive to record. The magnitude of the cue required to
trigger action would depend on the motivation to change
and the perceived benefit to cost ratio for the action.

The Health Belief Model

SECTION 3: BIOPSYCHOSOCIAL, SPIRITUAL MODEL IN


MEDICINE
The Bio psychosocial-spiritual model systematically considers
biological, psychological, social and spiritual factors and their
complex interactions in understanding health, illness and health care
delivery of the sick person.
The bio Psychosocial-Spiritual approach started as the bio
psychosocial model which was developed at Rochester by Drs.
George Engel and John Romano. George Engel believed that to
understand and respond adequately to patients' suffering-and to give
them a sense of being understood-clinicians must attend
simultaneously to the biological, psychological and social dimensions
of illness. His new model came to be known as the bio psychosocial
model. However, the Engel Biomedicine model has been criticized as
follows:
1. A biochemical alteration does not translate directly into an
illness.
2. The presence of a biological disturbance does not shed light on
the meaning of the symptoms to the patient, nor does it
necessarily assume the attitudes and skills that the clinician must
have to gather information and process it well.
3. Psychosocial variables are more important determinants of
susceptibility, severity and course of illness than had been
previously appreciated by those who maintained a biomedical
view of illness.
4. Adopting a sick role is not necessarily associated with the
presence of a biological problem.
5. Success of most biological treatments is influenced by
psychosocial factors, e.g. the so-called placebo effect.
6. The patient-clinician relationship influences medical outcomes.
7. Unlike inanimate subjects of scientific scrutiny, patients are
profoundly influenced by the way in which they are studied and
the scientists engaged in the study are influenced by their
subjects.
The model implies that treatment of disease processes, e.g. cancer
requires that the health care team address biological, psychological
and social influences upon a patient’s functioning. The bio
psychosocial model therefore states that the workings of the body can
affect the mind, and the workings of the mind can affect the body.
This means both a direct interaction between mind and body as well
as indirect effects through intermediate factors.

George Engel model was criticized for failing to take into account the
patient's spirituality. Spirituality was added to biopsychosocial model.
To apply the bio psychosocial-spiritual approach to clinical practice,
the clinician should:

a. Recognize that relationships are central to providing health care


b. Use self-awareness as a diagnostic and therapeutic tool
c. Elicit the patient's history in the context of life circumstances
d. Decide which aspects of biological, psychological, and social
domains are most important to understanding and promoting the
patient's health
e. Provide multidimensional treatment.

As a doctor, you must always respect the patients’ spiritual needs and
if you can accelerate the help the better, letting the spiritual matters be
addressed.

UNIT 2
SECTION 1: HEALTH BELIEFS IN CONSULTATION

Medical consultation is a two-way encounter between a doctor or a


practitioner and a patient. This may be initiated by a patient when
they are ill or by a doctor when instituting preventive medicine or
screening. The consultation is the central act of medicine.
Consultations are part of the “cycle of care” where patients learn
about their disease, come to terms with their condition and are given
the ability to share in its management.
The consultation process is influenced by the patient’s beliefs and
expectations, which in turn influences adherence, behavior change
and mediates the outcome. Health Beliefs refer to beliefs held by
individuals about health, illness and diseases. They are shaped by
people’s wider setting such as their structural location, cultural
context, personal experiences and social identity. Knowing the
patients’ health belief is important because:

1. A patient’s beliefs about health (e.g. cause of disease,


controllability of a condition, value of different remedies) predict
health behaviors such as medication adherence, utilization of health
care services and lifestyle decisions.

2. A better awareness of a patient’s health beliefs could help


physicians identify gaps between their own and the patient’s
understanding of his or her health situation and lead to treatment
decisions better suited to the patient’s expectations and needs.

3. The physicians’ skill at hearing and understanding patients’


perspectives is also a key component of empathy.

4. Research has also shown that patient satisfaction, commitment to


treatment, and perceived outcomes of care are higher when physician
and patient achieve a shared understanding on issues such as the
patient’s role in decision-making, the meaning of diagnostic
information and the treatment plan.

It is important for the doctor to understand some of the reasons why


the patients might not open up to them. Key among them is your
attitude. What is your attitude towards the patient? Is the doctor
knowing it all, the one who lords over every person? Are your health
beliefs such that your word is final? Trust. Does the patient trust you?
Can they confide in you? What can you do to win their trust? Another
reason is communication? How do you communicate to the patient?
Effective communication between doctor and patient leads to
improved outcome for many common diseases.

Encourage the patients to:

1. Ask questions
2. Express their worries
3. State preferences and opinions during the consultation.
Related to communication is style with which a doctor listens to a
patient this will influence what they say. Research into doctor–patient
communication has established a number of key tasks of the
consultation including:

1. Eliciting patients’ problems and concerns,


2. Giving information,
3. Discussing treatment options
4. Being supportive

How do you improve consultation?


1) Clarify of the patient's objectives for the consultation.

a. It is sensible to begin every clinical encounter with a


determination of the patient's beliefs/ expectations.
b. Patients consult for a variety of reasons, of which four are
particularly common:
c. to obtain cure or symptomatic relief;
d. to seek diagnostic clarification;
e. to seek reassurance and
f. to seek ‘‘legitimization of their symptoms.''
Often, patients will have a clear and explicit reason(s) for
consultation, but sometimes they just seem to wish to express distress,
frustration or anger.

2) To enable and encourage the patient to express his/her expectations


and concerns, try to establish a therapeutic climate encouraging self-
disclosure, adopt an appropriate communication style using
appropriate language and attend both to the verbal and non-verbal
aspects of communication.

SECTION 2: COMPLIANCE WITH MEDICAL REGIMENS

Compliance can be defined as “the extent to which a person’s


behavior coincides with medical advice”.
Compliance to medical regimens is influenced by a number of factors
which can be divided into two: those that influence compliance
positively and those that influence negatively.

Those that have a positive influence are:

a. Patient viewing disease as serious;

b. Family stability;

c. Patients satisfaction and expectations met;

d. Favourable doctor-patient relationship in which patient is involved


in the decision-making process

e. Private doctor (vs clinic) and seeing same doctor consistently (vs
different doctor)

f. Mental stability

g. Spirituality

Those that have a negative influence are:

a. Complexity of the regimen especially when four or more drugs are


involved

b. Unfavourable doctor-patient relationship

c. Psychological problems (especially mental illness).

d. Poverty

e. Distance to the health facility/doctor

f. Traditional and religious beliefs


g. Competing alternative practices

Compliance to medical regimen is important for both the doctor and


the patient. For the doctor there is satisfaction as the patient gets well.
For the patient, there are many benefits of getting well.
The doctor has to help the patient comply to the medical regimen by:

a. Simplifying drug regimens as much as possible e.g. prescribing


as few drugs as possible and as simple as dosage schedule (e.g.
once or twice daily) as possible;
b. To involve patients in the decision-making process as much as
possible. This way they will be able to carry out activities they
participated in charting out. This will mean that you must
psycho-educate them on the importance of following the
medical regimen that you want them to follow.

UNIT 3: ACCIDENTS AND INJURY PREVENTION

An accident can be looked at as mishap, a calamity a disaster, etc.


It is unintentional. Injuries include all the ways people can be
physically hurt, impaired or killed, involving unintentional or
intentional damage to the body. However, WHO has defined injury
in the following way:

"Injuries are caused by acute exposure to physical agents such as


mechanical energy, heat, electricity, chemicals, and ionizing
radiation interacting with the body in amounts or at rates that
exceed the threshold of human tolerance. In some cases, for
example drowning and frostbite, injuries result from the sudden
lack of essential agents such as oxygen or heat" Baker et al 1992.

Public Health science divides injuries into two categories:


intentional and unintentional injuries. Injuries and accidents are
also categorized according to the environment they take place in,
and according to the severity of the injury. In particular, children,
adolescents and the elderly are at risk.
Injuries need to be prevented because:
a. The impact of injuries to health and on society is great in terms
of mortality, morbidity, disability and cost.

b. Injuries also lead to suffering, grief and disability. The burden of


injury is felt not only by those who are injured, but also by their
families, caregivers and employers.

c. Many people especially in the developing countries do not


receive requisite treatment for their injuries leading to many of the
injured people suffering long-term or permanent disabilities.

d. Injuries also cause a major loss of human resources and


productivity for the societies and pose a great social and economic
burden to them.

e. The treatment and rehabilitation of injured persons often


accounts for a large proportion of national health budgets.

Burden of injury is particularly heavy on low-income families and


communities as they are more prone to injury and less likely to
survive or recover from disability.
The public health approach to injury control includes:

a. Identification of the problem;


b. Identification of risk factors and target groups;
c. Implementation of countermeasures;
d. Evaluation of effectiveness; and dissemination of results.

The government can help in injury preventions through:

1. Creating a climate of social cohesion and peace as well as of


equity, protecting human rights and freedoms, at a family, local,
national or international level.
2. The prevention and control of injuries and other consequences
or harms caused by accidents.
3. The respect of the values and the physical, material and
psychological integrity of the individuals.
4. The provision of effective preventive, control and rehabilitation
measures to ensure the presence of the three previous
conditions.

SECTION 2: CRISIS AND CRISIS INTERVENTION

A crisis can be defined as an individual's reaction to an event,


situation, or stressor.
When an individual registers an event as a crisis, it will have the
following characteristics:

1. Time limited: Generally lasting no more than six weeks.

2. Individual goes through the following typical phases:

a. Traditional attempt to problem solve

b. Attempts to try alternative methods

c. Disorganization

d. People are more open to change

e. Opportunity to resolve previously unresolved issues

f. Successful experience

The goal of crisis intervention is to stabilize the individual/family


situation and restore to the person’s/families’ pre-crisis level of
functioning. The process of interventions involves the following:
1. Assessment
2. Intervention
3. Termination

It is important to assess risk factors. The risk factors include:


a. Suicide or homicide
b. Risk of physical or emotional harm to self or others
c. Risk of break from reality (psychosis)
d. Risk of client fleeing the situation.

1. Assessment

When an individual who has undergone a crisis is being assessed, that


assessment involves:

a. Conducting the interview:

i. History: personal and familial of risk behaviour


ii. Any means and plans the client may have about carrying out the
risk behaviour
iii. Controls: internal and external that is stopping the client from
undertaking the risk behaviour.

b. Observations during the interview (Level of anxiety;


desperation; despair; sense of hopelessness; contact with
reality.)
c. Focusing technique can elicit more coherent information for
assessment as well as help the client pull themselves together
cognitively and emotionally.

2. Intervention

The person making an intervention needs to bear in mind the


following:

a. Planning occurs simultaneously as assessment is made about


how much time has elapsed between the occurrence of the
stressor event and this initial interview.
b. How much the crisis has interrupted the person’s life;
c. The effect of this disruption on others in the family;
d. Level of functioning prior to crisis and what resources can be
mobilized.
e. The goal of intervention is to restore the person to pre-crisis
level of equilibrium, not of personality changes.
f. Worker attempts to mobilize the client’s internal and external
resources.
g. Exact nature of the intervention will depend on the client’s pre-
existing strengths and supports and the worker’s level of
creativity and flexibility.

Three approaches to intervention are:

1. Affective:
– Expression and management of feelings involving techniques of
ventilation; psychological support; emotional catharsis.

2. Cognitive:
– Helping the client understand the connections between the stressor
event and their response. Techniques include clarifying the problem;
identifying and isolating the factors involved; helping the client gain
an intellectual understanding of the crisis
– It also involves giving information; discussing alternative coping
strategies and changing perceptions.

3. Environmental modification:
– Pulling together needed external, environmental resources (either
familial or formal helping agencies)

A defusing session is a short (30–45 minute), non-judgmental session


where one or more workers affected by the incident meets a trained
leader (defuser).
Defusings are conducted where the incident is particularly distressing,
complex or protracted.
Debriefing is the process in which the staff who have been working
with an individual(s) who have undergone a traumatic event are able
to talk to another person.
When conducting a debriefing, a trained debriefer will:

1. Introduce the session; outline the rules of confidentiality, non-


judgement and freedom to talk.
2. Invite the group to give an account of the incident, which is
then clarified and completed.
3. Invite participants to share their thoughts at the time of incident
or in the time since it occurred. These indicate important
meanings that will be significant factors in the development of
stress.
4. Review staff reactions, should indicate other aspects of the
meaning and significance of the events, and account for the
development of symptoms.
5. Review stress symptoms as these form the basis for the
following stage
6. Provide focused education, advice and information to assist in
understanding and managing the symptoms.
7. Undertake problem solving for issues arising in the course of the
session and prepare for the recovery process or return to work.

UNIT 4: MENTAL HEALTH IN PRIMARY HEALTH CARE

Primary health care is about providing 'essential health care' which is


universally accessible to individuals and families in the community
and provided as close as possible to where people live and work. It
refers to care which is based on the needs of the population.
There are a number of reasons why mental health services should be
provided in the primary health care. These reasons include:

1. Reduced Stigma for people with mental disorders and their


families
2. Improved access to care
3. Reduced chronicity and improved social integration
4. Human rights protection
5. Better health outcomes
6. Improving human resource capacity for mental health
Having mental health services in the primary health care requires a lot
of careful planning and there are likely to be several issues and
challenges that will need to be addressed. These include:

1. Investment in the training of staff to detect and treat mental


disorders. This could be a challenge as many countries might not have
these investments or are not willing to invest.

2. Lack of skills to identify mental health disorders. Within the


context of training, primary health care workers may be
uncomfortable in dealing with mental disorders and may also question
their role in managing disorders. Therefore, in addition to imparting
skills, training also needs to address the overall reluctance of primary
health care workers to work with people with mental disorders.

3. The issue of availability of time also needs to be addressed. In


many countries primary health care staff is overburdened with work
as they are expected to deliver multiple health care programs.
Governments cannot ignore the need to increase the numbers of
primary health care staff if they are to take on additional mental
health work.

4. Issue of adequate supervision of primary care staff is another key


issue which needs to be addressed. Mental health professionals should
be available regularly to primary care staff to give advice as well as
guidance on management and treatment of people with mental
disorders. Furthermore, the absence of a good referral system between
primary and secondary care can severely undermines the effectiveness
of mental health care delivered at primary health care level.

5. Finally, governments must pay attention to key human resource


management issues in primary health care – adequate working
conditions, payment, resources and support to carry out demanding
work.

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