Health Education, Advocacy and Community Mobilisation: 5. Human Behaviour and Health: 2

Study Session 5  Human Behaviour and Health: 2

Introduction

In the last study session you learnt about the main determinants of human behaviour and how to utilise this knowledge in your day to day health education activities. This session will help you look at some of the ways that people consider health and illness. The Health Belief Model and the theory of Diffusion of Innovations and their application in your health education activities will also be discussed.

Learning Outcomes for Study Session 5

When you have studied this session, you should be able to:

5.1  Define and use correctly all of the key words printed in bold. (SAQs 5.1, 5.2 and 5.5)

5.2  Discuss some of the important perspectives of human behaviour in relation to health, illness, sickness and disease. (SAQ 5.1)

5.3  Discuss various different explanations of illness and their role in influencing people’s health-seeking behaviour. (SAQ 5.2)

5.4  Explain the application of the Health Belief Model (HBM). (SAQ 5.3)

5.5  Explain the application of the theory of the Diffusion of Innovation model in health education. (SAQs 5.4 and 5.5)

5.1  Perspectives on health and illness

Disease, illness and sickness are all negative notions reflecting negative occurrences in human life. Disease calls for action by health workers who will be asked to identify and treat the occurrence – and then care for the person who has the disease. Illness changes the actions of the individual, making him or her communicate their personal perspective of the negative occurrence to others, for example by calling for help.

Disease is usually considered to be independent of subjective opinion and is objectively measurable through various medical tests. Illness, however, is the subjective feeling of the individual. These feelings are often referred to as symptoms, and ‘illness’ can only be indirectly accessed through the individual’s reports. ‘Sickness’ is a social identity as a result of the poor health of an individual defined by others with reference to the activity of that individual. Sickness in this sense is a social phenomenon. Sickness is assessed by measuring levels of performance with reference to expected social activities when these levels fail to meet social standards.

Figure 5.1  This person has a well recognised disease called podoconiosis (also known as ‘mossy foot’). It can be prevented by wearing shoes. (Photo: Henk van Stokkom)

5.2  Explanations of illness

Most people consider that disease is a defined pathological condition of the body, whereas illness is a feeling of not being normal and healthy. Illness may, in fact, be due to a disease. However, it may also be due to a feeling of psychological or spiritual imbalance. By definition, perceptions of illness are highly culture-related, while disease usually is not. 

For example, someone might feel ill after visiting a certain village where they believe that there are individuals with the evil eye. This is mainly due to the feeling that the individual has of not being normal and healthy. This is one example of illness. But if the individual goes to a health centre for treatment the nurse may not find any sign of a disease — and the person may be sent back home just with reassurance. That means that there is no diagnosed disease present in the individual, but they may still feel ill.

It is important for health professionals who treat people from other cultures to understand some of the things that their patients believe can cause them to be ill, and what kind of curing methods they consider to be effective, as well as acceptable.

For example many of the rural people in Ethiopia traditionally believe that some mental disorders are caused by possession of a bad spirit and that they can be cured by holy water from the church.

How illness is explained often varies radically from culture to culture. For example, in some rural areas people believe that mental disorders accompanied by unusual behaviours such as shouting and being aggressive are due to possession by a bad spirit or evil eye, while in some urban areas people believe that such illnesses are due to problems in the human mind and should be treated by a psychiatrist. Similarly, the methods considered acceptable for curing illness in one culture may be rejected by another. The people who believe in the evil eye or bad spirits are most likely to refer the sick person to a Holy Spirit; while those who believe that strange symptoms are because of a problem in the mind would probably take the person to a mental hospital. These differences can be broadly generalised in terms of two explanatory traditions about the cause of illness. These are:

1. Naturalistic explanation about the cause of illness
2. Personalistic explanation.

5.2.1  Naturalistic explanation

A naturalistic explanation assumes that illness is due to impersonal, mechanistic causes that can be potentially understood and cured by the application of the scientific method. Examples include that too little food will certainly be an organic cause for malnutrition or if people do not eat sufficient of the right types of food they will definitely become malnourished.

Health professionals usually attribute the cause of most illnesses to naturalistic explanations. When people perceive that the cause of their illness can be explained scientifically they are likely to seek modern medical treatment to cure their illness.

5.2.2  Personalistic explanation

Personalistic explanations for the cause of illness are more likely to be part of a traditional method of defining the cause of illness. According to this viewpoint, illness is seen as being due to acts or wishes of other people or supernatural beings and forces (Figure 5.2). Adherents to personalistic belief systems think that the causes and cures of illness are not to be found in the natural or scientific world.  Curers usually must use supernatural means to understand what is wrong with their patients in order to return them to health.  Examples include that personalistic causes for mental disorders include spirit possession or bewitching.

Figure 5.2(a)  This older woman puts a lot of faith in the amulet she wears around her neck that she believes will keep her healthy. (b)  Young people may also put their faith in traditional ways of keeping healthy. (Photo: (a) and (b) © 2009 Sean M. Winslow, www.larkvi.com.)

The way the community perceives or explains the causes of illnesses has a far-reaching effect on influencing people’s health-seeking behaviour and their choice of treatment options when deciding between modern or traditional treatment. Individuals or communities who think that illnesses are caused by naturalistic causes are more likely to choose modern treatment and attend for treatment at a hospital or health centre. Those individuals who perceive illnesses as having personalistic causes are more likely to choose traditional treatments such as holy water and go to see a traditional healer or a religious leader. As health educators your responsibilities will be to understand and identify the individual and community-level perceptions towards disease and educate people towards naturalistic explanations of the cause of illnesses, while being aware of their personalistic ideas.

5.3  The Health Belief Model

The Health Belief Model (HBM) is a model at the individual level that has been used to explain change and maintenance of health-related behaviours. You will be able to use it as a guiding framework for your health education work, especially during any health behaviour interventions.

The Health Belief Model has four major concepts. It assumes that people will take action to prevent or to control ill-health if they regard themselves as susceptible to the condition (perceived susceptibility). Also they will take action if they believe that the condition will have potentially serious consequences for them (perceived severity), and if they believe that the course of action available to them is beneficial in reducing their susceptibility to, or severity of, the condition (perceived benefits). They also need to believe that the anticipated barriers to taking the action are outweighed by its benefits (perceived barriers).

Figure 5.3  This child is getting vitamin A drops, but if parents don’t perceive the susceptibility or severity of vitamin A deficiency, or the benefits of this intervention, they are unlikely to let their children have the drops. (Photo: UNICEF Ethiopia/Indrias Getachew)

Let us consider this now in a practical context. According to the HBM, a young, single individual is most likely to attend for an HIV test if the following applies:

• If they believe that they are likely to get an HIV infection (perceived susceptibility)
• If they believe that HIV is a serious disease (perceived severity)
• If they believe that it is important to know their HIV status and also that this will help them to get other services such as medication (perceived benefits)
• If they also believe that they can get the HIV test for free and there are no major problems to get the test (perceived barriers).

Therefore if you are applying the HBM in designing health education sessions about the importance of HIV testing, your role as a health educator will be to teach people about:

• Their susceptibility to HIV infection
• The serious consequences and severity of HIV/AIDS
• The benefits of getting professional help.

5.4  Theory of Diffusion of Innovations

Diffusion of Innovations is a theory of how, why, and at what rate new ideas and technology spread through cultures. This theory shows for example how the utilisation of insecticide treated bed nets (ITNs) could be disseminated in your community starting from one household, a model family, to the other households. The theory can help you find out how fast or how slow the dissemination was and why the innovation has spread to other households.

5.4.1  Five stages of the adoption process

Diffusion of an innovation is usually considered to occur through a five step process. The five stages (steps) in the adoption process are: knowledge, persuasion, decision, implementation and confirmation.

1. Knowledge

   During this stage the individual is first exposed to an innovation but lacks information about the innovation.

   A sexually active adolescent called Ermias hears or is told about condoms for the first time, but doesn’t know much about the subject.

2. Persuasion

   At this stage the individual is interested in the innovation and actively seeks information and more details about the innovation.

   Ermias becomes interested in condoms and tries to find out more information about condoms and how he should use them.

3. Decision

   In this stage the individual takes the concept of the innovation and weighs the advantages and disadvantages of using the innovation — and then decides whether to adopt or reject the innovation.

   Based on the information he has found out about condoms and considering his own situation, Ermias has decided to use condoms.

4. Implementation

   During this stage the individual determines the usefulness of the innovation and may search for further information about it.

   Ermias has used condoms and he has appreciated the usefulness of condoms for his own situation. There will be benefits for him if he continues to use them.

5. Confirmation

   In this stage the individual finalises their decision to continue using the innovation and may use the innovation to its fullest potential.

   Ermias has made his final decision to use condoms always, consistently and correctly.

Remember that some young people might be reluctant to talk about issues to do with their sexual health and may need skilled help before they adopt safe practices such as condom use.

5.4.2  Rate of adoption

The rate of adoption is defined as the relative speed with which members of a social system adopt a new innovation. It is usually measured by the length of time required for a certain percentage of the members of that social system to adopt an innovation. In general individuals who first adopt an innovation require a shorter adoption period than late adopters.

There becomes a point at which an innovation reaches a ‘critical mass’. This is a point in time within the adoption process that sufficient individuals have adopted an innovation so that the continued adoption of the innovation becomes self-sustaining.

There are some strategies that help an innovation to become accepted (Figure 5.4). These include having an innovation adopted by respected individuals in your community. It is always helpful to introduce an innovation into a group of individuals who are ready to accept an innovation and who will provide positive reactions and benefits for early adopters of the innovation.

Figure 5.4  Health innovations do spread through communities, but they may need some help. Here there is a community ceremony to reward volunteer health workers who have been helping to spread positive health messages. (Photo: FMOH/WT)

5.4.3  Adopter categories

Adopters are defined as categories of individuals within a social system on the basis of how innovative they are. The categories of adopters are usually considered to be innovators, early adopters, early majority, late majority and laggards.

1. Innovators — innovators are the first individuals to adopt an innovation.
2. Early adopters — this is the second fastest category of individuals who adopt an innovation.
3. Early majority — individuals in this category adopt an innovation after a varying degree of time. This time of adoption is significantly longer than the innovators and early adopters.
4. Late majority — individuals in this category will adopt an innovation after the average member of their society. These individuals approach an innovation with a high degree of scepticism and after the majority of their society has adopted the innovation.
5. Laggards — individuals in this category are the last to adopt an innovation.

Figure 5.5  Some people are keen to try out new ideas. This family is happy to try out their new bed net. In their village they are innovators. (Photo: UNICEF Ethiopia/Indrias Getachew)

When it comes to innovation there is also one other category of person who is very important — opinion leaders. These are people in a given community who are influential in spreading either positive or negative information about an innovation.

Summary of Study Session 5

In Study Session 5 you have learned that:

1. This session has helped you look at some of the ways that people consider health and illness. This will be important for your work in the community because understanding these theories and concepts will help you think more closely about your work and how people behave when they are ill.
2. Understanding health behaviours is often the key to delivering health messages that are effective and that will improve the health of your community. This session has also discussed the importance of using theories and models in your health education activities.
3. The naturalistic explanation is based on medical beliefs and assumes that illness is due to impersonal, mechanistic causes in nature that can be potentially understood and cured by using scientific methods. 
4. The personalistic explanation for the cause of illness is a traditional method in which illness is seen as being due to acts or wishes of other people or supernatural beings and forces. 
5. The Health Belief Model assumes that the most important determinants of people’s health-related behaviours are their beliefs and perceptions.
6. Diffusion of Innovations is a theory of how, why, and at what rate new ideas and technology spread through cultures.
7. An adopter category is a classification of individuals within a social system on the basis of innovativeness. A total of five categories of adopters are used: innovators, early adopters, early majority, late majority and laggards.
8. Opinion leaders are personalities in a given community who are influential in spreading either positive or negative information about an innovation.

Self-Assessment Questions (SAQs) for Study Session 5

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.