5. Homework:
Read the assignment before the lab experience.
Complete Forms Chapter 5
After the lab, write up the lab report per guidelines
Chapter Seven
Culture and Health
Learning Objectives
Define culture
Describe the most important conceptual relationships between
culture and health
Outline some of the theories of how behavior change occurs in
health
Describe some key measures to promote behavior change for
better health
The Importance of Culture to Health
Culture is related to health behaviors
Culture is an important determinant of people’s perceptions of
illness
Culture affects usage of health services
Different cultures have different health practices
The Importance of Culture on Health
7. 7
Health Beliefs and Practices
Folk Illness
Cultural interpretations of physical states that people perceive
to be illness, but that do not have a physiologic cause
Efforts to improve health need to consider these beliefs
Table 7-1: Health Beliefs and Practices
Modified from Scrimshaw, S. C. (2006). Culture, behavior, and
health. In M. H. Merson, R. E. Black, & A. Mills (Eds.),
International public health: Diseases, programs, systems, and
policies (pp. 53–78). Sudbury, MA: Jones and Bartlett.
Health Beliefs and Practices
The Prevention of Illness
Many cultures have taboos that concern avoiding illness
Many concern foods to avoid during pregnancy
Wide variety of ritual practices to avoid illness
Health Beliefs and Practices
The Diagnosis and Treatment of Illness and the Use of Health
Services
Common to try a home remedy, then visit a local healer, then
consult a “western doctor”
“Patterns of resort” affected by cost of services and manner in
which the provider treats them socially
Health Beliefs and Practices
8. Modified from Scrimshaw, S. C. (2006). Culture, behavior, and
health. In M. H. Merson, R. E. Black, & A. Mills (Eds.),
International public health: Diseases, programs, systems, and
policies (pp. 53–78). Sudbury, MA: Jones and Bartlett.
Health Behaviors and Behavior Change
Risk factors for leading causes of death related to culture
include:
Nutrition and eating practices
Tobacco use
Unsafe sex
Hygiene
How can unhealthy behaviors be changed?
Health Behaviors and Behavior Change
Improving Health Behaviors
The Ecological Perspective
The Health Belief Model
Stages of Change Model
The Diffusion of Innovations Model
Health Behaviors and Behavior Change
The Ecological Perspective
“Health related behaviors are affected by, and affect, multiple
levels of influence”
“Behavior both influences and is influenced by the social
environments in which it occurs”
—E. Murphy
Health Behaviors and Behavior Change
9. Modified with permission from Murphy, E. (2005). Promoting
healthy behavior. Health bulletin 2. Washington, DC:
Population Reference Bureau.
Health Behaviors and Behavior Change
The Health Belief Model
People’s health behaviors depend on their perceptions of their
likelihood of getting the illness, the severity of the illness, the
benefits of engaging in behaviors that prevent the illness, and
barriers to engaging in preventive behaviors
Self-efficacy: whether or not people feel that they could carry
out the behavior
17
Health Behaviors and Behavior Change
Stages of Change Model
Change is a process and different people are at different stages
of the process
The stages of behavior change are:
Precontemplation
Contemplation
Decision/determination
Action
Maintenance
Health Behaviors and Behavior Change
The Diffusions of Innovations Model
Communication promotes social change
Diffusion is the process by which innovations are communicated
10. over time among members of different groups
This model focuses on how people adopt innovation, but not
how they might maintain what they have adopted
Understanding and Engendering Behavior Change
Understanding behaviors requires assessment of:
Behaviors that are taking place
Extent to which they enable better health or may harm health
Underlying motivation for these behaviors
Likely responses to different approaches to changing the
unhealthy behaviors
20
Understanding and Engendering Behavior Change
Changing Health Behaviors
Community Mobilization
Mass Media
Social Media
Social Marketing
Health Education
Conditional Cash Transfers
Achieving Success in Health Promotion
Understanding and Engendering Behavior Change
Community Mobilization
Engage entire community in efforts to identify problems and
promote healthy behaviors
Leaders in community need to be mobilized, willing to
11. champion change
Understanding and Engendering Behavior Change
Mass Media
“Entertainment-education”
Most people in low- and middle-income countries have access
to radio
Soap operas are also popular
The use of mobile technologies for promoting behavior change
is growing
Understanding and Engendering Behavior Change
Social Media
Social media allows people to engage with content, rather than
passively receiving it
Messages on social media platforms may spread misinformation
Information technologies are becoming increasingly accessible
in low- and middle-income countries
Understanding and Engenderi ng Behavior Change
Social Marketing
Application of tools of commercial marketing to promote a
behavior change
Depends on the four Ps:
Attractive product
Affordable price
Convenient places to buy the product
Persuasive promotion
12. Understanding and Engendering Behavior Change
Health Education
Comes in many forms such as classroom or mass media
Successful programs are clear, provide accurate information,
engage stakeholders, and gear content to target group
Understanding and Engendering Behavior Change
Barber shops in many countries are “community centers” in
which men congregate for discussion. Several countries have
created programs in which barbershops and barbers provide
health education messages
Courtesy of Mark Tuschman.
Understanding and Engendering Behavior Change
Conditional ( and not) Cash Transfers
A government agency provides an economic incentive for
families who engage in a certain healthy behavior
Incentivized behaviors; for example, giving birth in a hospital
or participating in nutrition and baby care programs
Unconditional transfers might be just as effective in arenas
Social Assessment
Social assessment: “a process for assessing the social impacts of
planned interventions or events and for developing strategies
for the ongoing monitoring and management of those impacts”
Important to include the affected communities in the design and
implementation of the assessment and its follow-up
13. Main Messages
Culture is an important determinant of health
Perceptions of illness and disease vary considerably across
cultures
Many forms of traditional behavior are conducive to good
health but some are not
It is important to consider how healthy behaviors can be
promoted
Main Messages
There are a number of models of how behaviors can be changed
Several approaches are often important to changing behaviors
Social assessments can be an effective tool for setting the
foundation for health efforts and behavior change
Chapter Five
Ethical and Human Rights Concerns in Global Health
Learning Objectives
Review key ethical and human rights concerns as they relate to
global health
Discuss some of the central treaties and conventions related to
human rights
Use the most important ethical guidelines for research with
human subjects
Learning Objectives
Discuss some historically significant cases in research with
14. human subjects
Identify key ethical principles for priority setting in health
The Importance of Ethical and Human Rights Issues in Global
Health
International conventions and treaties recognize access to health
services and health information as human rights
Failure to respect human rights is often associated with harm to
human health
Health research with human subjects puts people at risk for the
sake of other people’s health
Health investments must be made fairly, because resources are
limited
The Foundations for Health and Human Rights
Universal Declaration of Human Rights and other legally
binding multilateral treaties
Governments are obliged to respect, protect, and fulfill the
rights they state
Resource-poor countries are required to “take steps” toward
realization of positive rights
Selected Human Rights Issues
The Rights-Based Approach
Assess health policies, programs, and practices in terms of
impact on human rights
Analyze and address the health impacts resulting from
violations of human rights when considering ways to improve
population health
Prioritize the fulfillment of human rights
15. Selected Human Rights Issues
Limits to Human Rights
Circumstances in which someone’s rights may be suspended; for
example, outbreak of an emerging or a reemerging disease
Suspension of rights should be as narrow as possible
Suspension should be carried out with due process and
monitored
Selected Human Rights Issues
Human Rights and HIV/AIDS
Health condition that is stigmatized and discriminated against
Associated issues:
Protecting the rights of people who are HIV-positive to
employment, schooling, and participation in social activities
Ensuring access to care
Policies regarding testing
Protection of confidentiality
Research on Human Subjects
Research is essential for improving global health
However, most research studies do not benefit the people who
participate in them
Ethical concerns about putting participants at risk for the sake
of other people’s health
Key Human Research Cases
Nazi Medical Experiments
Experiments on euthanasia victims, prisoners of war, occupants
of concentration camps
International Scientific Commission investigated and
documented abuses after war
Questions over whether it is ethical to use data the Nazis
generated
16. Key Human Research Cases
The Tuskegee Study
U.S. Public Health Service conducted a study on the natural
history of syphilis in African American men
Study went on for 40 years
Subjects were never given treatment
Eventually led to regulations for the protection of human
research subjects
Key Human Research Cases
The “Short-Course” AZT Trials
Trials of a “short-course” AZT regimen to prevent mother-to-
child transmission of HIV
Opponents noted trials not permitted in high-income countries,
where a more complex “076 regimen” was the standard of care
Debated ethical double standard
Studies remain controversial
Research Ethics Guidelines
The Nuremberg Code
First document to specify ethical principles that should guide
physicians engaged in human research
“Voluntary consent of the human subject is absolutely
essential”
Human subjects should only be involved in research if it is
necessary for an important social good
Requires limits on and safeguards against risks to participants
Research Ethics Guidelines
17. The Declaration of Helsinki
World Medical Association
Developed ethical principles to guide physicians/non-physicians
conducting biomedical research on humans
Most influential and most cited set of international research
ethics guidelines
Research Ethics Guidelines
The Belmont Report
U.S. National Commission for the Protection of Human Subjects
of Biomedical and Behavioral Research
Identified basic ethical principles
Developed research guidelines
Evaluating the Ethics of Human Subjects Research
Clinical research protocol must satisfy at least six conditions:
Social value
Scientific validity
Fair subject selection
Acceptable risk/benefit ratio
Informed consent
Respect for enrolled subjects
Evaluating the Ethics of Human Subjects Research
Research in Low- and
Middle-Income Countries
Important issues when the subjects are likely to be poor, under -
educated, and without access to good care:
Standard of care
Post-trial benefits
Ancillary care
18. Evaluating the Ethics of Human Subjects Research
Human Subjects Research
Oversight Today
In most countries, it is a legal requirement to undergo
independent ethical review by a research ethics committee if
human subjects are involved
Safeguard against exploitation
Regulations vary from country to country
Evaluating the Ethics of Human Subjects Research
The Andean countries are characterized by substantial
disparities between the highlands and lowlands and between
indigenous people and people of European decent
Courtesy of Mark Tuschman.
Ethical Issues in Making Investment Choices in Health
Resources will always be fewer than needed to meet all needs,
so choices must be made
Better that the choices be made according to explicit, publicly
justified criteria
Cost-effectiveness analysis is useful but rarely sufficient
Judgments must be made about what is fair, using a fair process
Ethical Issues in Making Investment Choices in Health
Principles for Distributing Scarce Resources
Health maximization
Equality
Priority to the worst off
Personal responsibility
19. Ethical Issues in Making Investment Choices in Health
Fair Processes
Transparency about how decisions are made
Representation from affected stakeholders
Appropriate use of scientific data
Challenges for the Future
Students of global health get insufficient exposure in their
training to ethical issues
No mechanisms for enforcing human rights
Shortage of trained personnel for reviewing research
Lack of reviews of how investments are made
Unsolved ethical problems
