TABLE OF CONTENT

COURSE OUTLINE .......................................................................................................... 3

CHAPTER ONE: INTRODUCTION........................................................................ 5
CHAPTER TWO: HUMAN DEVELOPMENT..........................................................11
CHAPTER THREE: HUMAN BEHAVIOUR ............................................................. 16
CHAPTER FOUR: BIOLOGICAL BASIS OF BEHAVIOUR 33
CHAPTER FIVE: CULTURAL BASIS OF BEHAVIOUR 37
CHAPTER SIX: HEALTH RELATED BEHAVIOUR................................... 45
CHAPTER SEVEN: HEALTH BEHAVIOUR CHANGE .. 61

SAMPLE EXAM............................................................................................................ 66

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COURSE OUTLINE

HRIM 1209: BEHAVIOURAL SCIENCES

LECTURE HOURS: 42

Medicine and medical practice have undergone dramatic changes both in the way the patients relate
with the health care system and the way practitioners make their diagnosis and treatment. Advances
in technology, the upsurge of chronic illnesses, increasing litigations and the diminishing autonomy
of medicine have necessitated the need for doctors and other health care workers to understand the
behavior of the patients. An understanding of behavioral sciences for practitioners of medicine can
help the health care providers to be able to look at the patients not only in terms of disease and this
could lead to improvement in the delivery of medical care.

The course introduces students to the fundamental principles of human behavior and development,
with particular emphasis upon the role of behavior within the context of illness. It is designed to
acquaint students with the basic tools, concepts and methods for the study of health, illness and
community life by focusing on the disciplines of psychology, medical anthropology, sociology and
community oriented health care.

Expected Learning Outcomes

By the end of this course unit the student should be able to: -

i. Describe the basic principle of psychology, medical sociology and anthropology.

ii. Discuss the relationship between human lifestyles and diseases.

iii. Identify and classify psychological, sociological and anthropological factors that affect health
in the community

iv. Discuss culture, religion and health

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Week 1: Introduction

Week 2: Basic principles of psychology

Behaviour
Attitude
Personality

Week 3: Biological basis of behavior

Week 4: CAT

Week 5: Theories of human development

Week 6: Cultural basis of behavior

Definition of culture

Health lifestyles and health

Week 7: Explanations of disease and health

Social determinants of health and disease

Week 8: CAT

Week 9: Health related behavior

Health care system

Health seeking behaviours

Week 10: Defense mechanisms

Week 11: Health education

Week 12: Empathy

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LEARNING AND TEACHING METHODOLOGIES: Online, Tutorials

ASSESSMENT: EXAMINATION - 70%; CONTINUOUS ASSESSMENT - 30%; TOTAL - 100

REQUIRED TEXTBOOKS

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 CHAPTER ONE

INTRODUCTION

By the end of the chapter the learner should be able

Define behavioural sciences, psychology, sociology and medical

anthropology
Describe the importance of studying behavioural sciences

Medicine and medical practice have undergone dramatic changes both in the way the patients relate
with the health care system and the way practitioners make their diagnosis and treatment. Advances
in technology, the upsurge of chronic illnesses, increasing litigations and the diminishing autonomy
of medicine have necessitated the need for doctors and other health care workers to understand the
behavior of the patients. An understanding of behavioral sciences for practitioners of medicine can
help the health care providers to be able to look at the patients not only in terms of disease and this
could lead to improvement in the delivery of medical care.

There is strong evidence to link biological, behavioural, psychological, and social variables to health,
illness and disease. To achieve a more comprehensive understanding of the maintenance of health and
the genesis of disease, therefore, there is need to learn how stressors and a variety of psychological,
behavioral, and social factors alter physiology to make disease more likely, and how the systems that
maintain homeostasis are interconnected.

Behavioral science is concerned with the study of human and animal behavior by encompassing such
fields as anthropology, psychology and sociology. The discipline addresses individuals and their
behavior along with the behavior of societies, groups, and cultures, as well as processes that can
contribute to specific behaviors. There is a great deal of overlap between this field and the social

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sciences, which can sometimes lead to confusion. The social sciences tend to focus more on structural
systems and cultures, while behavioral science tends to look at the reactions within and between
organisms that dictate behavioral trends.

The interaction between patients, groups, and societies is a complex one. The course introduces
students to the fundamental principles of human behavior and development, with particular emphasis
upon the role of behavior within the context of illness and the medical encounter. An overview of
several major psychological theories of human behavior is provided, including psychodynamic,
behavioral, cognitive, and biological models. Exposition of these systems leads to discussion of a
number of topics, including systems of psychotherapy, behavior modification, biological/genetic
bases of behavior, psychological assessment, complementary/alternative treatment approaches, and
psychopharmacological intervention.

There is an emphasis upon behavioral medicine/health psychology and the role of

cognitive/behavioral approaches in the modification of risky health behavior. Special attention is
given to the crucial role of cultural factors within the doctor-patient encounter and health care setting,
as well as to the importance of cultural competence in the provision of medical care. The role of the
family is noted within this context, and life-disrupting disorders, such as substance abuse, domestic
violence, and child abuse are discussed with reference to the physicians role and responsibility, in
terms of detection and intervention.

Many studies have shown that competency and efficiency in physician patient communication is
linked to enhanced diagnoses and medical outcomes, better patient adherence, improved patient and
physician satisfaction, and less likelihood of malpractice litigation. Training medical students in
communication skills has been shown to result in improved relationship building, time management,
and shared decision-making.

Behavioral medicine is a vast field, and one in which research is advancing rapidly. Health
communication research continues to identify ways in which we can improve our rapport with
patients and more effectively deliver health messages. Research in behavior change is giving
clinicians more tools to help patients overcome behaviors that threaten their health. The increasing
recognition of the interconnected nature of behavioral health topics with other medical issues is
leading to improvements in the management of both types of conditions. And finally, we continue to

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make progress not only in knowing what care to deliver, but in teaching physicians to deliver it and
assessing their ability to do so.

PSYCHOLOGY

Psychology is the study of behavior and mental processes that seeks to both describe and explain
every aspect of human thought, feelings, perceptions, and actions. Behaviors are everything that we
do that can be directly observed. Mental processes refer to the thoughts, feelings, and motives that are
not directly observable. Being a science, it psychology employs the use of systematic methods to
observe, describe, predict, and explain behavior.

The word Psychology comes from two ancient Greek words - psyche which is the mind or the soul
and logos means study.

Psychology aims at discovering the general laws that explain the behaviour of living human beings as
well as other living organisms.
An individual responds to stimulation and by such responses adjusts to the environment. Patients will
therefore respond to the health care system including the health care providers continually as long as
they come into contact with the system. Psychology is a study which focuses on both abnormal as
well as the normal persons. It also attempts to discover the source of knowledge, beliefs, and customs
and to trace the development of thinking and reasoning, so as to find the kinds of environmental
stimulation that produce certain types of activity.
This knowledge of psychology is useful to both the patients and the personnel because it will help
them to find causes of prejudice, the habit of sticking to old practices and ways of health care
utilization.

SOCIOLOGY

Sociology is the study of human social relationships and institutions. The scope of sociology is
extremely wide, ranging from the analysis of passing encounters between individuals in the street up
to the investigation of world-wide social processes.

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Sociology offers a distinctive and enlightening way of seeing and understanding the social world in
which we live and which shapes our lives. Sociology looks beyond normal, taken-for-granted views
of reality, to provide deeper, more illuminating and challenging understandings of social life.
Through its particular analytical perspective, social theories, and research methods, sociology is a
discipline that expands our awareness and analysis of the human social relationships, cultures, and
institutions that profoundly shape both our lives and human history.

It describes and analyses social behaviour. It seeks to discover how human society has come to be the
way it is, and reveal the social forces that shape peoples lives. Society shapes what we do, how we
do it, and how we understand what others do.

Medical Sociology

This is one of the biggest branches of sociology, and has become an important component of health
care disciplines such as public health, health care management, clinical medicine and nursing. It
involves a sociological analysis of medical organizations, the actions of healthcare professionals, and
the social and cultural effects of medical practice. The field of medical sociology regularly interacts
with the sociology of science, knowledge, and technology studies, while also working alongside
social epistemology. Medical sociologists are interested in the experiences of patients and the health
systems.

MEDICAL ANTHROPOLOGY

Medical anthropology is the study of human health and disease as they are influenced by one's culture
and society.

The applied anthropology of medicine can be defined as the merger of the biomedical study of
disease with the sociobehavioral ramifications of disease. It results from the fact that the cumulative
effects of a medical illness are what people ultimately experience, and that experience is colored by
the patient's background, behavior and beliefs. For instance even biologist determines that
tuberculosis is caused by the pathogen mycobacterium, the behavioral scientist will determine that
tuberculosis is a result of poor nutrition and low socioeconomic status.

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PRINCIPLES OF BEHAVIOURAL SCIENCES

This is a set of principles for practice, derived from multiple behavioral science theories and having
many direct implications for practice. Health educators who are knowledgeable of these principles
may be better prepared to consolidate their knowledge of multiple theories and better prepared to
derive implications for practice from their theoretical knowledge.

Principle 1: Interventions as a series of highly specific behavior change objectives and of delivering
interventions so that individuals have the opportunity to begin 'where they are' in the process, and
proceed incrementally from there. Individuals change differently and change in most cases is gradual.

Principle 2: Psychological factors, notably beliefs and values, influence how people behave

For example, individuals make attributions about the causes of specific events; they have
expectations about the likelihood of certain outcomes. It is important to understanding the
relationships between beliefs and values, as well as their relationships with behavioral variables, is
key to understanding some of the important differences between behavioral science theories.

Principle 3: The more beneficial or rewarding an experience, the more likely it is to be repeated; the
more punishing or unpleasant an experience, the less likely it is to be repeated.

The positive or negative aspect of any experience, whether psychological or behavioral, is

subjectively defined

Principle 4: Behavioral experience can influence individuals' expectancies and values. That means
that, individuals can modify their beliefs and values as a result of behavioral experience.

Principle 5: Individuals have a proactive role in the behavior change process.

Principle 6: Social relationships and social norms have a substantial and persistent influence on how
people behave.

Principle 7: Behavior is not independent of the context in which it occurs; people influence, and are
influenced by, their physical and social environments. The principle underscores the fact that health

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behaviors are influenced by an array of biologic, psychological, social, physical, economic and
regulatory factors.

Principle 8: The process of applying behavioral science theories in practice situations should be
guided by research and evaluation methods thought to explain variation in health

Review questions

1. What is the importance of studying medical anthropology and sociology as health care providers?

2. With the use of the principles in this chapter explain how you would hanle a child brought to
casualty because of drug addiction.

References

Gade, Jonathan; Barry, Mike; Elston, Mary Ann, (2005). Key concepts in medical sociology. Sage
Publications, London.

Kerr Anne, (2004). Genetic and society: a sociology of disease. Routledge, London.

Scambler, Graham (ed), (2003). Sociology as applied to medicine (5th ed.). saunders, Edindurg.
Helman, Cecil, G., (2001). Culture, Health and Illness (4th ed.). Arnold, London.

Edward P. Sarafino Health Psychology: Biopsychosocial Interactions, (6th Ed), Wiley publishers

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 CHAPTER TWO

HUMAN DEVELOPMENT

At the end of the chapter, the learner should

Describe normal developmental events in infancy and childhood that might influence
behaviour
Discuss the major arguments in the nature vs nurture controversy in human
Discuss several theories of human development

Human beings have a typical life course that consists of successive phases of growth, each of which
is characterized by a distinct set of physical, physiological, and behavioral features. These phases are
prenatal life, infancy, childhood, adolescence, and adulthood (including old age). Human
development, or developmental psychology, is a field of study that attempts to describe and explain
the changes in human cognitive, emotional, and behavioral capabilities and functioning over the
entire life span

An understanding of child development is essential, allowing us to fully appreciate the cognitive,

emotional, physical, social and educational growth that children go through from birth and into early
adulthood. The understanding of human development can be viewed from different perspectives
among them;

1. Psychodynamic approach

The theories proposed by Sigmund Freud stressed the importance of childhood events and
experiences, but almost exclusively focused on mental disorders rather that normal functioning.

Major theorists include Sigmund Freud and Erik Erikson

Psychodynamic Approach Assumptions

1. Our behavior and feelings are powerfully affected by unconscious motives.

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 2. Our behavior and feelings as adults (including psychological problems) are rooted in what we
experienced as children.

3. All behavior has a cause (usually unconscious), even slips of the tongue. Therefore all
behavior is determined.

4. Personality is made up of three parts the id, the ego and the super ego

5. Behavior is motivated by two instinctual drives: Eros (the sex drive & life instinct) and
Thanatos (the aggressive drive & death instinct). Both these drives come from the id.

6. Parts of the id and superego which is the unconscious part, are in constant conflict with the
conscious part of the mind (the ego).

2. Cognitive Child Development Approach

These theories are based on the fact that children think differently from adults and focus on a stage
theory of cognitive development. A major theorist is Jean Piaget who was the first to note that
children play an active role in gaining knowledge of the world. According to his theory, children can
be thought of as "little scientists" who actively construct their knowledge and understanding of the
world.

3. Behavioral Child Development Approach

Behavioral theories of child development focus on how environmental interaction influences

behavior.

Major theorists include Ivan Pavlov and B. F. Skinner. These theories deal only with observable
behaviors and development is viewed as a reaction to rewards, punishments, stimuli and
reinforcement.

Psychosexual theory
The theory was in response mainly to patients with hysterical symptoms who had reported sexual
traumas that occurred early in their lives and the subsequent repression, or subconscious "pushing
away", of these sexual traumas as well as other uncomfortable thoughts of previous life events.

Freud's theory subdivides the human mind into three distinct categories; the conscious, pre-conscious

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and sub-conscious areas.

The conscious mind consists of those things of which we are currently aware and to which we are
currently attentive including our current thinking processes, behaviors and environmental awareness.
The preconscious mind consisted of all those things of which we are aware, but currently are not
attentive. According to Freud, we can choose to pay attention to these and deliberately bring them
into the conscious mind.

The subconscious level, is where the process and content are out of direct reach of the conscious
mind. The subconscious thus thinks and acts independently.

According to Freud, child development is achieved through 'psychosexual stages namely oral, anal,
phallic, latency and genital.

In every stage of child development there are certain needs and demands.

The Oral Stage

The oral stage begins at birth, when the oral cavity is the primary focus of libidal energy. The child,
of course, preoccupies himself with feeding, with the pleasure of sucking and accepting things into
the mouth. The oral character who is frustrated at this stage, whose mother refused to nurse him on
demand, is characterized by pessimism, envy, suspicion and sarcasm. On the other hand if a child's
mother overindulged in the oral character, and was always and often excessively satisfied, eventually
becomes optimistic and appreciates those around him.

The Anal Stage

At one and one-half years, the child enters the anal stage. Around this time, has obsession with the
erogenous zone of the anus and with the retention or expulsion of the faeces. The child has conflicting
urges guided by the id, the ego and the superego, whereby the id derives pleasure in voiding the
waste, and the ego and the superego controlling this process as per the societal norms.

If the child manages is allowed to void his faeces caressly by very lenient parents, this can result in
the formation of an anal expulsive character. This character is generally messy, disorganized,
reckless, careless, and defiant. Conversely, a child may opt to retain feces, thereby spiting his parents
while enjoying the pleasurable pressure of the built-up feces on his intestine. If this tactic succeeds

13
and the child is overindulged, he will develop into an anal retentive character. This character is neat,
precise, orderly, careful, stingy, withholding, obstinate, meticulous, and passive-aggressive.

The Phallic Stage

The phallic stage is the setting for the greatest, most crucial sexual conflict in Freud's model of
development. In this stage, the child's erogenous zone is the genital region.

Fixation at the phallic stage develops a phallic character, who is reckless, resolute, self-assured, and
proud. The failure to resolve the conflict can also cause a person to be afraid or incapable of close
love; Freud also postulated that fixation could be a root cause of homosexuality.

Latency Period

The resolution of the phallic stage leads to the latency period, which is not a psychosexual stage of
development, but a period in which the sexual drive lies dormant. Freud saw latency as a period of
unparalleled repression of sexual desires and erogenous impulses. During the latency period, children
pour this repressed libidal energy into asexual pursuits such as school, athletics, and same-sex
friendships. But as soon they get to the puberty stage, and the genitals once again become a central
focus of libidal energy.

The Genital Stage

In the genital stage, as the child's energy once again focuses on his genitals, interest turns to
heterosexual relationships. The less energy the child has left invested in unresolved psychosexual
developments, the greater his capacity will be to develop normal relationships with the opposite sex.
If, however, he remains fixated, particularly on the phallic stage, his development will be troubled as
he struggles with further repression and defenses.

Psychosocial theory of development

Developed by Erik Erikson

Although greatly influenced by Freud, he developed an interest in how children socialize and how
this affects their sense of self.

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He saw personality as developing throughout the lifetime and looked at identity crises at the focal
point for each stage of human development. He divided this development into eight distinct stages,
each with two possible outcomes. According to the theory, successful completion of each stage results
in a healthy personality and successful interactions with others. On the other hand, if an individual
does not successfully complete a stage, this could result in a reduced ability to complete further stages
and therefore a more unhealthy personality and sense of self.

1. Trust Versus Mistrust (birth - 1 year)

In this stage the child will develop a sense of basic trust in the world and in his ability to affect events
around him. If the caregiver is consistent predictable and caring, the child will develop a sense of
trust as compared to where the care has been harsh or inconsistent, unpredictable and unreliable in
which case then the child will develop a sense of mistrust and will not have confidence in the world
around them or in their abilities to influence events.

In life this person may insecure in relationships resulting because he/she deeply mistrusts other
people.

2. Autonomy vs. Shame and Doubt (2 - 3 years)

This is the stage where children begin to assert their independence, by walking away from their
mother/care giver.

Erikson says that this is the point at which the child can develop a certain amount of
independence/autonomy. The child needs encouragement so as to develop a sense of independence
whilst at the same time protecting the child so that constant failure is avoided.

If children in this stage are encouraged and supported in their increased independence, they become
more confident and secure in their own ability to survive in the world. If children are criticized,
overly controlled, or not given the opportunity to assert themselves, they begin to feel inadequate in
their ability to survive, and may then become overly dependent upon others, lack self-esteem, and feel
a sense of shame or doubt in their own abilities.

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3. Initiative vs. Guilt (3 - 5 years)

In this stage children start to plan and initiate activities with others. When the parents guide them
properly, children develop a sense of initiative, and feel secure in their ability to lead others and make
decisions. If however, the parents overly criticize or control, children develop a sense of guilt.

4. Industry (competence) vs. Inferiority (6 - 12 years)

Children are at the stage where they will be learning to read and write, to do sums, to make things on
their own. Teachers begin to take an important role in the childs life as they teach the child specific
skills. It is at this stage that the childs peer group will gain greater significance and will become a
major source of the childs self esteem. The child now feels the need to win approval by
demonstrating specific competences that are valued by society, and begin to develop a sense of pride
in their accomplishments.

If children are encouraged and reinforced for their initiative, they begin to feel industrious and feel
confident in their ability to achieve goals. If this initiative is not encouraged, if it is restricted by
parents or teacher, then the child begins to feel inferior, doubting his own abilities and therefore may
not reach his potential.

5. Identity vs. Role Confusion (13 - 18 years)

This is a crucial stage in human development. During adolescence, the transition from childhood to
adulthood is most important. Children are becoming more independent, and begin to look at the
future in terms of career, relationships, families, housing, etc.

Erikson suggests that two identities are involved: the sexual and the occupational. The adolescent
may feel uncomfortable about their body for a while until they can adapt and grow into the
changes. 6. Intimacy vs. Isolation (young adulthood)

This is when young adults start intimate relationships with others. If this stage is well handled, the
young adult can be able to start enduring relationships. Avoiding intimacy, fearing commitment and
relationships can lead to isolation, loneliness, and sometimes depression.

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7. Generativity vs. Stagnation (middle adulthood)

During middle adulthood, we establish our careers, settle down within a relationship, begin our own
families and develop a sense of being a part of the bigger picture. By failing to achieve these
objectives, we become stagnant and feel unproductive.

8. Integrity vs. Despair (old age)

As we grow older, human beings tend to slow down in productivity. Indeed those who are employed
also retire. It is during this time that people contemplate their accomplishments and are able to
develop integrity if they feel that they are leading a successful life.

Review questions

1. How does ego versus id conflict affect patients compliance with proper queuing at the health
records department.

2. Describe the Erik Erikson stages of development

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 CHAPTER THREE

HUMAN BEHAVIOUR

The learner should be

Able to describe how human behaviour is shaped

Describe the socialization process
Describe the basic principles of personality

Human behaviour is experienced throughout an individuals entire lifetime. It includes the way they
act based on different factors such as genetics, social norms, and attitude. The traits vary from person
to person and can produce different actions or behaviour from each person. Social norms determine
which behaviours are acceptable or unacceptable. This determines how they will view their
symptoms, seek help from the health care workers, the way they relate with the workers and indeed
the way they will take medication and respond to treatment.

Factors affecting human behavior and actions

Genetics: Human behaviour can be affected in many ways, one of which is genetics. Everyone has
different traits such as intelligence and shyness which they inherit through heredity. These traits
impact human behaviour and there are indications that behaviour is affected by genetics.

Social Norms: Social norms are essential in understanding human behavior. Norms is described as an
unwritten rule on how society must behave, and what majority of people believe about others and
how they should act in a particular social group or culture. An example of a social norm would be
students, and how they are expected to attend school on time and complete any task given to them by
the teacher (Perkins, 2006). Having norms allows people to have an understanding of social influence
in a general and orthodoxy way. The types of groups that affect a person social norm would range
from friendships, family members, workplace, and state.

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Socialization is defined as the process of learning ones culture and how to live within it. It can be

Primary socialization is the process whereby people learn the attitudes, values, and actions
that conform to a certain culture. The major institution responsible for this type of learning is
the family.
Secondary socialization refers to process of learning - what is appropriate behaviour as a
member of a smaller group within the larger society. Involves peers, and entails smaller
changes than those occurring in primary socialization.

Agents of Socialization

These are specific groups representing and working on behalf of the society in carrying out the
socialization process. These are
1. Family
2. School
3. Media
4. Religion
5. Peers

The family is the earliest and the most influential agent of socialization. The child is socialized from
birth, when the child is most helpless and dependent, and doesn't let go for a whole lifetime.
Socialization in the family is continuous. The individual learns language, body abilities, emotional
control and moral values in the family setup.

Mass media
This is a secondary agent of socialization comes through the characters, images, words, and narrative
story lines and specific programmes.
Children as well as adults spend as much or more time in front of the TV rather than interacting with
others. Messages and values carried by the media can be powerful and seductive. Many of those
messages and values challenge or directly contradict what parent's teach their children.
Media influence continues and strengthens in adolescence based on a merger of teen subculture, pop
culture (music & movies), and corporate marketing.

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The power of the media declines in adult years but still remains strong.

Religion

The role of religion and spirituality in the lives of children and young adults is still a big issue in the
developing world. The role of religion as an agent of socialization cannot be ignored. It is a primary
transmitter of our core personal and societal values. Without the socializing influences of religion, the
powerful external forces faced by teens drugs, a sexualized culture, violence, negative peer
pressures, and other dysfunctional influences become more influential. Parents need to be aware of
the stabilizing influences of religion in a childs life and realize that religion is not so much a
polarizing issue as it is an important element of the socialization process.

Peer Groups
Peers are people of roughly the same age (same stage of development and maturity), similar social
identity, and close social proximity. With peers, the child begins to broaden his or her circle of
influence to people outside of the immediate family.
As childhood progresses in age, peer group interactions become more autonomous (less observed and
supervised by adults). The lessons learned also progress from basic rules of group interaction to more
complex strategies of negotiation, dominance, leadership, cooperation, compromise, etc. These
lessons are learned first in play and later through games. Peers also establish the platform for children
to begin challenging the dominant power of parents and family.
influence of peers seriously declines as an agent of socialization, only to return during the elderly
years.

School
Today the process often starts earlier in Kindergarten or day care where our children are taken at a
very early age. Socialization takes three forms in school-
Official curriculum which involves acquisition of knowledge in school.
Social curriculum which is involve in the learning of social behavior appropriate for peer
groups that are not friendship groups, which then become the model for secondary group
interactions. Many of the skills learned in peer groups are transferable but now the child

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 learns to communicate, negotiate, dominate, etc. with peers outside of their immediate social
circle, often from diverse social backgrounds.
Hidden curriculum where learning of rules of behavior needed for functioning in formally
organized groups takes place. It includes such behavior maxims as Get your assignments in
on time.

APPROACHES TO UNDERSTANDING HUMAN BEHAVIOUR

Understanding behaviour is dependent on the particular view point taken, in other words, how any
behaviour is interpreted will depend on the theory used to explain it. For example, some scholars
would argue that smoking is encouraged by the approval by peers and the significant others while
others will look at the same behavior as failure resolve some childhood conflicts. There are five
approaches.

1. Biological perspective.
The psychologist working from this viewpoint is interested in how biology can assist in enabling us
to understand ourselves. The emphasis is on the growth and development of the fetus, and continues
with a study of biological changes which take place right through the course of a lifetime.
2. The behaviourist perspective
The focus in this perspective is on the relation between objects, people or events in the environment
(stimuli) and the persons response to these objects or events. It takes the view that human behaviour
can be understood entirely without reference to internal states such as thoughts or feelings.
B.F.Skinner observed that the behaviour of animals and people can be controlled by environmental
conditions that either increase the likelihood of the behavior being repeated (through reinforcement)
or decrease the likelihood of a repetition of the behaviour (through punishment). He developed a
theory around the notion of reinforcing behaviour. He believed that behaviour can be understood as a
learned response to environmental events, and that behaviours are selected on the basis of their
consequences.
3. The Psychoanalytic perspective
In this perspective, behavior is viewed as being a result of activities of not only the conscious but
also the unconscious mind is presumed to have an influence on how we behave. This approach is
derived from Freuds psychoanalytical theories in which the central concept is the unconscious mind.

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Freud considered that the mind is the principal determinant of motivation and personality and that
what happens in our first five years of life is crucial to the formation of adult personality. He
described three aspects of mind namely, the id, ego and superego.
The ego represents reason (rationality) which must be in control of both the other two aspects in order
to enable the person to conform to social demands.
The id represents the natural urges which want immediate gratification, while the superego represents
social/cultural sanctions and can be as insistent as the id.

4. Cognitive developmental perspective

Some of the scholars associated with this perspective are Jean Piaget and Lawrence Kohlberg.
The cognitive process is defined as the psychological processes through which we acquire, store and
use knowledge. Human behaviour is viewed as being as being a result of cognition or thought. For
these scholars of behavior, a human being is like a computer and the human being is viewed as one
who gets a lot of information from the environment which is transformed, stored, and retrieved using
various mental programmes, leading to specific response outputs or behaviours.

The humanistic perspective

It emphasizes on a positive approach to the analysis human being as evolving towards actualization or
the full development of the self. . Carl Rogers is one of the psychologists recognized as coming from
this perspective. He holds that the 'self' is a dynamic concept which has many aspects to it. The
individuals notion of his/her self is grounded in social relationships and as such while trying to
understand behavior, the relationships within a family or a school or a group of friends are an integral
part. Carl Rogers views the person as being very vulnerable to the positive regard that people
emotionally close to her/him feel for her/him.

PERSONALITY

The term personality is derived from the Latin word persona, which means mask.
Personality is the sum total of all that an individual is everything that constitutes a
Individuals physical, mental, emotional, and temperamental make-up. This is a dynamic concept
describing the growth and development of a persons whole psychological system. This set of

22
characteristics possessed by a person that uniquely influence his/ her cognitions, motivations, and
behaviours in various situations. No two people have exactly the same personalities - not even
identical twins. People differ in intelligence, abilities, ambition, motivations etc. To understand,
explain, or predict human behaviour we therefore need to focus on individual differences.
Patients/Clients coming to our health care facilities are therefore not homogeneous in their behavior
and this should be taken into account as we strive to serve them.
The most frequently used definition of personality was produced by Gordon Allport (1937) which
states that personality is the dynamic organization within the individual of those psychophysical
systems that determine his unique adjustments to his environment.
Robbins (2001) defined personality as the sum total of ways in which individual reacts to and
interacts with others. It is most often described in terms of measurable traits that a person exhibits.

DETERMINANTS OF PERSONALITY

Nature versus nurture

Since the use of the phrase "Nature versus nurture" by the Francis Galton (1883) in discussion of the
influence of heredity and environment on social advancement, there have been a lot of debates as to
what relative roles are played by nature and nurture on human development. This debate concerns the
relative importance of an individual's innate qualities ("nature," i.e. nativism, or innatism) versus
personal experiences ("nurture," i.e. empiricism or behaviorism) in determining or causing individual
differences in physical and behavioral traits. Some scholars argue that
human beings acquire all or almost all their behavioral traits from the upbringing and the environment
(nurture) while others think otherwise. However, it has generally been accepted that personality is
made up of hereditary and environmental factors and moderated by situational conditions.

Heredity refers to those factors that were determined at conception. These include Physical stature,
gender, temperament, and reflexes, and biological rhythms are characteristics. These we inherit from
our parents where genes transmit their biological, physiological, and inherent psychological makeup.
The hereditary approach argues that the ultimate explanation of an individuals personality is the
molecular structure of the genes, located in the chromosomes.

23
Evidence demonstrates that traits such as shyness, fear, and distress are most likely caused by
inherited genetic characteristics. If personality characteristics were completely dictated by heredity,
they would be fixed at birth and no amount of experience could alter them.

Environment to which we are exposed plays a substantial role in shaping our personalities.
For example, culture establishes the norms, attitudes, and values that are passed along from one
generation to next and create consistencies over time. Thus, a lot of the behaviours exhibited by the
patients and the personnel have been transmitted culturally. The way the patients will queue at the
health records department will be from the way we have been socialized either to be or not to be
orderly. The environment factors that exert pressures on our personality formation are culture in
which we raised, our early conditioning, the norms among our family, friends, social groups etc that
we experience.
Situation influences the effects of heredity and environment on personality. An individuals
personality, although generally stable and consistent, does change in different situations. In situations
where the system is corrupt for instance, the patients are likely to try and conform to achieve good
health.

Abraham Maslows theory of personality

Maslow was a humanist, those that do not believe that human beings are pushed and pulled by
mechanical forces, either of stimuli and reinforcements (behaviourism) or of unconscious instinctual
impulses (psychoanalysis). This group of scholars believe that the human being always strive to be
better.

Maslow has set up a hierarchy of five levels of basic needs.

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Physiological Needs
These are biological needs such as food, water, and a relatively constant body temperature. They are
the strongest needs because if a person were deprived of all needs, the physiological ones would
come first in the person's search for satisfaction.
Safety Needs
When all physiological needs are satisfied and are no longer controlling thoughts and
behaviours, the needs for security can become active. Adults have little awareness of their security
needs except in times of emergency or periods of disorganisation in the social structure (such as
widespread rioting). Children often display the signs of insecurity and the need to be safe.

Needs of Love, Affection, and Belongingness

When the needs for safety and for physiological well-being are satisfied, the next class of needs for
love, affection, and belongingness can emerge. Maslow states that people seek to overcome feelings
of loneliness and alienation. This involves both giving and receiving love, affection and the sense of
belonging.

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Needs for Esteem
When the first three classes of needs are satisfied, the needs for esteem can become dominant. These
involve needs for both self-esteem and for the esteem a person gets from others. Humans have a need
for a stable, firmly based, high level of self-respect, and respect from others. When these needs are
satisfied, the person feels self-confident and valuable as a person in the world. When these needs are
frustrated, the person feels inferior, weak, helpless, and worthless.

Needs for Self-Actualization

Maslow describes Self Actualization as the intrinsic growth of what is already in the organism, or
more accurately, of what the organism is."Self-actualization implies the attainment of the basic needs
of physiological, safety/security, love/belongingness, and self-esteem.
Gordon Allports Trait Theory

ALLPORTS TRAIT THEORY

He categorized these personality traits into three levels
1. Cardinal Traits:-These are traits that dominate an individuals whole life, often to the
point that the person becomes known specifically for these traits. People with such
personalities often become so known for these traits that their names are often synonymous
with these qualities.
2. Central Traits:-These are the general characteristics that form the basic foundations of
personality. These central traits, while not as dominating as cardinal traits, are the major
characteristics you might use to describe another person. Terms such as intelligent, honest,
shy and anxious are considered central traits.

3. Secondary Traits:- These are the traits that are sometimes related to attitudes or
preferences and often appear only in certain situations or under specific circumstances.
Some examples would be getting anxious when speaking to a group or impatient while
waiting in line.

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PERSONALITY TYPES BASED ON TEMPERAMENT
The sanguine type is cheerful and optimistic, pleasant to be with, comfortable with his or her work.
According to the Greeks, the sanguine type has a particularly abundant supply of blood (hence the
name sanguine, from sanguis, Latin for blood) and so also is characterized by a healthful look,
including rosy cheeks.
The choleric type is characterized by a quick, hot temper, often an aggressive nature. The name
refers to bile (a chemical that is excreted by the gall bladder to aid in digestion). Physical features of
the choleric person include a yellowish complexion and tense muscles.
Phlegmatic temperament. These people are characterized by their slowness, laziness, and dullness.
The name obviously comes from the word phlegm, which is the mucus we bring up from our lungs
when we have a cold or lung infection.
Melancholy temperament. These people tend to be sad, even depressed, and take a pessimistic view
of the world. The name has, of course, been adopted as a synonym for sadness, but comes from the
Greek words for black bile.

PERCEPTION
Perception is the process or the capability to attain awareness and understand the environment
surrounding us by interpreting, selecting and organizing different type of information. After this
process of interpreting and organizing the information, then the organism evokes some response.
Perception can be shaped by our learning, experiences and education.
Through the perceptual process, we gain information about properties and elements of the
environment that are critical to our survival. Perception not only creates our experience of the world
around us; it allows us to act within our environment. The health care system is replete with examples
where perception plays an important role in utilization of health care.
Perception includes the five senses; touch, sight, taste smell and taste. It also includes what is known
as proprioception, a set of senses involving the ability to detect changes in body positions and
movements.

The Perceptual Process

The perceptual process is a sequence of steps that begins with the environment and leads to our
perception of a stimulus and an action in response to the stimulus. This process is continual, but you

27
do not spend a great deal of time thinking about the actual process that occurs when you perceive the
many stimuli that surround you at any given moment.
The process of transforming the light that falls on your retinas into an actual visual image happens
unconsciously and automatically. The subtle changes in pressure against your skin that allow you to
feel object occur without a single thought.

ATTITUDE

An attitude can be defined as a positive or negative evaluation of other people, objects, event,
activities and ideas. These are lasting patterns of beliefs and opinions which predispose reactions to
objects, events, and people. Attitudes can be explicit and implicit in nature.

Dimensions of Attitudes

1. Attitude strength: Strong attitudes are those that are firmly held and that highly influence
behavior.
2. Attitude accessibility: The accessibility of an attitude refers to the ease with which it comes
to mind. In general, highly accessible attitudes tend to be stronger.
3. Attitude ambivalence: Ambivalence of an attitude refers to the ratio of positive and negative
evaluations that make up that attitude.

The Influence of Attitudes on Behavior

Behavior does not always reflect attitudes. However, attitudes do determine and influence behavior
in some situations.

Attitudes structure can be described in terms of three components.

1. Affective component: this involves a persons feelings / emotions about the attitude object.
For example: I am scared of spiders.

2. Behavioral component: the way the attitude we have influences how we act or behave.

3. Cognitive component: this involves a persons belief / knowledge about an attitude object. For
example: I believe spiders are dangerous.

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The Function of Attitudes

Daniel Katz (1960) outlines four functional areas-

Knowledge. Attitudes provide meaning (knowledge) for life. The knowledge function refers to our
need for a world which is consistent and relatively stable. This allows us to predict what is likely to
happen, and so gives us a sense of control.

Self / Ego-expressive. The attitudes we express (1) help communicate who we are and (2) may
make us feel good because we have asserted our identity. Therefore, our attitudes are part of our
identity, and help us to be aware through expression of our feelings, beliefs and values.

Adaptive. If a person holds and/or expresses socially acceptable attitudes, other people will reward
them with approval and social acceptance. Attitudes then, are to do with being apart of a social group
and the adaptive functions helps us fit in with a social group.

The ego-defensive function refers to holding attitudes that protect our self-esteem or that justify
actions that make us feel guilty.

DEFENSE MECHANISMS

Defense mechanism is defined as the behavior of a person manifest to cope the uncomfortable
situations affecting his emotions. They are important in able to form a healthy relationships or help us
cope with unhealthy experiences and realities. Defense mechanisms can be good in that they allow us
to adjust to our environment. Or, they can become a problem when they prevent us from facing and
living in reality.

Defense mechanisms protect us from being consciously aware of a thought or feeling which we
cannot tolerate. They allow the unconscious thought or feeling to be expressed indirectly in a
disguised form. They help individuals to defend themselves against threat and to avoid or manage
powerful, threatening feelings. They begin as healthy adaptations to deal with anxiety, grief, fear,
anger, hurt, etc. they are important in the maintenance of self-esteem and a positive sense of self.

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 Human beings have preferred defenses that have become incorporated into their individual styles
of coping. Our preferences for particular defenses develop from an interaction of several factors
including one's inborn temperament, the defenses our parents modeled for us, types of stress we were
exposed to in early childhood, and the reinforcement or consequences of using the particular
defenses.

There are categories of defenses ranging from primitive defenses (meaning that the defenses
originated in infancy and function on a global, undifferentiated level in a person's total
mental/behavioral/feeling experience), to more mature, advanced defenses, which make specific
transformations of thought, feeling, behavior, or some combination.

1. Denial

This is a primitive defense mechanism. Denial involves blocking external events from awareness
when the situation is just too much to handle. In other words, when you use denial, you simply refuse
to accept the truth or reality of a fact or experience. A cancer of the colon patient might deny ever
having experienced blood stained stools in which case the making of a diagnosis becomes more
difficult.

2. Repression

Repression involves simply forgetting any bad experience encountered. A person who uses this kind
of defense mechanism will simply keep any disturbing or threatening thoughts from becoming
conscious. A patient who is afraid of surgery, probably because of a past experience might forget
an appointment for surgery.

It is worth noting that more often than not though temporarily beneficial, if it is not dealt with the
repressed experience will come back to haunt the individual.

3. Regression

When we are troubled or frightened, our behaviors often become more childish or primitive. A child
may begin to suck their thumb again or wet the bed when they need to spend some time in the
hospital.

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4. Displacement

In displacement you transfer your original feelings that would get you in trouble (usually anger) away
from the person who is the target of your rage to a more hapless and harmless victim.

5. Projection.

This involves individuals attributing their own thoughts, feeling and motives to another person.
Thoughts most commonly projected onto another are ones that would cause guilt such as aggressive
and sexual fantasies or thoughts. For instance, you might hate someone, but your superego tells you
that such hatred is unacceptable. You can 'solve' the problem by believing that they hate you.

6. Reaction formation.

In this defense mechanism, a person shows the opposite attitude to what which you truly possess. A
man who has lustful feelings for a lady might start saying how bad the lady is.

7. Intellectualization.

This involves neutralizing ones feelings of anxiety or anger, or insecurity in a way that is less likely
to lead to embarrassing moments. Patients are sometimes embarrassed by the labeling given to them
during the diagnosis process. For instance those diseases which carry with them stigmatization will
make a patient want to hide the fact that they have been diagnosed as having those diseases. This is
because the think and believe that no one will accept them with that kind of ailment. Therefore,
rather than confront the intense distress and rejection, they might start looking at it as this was the
will of God as everything is predestined to happen.

7. Rationalization

As a defense mechanism, rationalization involves dealing with a piece of bad behavior on your part
rather than converting a painful or negative emotion into a more neutral set of thoughts.

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It involves the cognitive distortion of "the facts" to make an event or an impulse less threatening. A
patient who has lost the card may tell the attending health care work that the card was left in the
hospital the last time he/she was attended to.

8. Sublimation

Sublimation involves redirecting unacceptable sexual or aggressive impulses to socially acceptable

ones. Sublimation develops over a long period of time

Review questions

1. How are defense mechanisms to the understanding of patients behavior?

2. Discuss Abraham Maslows model

3.Differentiate between perception and attitude

References

Allport, G.W. & Odbert, H.S. (1936). Trait-names: A psycho-lexical study. Psychological
Monographs, 47(211).

Boeree, C.G. (2006). Gordon Allport. Personality Theories. Found online at

http://webspace.ship.edu/cgboer/allport.html Cattell, R.B. (1965). The scientific analysis of
personality. Baltimore: Penguin Books. Eysenck, H.J. (1992). Four ways five factors are not basic.
Personality and Individual Differences, 13, 667-673.

Kerr Anne, (2004). Genetic and society: a sociology of disease. Routledge, London

McCrae, R.R., & Costa, P.T. (1997) Personality trait structure as a human universal. American
Psychologist, 52, 509-516.

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 CHAPTER FOUR

BIOLOGICAL BASIS OF BEHAVIOR

At the end of the learner should be

Able to describe how human brain affects behaviour

Describe the mind body interaction

Biology is defined as the study of life and human beings go through this journey of life responding to
different stimuli and therefore exhibiting different behaviours.

A biological perspective is relevant to the study of behaviour in several ways:

1. Comparative method: different species of animal can be studied and compared. This can help in
the search to understand human behavior.

2. Physiology: how the nervous system and hormones work, how the brain functions, how changes
in structure and/or function can affect behavior.

The brain is a network that controls our behaviors and mental processes. Most scientists believe that
behavior is determined by the interaction of the environment and the organism's biological

BRAIN AND THE NERVOUS SYSTEM

Our nervous system plays a vital role in how we think, feel and act. Neurons, the basic building
blocks of the body's circuitry, receive signals through their branching dendrites and cell bodies
and transmit electrical impulses down their axons. Chemical messengers called neurotransmitters
traverse the tiny synaptic gap between neurons and pass on excitatory or inhibitory messages.
The central nervous system consists of the brain and spinal cord. The peripheral nervous system
consists of the somatic nervous system, which directs voluntary movements and reflexes, and the
autonomic nervous system, which controls the glands and muscles of our internal organs.

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inheritance and therefore the brain becomes an important aspect of behavioural studies.

The nervous system is divided into the central nervous system and the peripheral nervous system. The
central nervous system consists of the brain and spinal cord. The peripheral nervous system connects
the brain and spinal cord to the other parts of the body. The peripheral nervous system is divided into
the somatic nervous system, which contains sensory and motor nerves, and the autonomic nervous
system, which monitors the body's internal organs.

The nervous system is made up of interconnected nerve cells that transmit information throughout the
body. Cells that carry input to the brain are called afferent neurons and those that carry output from
the brain are called efferent neurons. Most of the communication in the nervous system takes place
through neural networks, which are nerve cells that integrate sensory input and motor output.

The midbrain is an area where many nerve-fibers ascend and descend and relay information between
the brain and the eyes and ears. An important structure of the midbrain is the reticular formation. The
highest region of the brain is the forebrain. Its major structures included the limbic system, thalamus,
basal ganglia, hypothalamus, and cerebral cortex. Each performs certain specialized functions
involving emotion, memory, senses, movement, stress, and pleasure. The cerebral cortex comprises
the largest part of the brain and consists of two hemispheres (left and right) and four lobes (occipital,
temporal, parietal, and frontal). The cerebral cortex consists of the sensory cortex, motor cortex, and
association cortex. Two important areas in the cerebral cortex involved in language are Broca's area
and Wernicke's area. The two hemispheres are connected by the corpus callosum. No complex
function can be assigned to one single hemisphere or the other. There is interplay between the two
hemispheres.

A number of important body reactions produced by the autonomic nervous system result from its
action on the endocrine glands. The endocrine system is a set of glands (pituitary, thyroid,
parathyroid, adrenal, pancreas, and the ovaries in women and testes in men) that regulate the activities
of certain organs by releasing hormones into the bloodstream. The anterior part of the pituitary is
called the master gland; it is controlled by the hypothalamus. The adrenal glands play an important
role in mood, energy, and stress.

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GENES

Genes are located within all the cells of our body and contain the hereditary information of each
individual and they determine a person's characteristics - both physical and mental. For example,
when we know that there is a gene that increases intelligence in an individual, then, studying how
genes can affect a person's mental being is likely to lead to a better understanding about the biological
influences on behavior. We might also want to know whether high intelligence is inherited from one
generation to the next. They serve as blueprints for all living organisms. Some forms of behaviour
seem to be innate or predisposed by genes. However, scientists agree that genes alone do not cause
behaviour, but merely influence how an individual will react to a particular set of environmental and
biographical circumstances. Genes are seen as determinants of behaviour insofar as they code for the
assembly of the neural circuits that are necessary for the development and survival of the organism.

H0RMONES

Hormones released by endocrine glands affect other tissues, including the brain. The most influential
endocrine gland, the pituitary gland, releases hormones that influence growth, and its secretions also
influence the release of hormones by other glands. The nervous system directs endocrine secretions,
which then affect the nervous system.

MIND- BODY INTERACTION

Many patients have respond to treatment by use of placebo, is a substance or other kind of treatment
that looks just like a regular treatment or medicine, but its not. This has made scientists try and
research on the interaction between the body and the mind.

The mind plays an important role in health and disease. A central tenet of mindbody medicine is the
recognition that the mind plays a key role in health and that any presumed separation of mind and
body is false. The medical sciences had relegated this fact to the backyard especially after the
discovery of the antibiotics which gave the notion that the elimination of the disease only required the
elimination of the foreign organism or agent that triggers the illness. However, we all know that

35
social and psychological stress can trigger or aggravate a wide variety of diseases and disorders, such
as diabetes mellitus, high blood pressure, peptic ulcers and migraine headache.

The immune system responds automatically to pathogens and foreign molecules through the cellular
and humoral responses. These two response systems are the body's principal means for maintaining
an internal steady state called homeostasis. The immune system has a direct relationship with the
workings of the brain.

The central nervous and immune systems, however, are more similar than different in their modes of
receiving, recognizing and integrating various signals and in their structural design for accomplishing
these tasks. Both the central nervous system and the immune system possess "sensory" elements,
which receive information from the environment and other parts of the body, and "motor" elements,
which carry out an appropriate response.

The mind-body interaction acts as a two way system where the dysfunction of one will impact on the
other. Psychological factors contribute to the onset or aggravation of a wide variety of physical
disorders, but also physical diseases can affect a person's thinking or mood. People with life-
threatening, recurring, or chronic physical disorders commonly become depressed.

Review questions
How does the mind affect behaviour of an individual?
How is the immunity of an individual influenced by the mind?

References

Bob Garrett (2010), Brain & Behavior: An Introduction to Biological Psychology, New York,Sage
Publishers

Stanford encyclopedia of Philosophy

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 CHAPTER FIVE
CULTURAL BASIS OF BEHAVIOUR

At the end of the chapter, the learner should be able to

1. Define the concept culture

2, Describe how culture influences health and disease.

3. Describe the process of consultation

WHAT IS CULTURE?
All cultures have systems of health beliefs to explain what causes illness, how it can be cured or
treated, and who should be involved in the process. The extent to which patients perceive patient
education as having cultural relevance for them can have a profound effect on their reception to
information provided and their willingness to use it. Western industrialized societies such as the
United States, which see disease as a result of natural scientific phenomena, advocate medical
treatments that combat microorganisms or use sophisticated technology to diagnose and treat disease.
Other societies believe that illness is the result of supernatural phenomena and promote prayer or
other spiritual interventions that counter the presumed disfavor of powerful forces. Cultural issues
play a major role in patient compliance. One study showed that a group of Cambodian adults with
minimal formal education made considerable efforts to comply with therapy but did so in a manner
consistent with their underlying understanding of how medicines and the body work.

Cultural differences affect patients attitudes about medical care and their ability to understand,
manage, and cope with the course of an illness, the meaning of a diagnosis, and the consequences of
medical treatment. Patients and their families bring culture specific ideas and values related to
concepts of health and illness, reporting of symptoms, expectations for how health care will be
delivered, and beliefs concerning medication and treatments. In addition, culture specific values
influence patient roles and expectations, how much information about illness and treatment is desired,
how death and dying will be managed, bereavement patterns, gender and family roles, and processes

37
for decision making.Culture consists of all those things, including actions and beliefs which human
beings (as physical animals) learn, which make them human. Culture includes learned behaviour, but
not things which are determined genetically. Culture is stored and transmitted by symbols; never by
chromosomes. While some culture is learned in childhood (e.g how to talk), other culture is learned
by adults.

Culture is shared, by which we mean that every culture is shared by a group of people. Depending on
the region they live in, the climatic conditions they thrive in and their historical heritage, they form a
set of values and beliefs. Culture is used in two senses, a general and a specific sense.

In general sense, it implied the some total of those characteristics which are unique to
mankind and which have no parallel in the animal kingdom.
In a specific sense, it refers to the totality of the life ways and behavior patterns of a
community or a group.

Definitions

Edward B. Taylor (1871): offered a broad definition, stating that culture is that complex
whole which includes knowledge, belief, art, morals, law, custom, and any other capabilities
and habits acquired by man as a member of society
Franz Boas (1911): Culture may be defined as the totality of the mental and physical
reactions and activities that characterize the behavior of individuals composing a social group
collectively and individually in relations to their natural environment, to other groups, to
members of the group itself and of each individual to himself. It also includes the products of
these activities and their role in the life of the groups. The mere enumerations of these various
aspects of life, however, does not constitute culture. It is more, for its elements are not
independent, they have a structure.
Margaret Mead (1937): Culture means the whole complex of traditional behavior which has
been developed by the human race and is successively learned by each generation. A culture is
less precise. It can mean the forms of traditional behavior which are characteristics of a given
society, or of a group of societies, or of a certain race, or of a certain area, or of a certain
period of time. (p.17)

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 Clifford Geertz (1966): Argues that culture denotes an historically transmitted pattern of
meanings embodied in symbols, a system of inherited conceptions expressed in symbolic
forms by means of which men communicate, perpetuate, and develop their knowledge about
and attitudes toward life... (p.89)

There are so many relations between culture and health. Some sickness comes from someone
cultural habit. Cultural factors significantly influence health and sickness in society. Certain types
of ailments are significantly correlated with such factors as class occupation, ethnicity and food
habits. Diabetes, ulcer, hypertension may be regarded as urban disease, generally connected with
sedentary occupations. Environmental pollution brought about by technological advancement, is
now identified as one of the major causes for the growing incidence of cancer. Consumption of
fatty foods and high salt intake habits are significantly correlated with cardiovascular diseases.
Generally a culture defines what diseases are to be considered as illness, and therefore requiring
treatment. Intestinal worms are regarded as necessary for digestion for the Thonga of Africa and the
Yap islanders. In most primitive societies, diagnosis and treatment of diseases are invariable
associated with magical beliefs and rites and shamanistic practices.

Culture defines what types of food are worthy of consumption by a given people or a community, and
what food items are to be avoided. Consequently, a given food item, which is relished by one people
may be abhorred by another. The aphorism a short sentence packed with meaning, one mans food is
another mans poison is very true in a culture sense. Pork which is forbidden to Jews and Muslims is
eaten with relish by the Christians. Milk and milk products are regarded as luxury food by many
tribes from East Africa and West Africa and Chinese consider them as inedible and nauseating.

A culture presents us with a set of guidelines a formula for living in the world. Just as a biologist
may need a particular culture to allow the growth of a particular organism, social cultures nurture
the growth of people with particular beliefs, values, habits, etc. But, above all, culture provides a
means of communication with those around us. Different styles of communication reflect the
customary habits of people from different cultures. Culture, then is the medium that people use for
communication; it is the lubricant of social relationships.

39
One reason why cultures vary in how their individual members present illness is that different
cultures require different paths to be followed in order to become legitimately ill. If the patient and
the clinician know the rules to be followed each can have faith in the other. The faith of a patient, or
client, in a treatment is often referred to as the placebo effect. This effect applies not just to treatments
but to clinicians as well. When a patient and a clinician come from different cultural groups, this may
influence the degree of faith that a patient has in the treatment offered and in the clinician who is
offering it.
Another aspect of the process of treatment concerns what sort of information is shared between
clinician and client. A cultural difference in diagnostic disclosure (whether clinicians tell their clients
the true diagnosis that they have made) is an example of this. Patients and clinicians are cast in
different roles by different cultures and this affects clinical decision-making. Clinicians are a product
of their culture and so too are their treatments. Sometimes inappropriate therapies can be oppressive.
Culture shapes and determines what a society believes and does about disease and illness. There are
many more aspects to health than simply the biological manifestation of an illness. In a culturally
diverse country like Kenya, there are many beliefs about health versus disease and illness. When
treating patients, it is important for the health care professional to understand that disease and illness
are a result of many interrelated aspects of a person's life, including their natural environment, their
biological self and their socio-cultural environment.

beliefs, opinions, or goals.

SEEKING HELP AND CONSULTING HEALTH PROFESSIONALS

More often than not, the pharmacists are usually the first port of call for members of the public
seeking advice on minor ailments or general health. However, the decision making process leading to
people seeking professional health care or advice is not triggered simply by the onset or the severity
of symptoms. This decision making process is in most cases influenced by how the symptoms are
perceived and interpreted. Furthermore, actions taken in response to symptoms are mediated by other
factors such as the costs and benefits of seeking help, and the responses of friends, colleagues and
relatives to an individuals illness.

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Health care systems all over the world have medical pluralism, where we find competing sectors
within a single society coexisting and forming distinct health subcultures with unique beliefs,
practices, and organizations.

Kleinman (1980) illustrated this medical pluralism in showing that complex societies have three
overlapping sectors or health care systems:

The popular (lay) sector involving culturally based personal and familial beliefs and practices
The folk sector involving cultural ethnomedical traditions and specialists
Professional sector

When a patient has symptoms or any other health concerns, they are initially addressed in the popular
sector with self-assessment and self-help procedures in consultation with significant others. This may
be followed by consultation with folk specialists or, if necessary and available, with biomedical or
other professional services. Biomedical resources may be the first choice but are generally accessed
through decision making at the family (popular) level. These sectors have implications for
biomedicine because they are often used in conjunction with or as an alternative to biomedicine.

Popular (Lay) Sector. The popular sector, also referred to as family care is the basis for most
personal health care decisions. Family members and other interpersonal relations and social networks
generally assist in assessing illnesses and m decisions on when and how to seek help. Knowledge of
popular health beliefs and behavioural patterns gives health care providers the basis for appropriate
interpretations of help-seeking behaviour, symptom presentation and complaints, communication
about the body, and sick-role behaviour and coping strategies. If health care providers are not aware
of the cultural frameworks used by patients to conceptualize and communicate about their ailments,
then noncompliance, patients' failure to comply with medical recommendations, is more likely.

Folk Sector. The folk sector involves a variety of traditional cultural healing practices that are
generally not part of an official or professional medical system. These include religious and spiritual
healers, natural and physical healers (such as herbalists, midwives, and masseuses), and
psychological healers (diviners, fortune-tellers). These ethnomedical systems have been called
superstitions, charlatanry, quackery, and worse, and biomedicine has generally discounted their

41
efficacy. But there is evidence that ethnomedical systems provide amelioration of suffering through a
combination of factors which include curative social, psychological, and physiological processes.

The extent of this alternative care indicates that health care providers need to understand this medical
pluralism and how its utilization affects patient care.

Professional Sector. The professional sector of medical care is generally dominated by biomedicine.
The professional sector provides the official and legally sanctioned medical care services. These
practitioners include pharmacists, physicians and all others personnel in the conventional medical
care.

CONSULTATION AS A SOCIAL PROCESS

The pharmacist is ideally positioned to contribute substantially towards meeting the publics need for
health care advice and treatment, particularly in the third world countries like Kenya, where existing
services are inappropriate or inadequate.

An individuals decision when or indeed whether or not to use health care services is influenced by
their immediate network of family and friends, their values and beliefs and their attitudes towards
professional health care. Irving K. Zola, has established five types of responses whereby a symptom
may be experienced by a patient as being abnormal, thereby triggering the individual to seek health
care advice. Zola (1973) identified these triggers as:

1. Perceived interference with vocational or physical activity.

If the experience of a symptom or symptoms begins to interfere with an individuals routine ability to
work or to take part in the usual routine activity, then the symptom(s) may be regarded as abnormal.

2. Perceived interference with social or personal relations.

Cause for concern may arise when the experience of symptoms interferes with ones normal patterns
of social interaction. What is considered normal will differ from individual to individual, depending
on such factors as occupation, lifestyle, age, etc.

3. The occurrence of an interpersonal crisis.

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During periods of stable and harmonious interpersonal relationships, common and trivial symptoms
may be regarded as inoffensive. The breakdown of such relationships can however, have profound
effects on the way symptoms are experienced. Symptoms that were previously barely perceived,
might, in the course of an interpersonal crisis,

4. Temporalising symptoms.

Another trigger may be the persistence of a symptom, which may or may not interfere with work or
personal relations, though nonetheless remaining a source of concern to the particular individual. This
may lead the person to decide to give the symptom a set number of days or weeks to abate. In the
event of the symptom not improving during this time, then the individual may seek professional help.
This is exemplified by statements such as if its not better by Monday Ill do something about it.
This process of giving deadlines to diseases is further reinforced by the media which has a rallying
call Maumivu yakizidi muone daktari

5. Sanctioning.

While the person experiencing the symptoms may feel they do not warrant professional attention,
perceiving them instead as either trivial or unimportant, pressure exerted by family or friends may
lead them to visit a health professional. Similarly, the symptom may be a cause of anxiety to the
sufferer but they may choose to avoid seeking professional help for fear that their complaint may be
considered trivial.

LAY REFERRAL SYSTEMS

The decision to act upon symptoms is not necessarily taken exclusively by the sufferer, but is often
the result of discussions with a range of people either immediate members of an individuals family,
their friends or colleagues. Freidson (1970) refers to this network of friends, relatives and colleagues
as the lay referral system. The decision to use or avoid professional health care services, Freidson
maintains, is influenced by:

the extent of close knit social relations between the members who make up a persons lay referral
system, and

the predominant values and attitudes to professional health care within that lay referral system.

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For example, whether or not a person lives in an extended family or the extent to which their ideas of
health and illness do, or do not, match those of health professionals, or whether or not people live
relatively independent of others, may each play a part in influencing an individuals decision to seek
professional health care.

An example of the lay referral system, as proposed by Freidson, was found in a study of the use of
maternity services by working class mothers in Aberdeen (Mckinlay, 1973). Those mothers who had
relatives living close by and who visited friends frequently were found to be under-utilizers of health
care services, whereas those mothers who lived more closely to friends rather than relatives, and who
had more friends of their own age, were found to be service users.

Review questions

1. What is culture?

2. How does culture influence health and illness?

References

Baer, R. D., Weller, S. C., Garcia de Alba Garcia, J. & Rocha, A. L. S. (2008). Cross-cultural
perspectives on physician and lay models of the common cold. Medical Anthropology
Quarterly 22(2), 148-166.

Helman, Cecil, G., (2001). Culture, Health and Illness (4th ed.). Arnold, London.

Hahn, R. A. & Inhorn, M. (2008). Anthropology and public health: Bridging the differences in
culture and society, 2nd ed. New York: Oxford University Press.

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 CHAPTER SIX

HEALTH RELATED BEHAVIOUR

By the end of this topic the learner should be able to:

a) Definition Health behaviours.
b) Demonstrate an understanding of the importance of studying health
related behaviours

With the increase in lifestyle related diseases, the improvement of health-related behaviors is
becoming more central to public health activities. Behavioral factors play a role in each of the leading
causes of death, including chronic diseases such as heart disease, cancer, and diabetes. These
behavioural factors include sedentary lifestyles, dietary habits, tobacco smoking and excessive
alcohol consumption and irresponsible sexual behaviours. Globally, there has been a rising interest in
preventing disability and death through changes in health-related behaviors, particularly changes in
lifestyle habits and participation in screening programs. Much of this interest was stimulated by the
change in disease patterns from infectious to chronic diseases as leading causes of death, combined
with the aging of the population, rapidly escalating health care costs, and data linking individual
behaviors to increased risk of morbidity and mortality.

Health behavior refers to the actions of individuals, groups, and organizations, as well as the
determinants, correlates, and consequences, of these actionswhich include social change, policy
development and implementation, improved coping skills, and enhanced quality of life.

Gochman defined health behavior as "those personal attributes such as beliefs, expectations, motives,
values, perceptions, and other cognitive elements; personality characteristics, including affective and
emotional states and traits; and overt behavior patterns, actions, and habits that relate to health
maintenance, to health restoration, and to health improvement."

There are three major categories of health related behaviours

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 1. Preventive health behaviour which involves any activity undertaken by individuals who
believe themselves to be healthy for the purpose of preventing or detecting illness in a
asymptomatic state. This can include self-protective behaviour, which is an action intended to
confer protection from potential harm, such as wearing a helmet when riding a bicycle, using
seat belts, use of prophylactic anti malarial tablets while travelling to hyperendemic areas
using a condom during sexual activity etc. Sometimes this kind of behaviour is also called
cautious behaviour.

2. Illness behaviour is any activity undertaken by individuals who perceive themselves to be ill
for the purpose of defining their state of health, and discovering a suitable remedy.

3. Sick-role behavior involves any activity undertaken by those who consider themselves to be
ill for the purpose of getting well. It includes receiving treatment from medical providers,
generally involves a whole range of dependent behaviors, and leads to some degree of
exemption from one's usual responsibilities.

Definitions

Behaviour versus Lifestyle.

Health behaviour can be something that is done once, or something that is done periodicallylike
getting screened for breast or prostate cancers or using a protective screen while using the computer.
Those actions that are performed over a long period of time, such as eating, going to the gym
regularly, eating healthy, balanced diets and avoiding tobacco use are called "lifestyle" behaviors. A
composite of various healthful behaviors is often referred to as "healthy lifestyle." However, most
people do not practice either healthful or risky behaviors continually like lack of exercise or risky
sexual behavior..

Health-Related and Health-Directed Behaviour.

Health-related behaviour is any action that is related to the process of disease prevention and health
maintenance, health improvement, or the restoration of health. This type of behaviour can be either

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voluntary or involuntary, and can be undertaken explicitly for health purposes, as a matter of habit, or
to comply with a law or requirement.

On the other hand, health-directed behaviour is any action taken by an individual to maintain a
healthy status which is disease specific eg.an adult who exercises to reduce the risk of heart disease is
engaging in that behaviour for the express purpose of restoring, maintaining, or improving his or her
health.

Sometimes these two types of health behaviour coexista toddler buckled into a safety seat is
participating in health-related behaviour, but for the parent this is a health-directed behavior.

Self-Care Behaviour

Self-care behaviour involves taking actions to improve or preserve one's health. Self-care includes
the actions taken to treat symptoms before (or instead of) seeking professional medical attention eg.
taking over-the-counter medications for common cold symptoms. It also includes treating minor
injuries such as bruises and twisted ankles when a person does not think a health care professional is
needed. The use of alternative and complementary medical treatments, without medical supervision,
is also self-care behavior. An important feature of self-care behaviour is that it involves active
participation in the health care process.

Health Care Utilization Behaviour

Health care utilization is the use of health services, whether it conventional or alternative health care.
Health care utilization is influenced by many different factors, and therefore the study of utilization
behavior includes examining who uses medical services, when and why they use these services, and
how satisfied they are with the services.

Dietary Behaviour. Dietary behavior refers to eating patterns that people engage in, as well as
behaviors related to consuming foods, such as shopping, eating out, or portion size. Dietary behavior

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differs from some other types of health behavior in that it is, in its basic forms, essential for life.
Dietary behaviors play a role in preventing or managing disease when they are sustained over the
long term. Behavioral considerations are key to any attempts to promote healthful dietary behavior.
Several core issues about dietary behavior have been recognized. First, most diet-related risk factors
are asymptomatic and do not present immediate or dramatic symptoms. Second, health-enhancing
dietary changes require qualitative charge, not just changes in the amount of food consumed. Third,
both the act of making changes and self-monitoring dietary behaviors require knowledge about foods.
Thus, information acquisition and processing may be more complex for dietary change than for
changes in some other health behaviors, such as smoking and exercise.

Others are Substance-Use Behavior and Sexual Behavior,

FIVE STAGES OF ACCEPTING AN ILLNESS

Though symptoms of chronic illnesses differ, people with them are united by the denial, anger, fear,
hope, and acceptance and other feelings they bring. Below are the five stages that people typically go
through when they find out they have a chronic illness. Not everyone goes through these stages in the
same order and it is common to go back and forth between stages as your physical health improves or
worsens. We all have problems that we need to cope with besides this illness, and they can
sometimes prevent this process from occurring naturally.

1. Denial- Any change or loss in your life is likely to bring denial, and learning that you have a
chronic disease can bring large doses of it. Someone in denial may believe a disease can't hurt them.
They may ignore their doctors' advice that could help keep the disease under control. In the case of
people with diabetes that may mean refusing to take medications or eat a proper diet. On the other
hand, some people quickly accept a disease and turn their attention toward healing. These people stay
abreast of medical advances and work with doctors to keep the disease in check.

2. Anger- What often fuels denial is anger. Anger may also be directed inward, with an
individual blaming himself or herself for having the illness. The best way to minimize anger is to find
outlets for it.

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3. Fear- Often underlying anger is the fear that comes with having a disease that can't be cured.
People with chronic illnesses may start to view life through a "telephoto lens" instead of a "wide-
angle lens". They stop planning ahead or making life changes because they believe they won't be
around much longer. Fear is often enhanced when people know little about a disease, so combating it
often begins with education. The more a person learns about a disease, the more they feel in control
of it.

4. Grief-Feelings of grief and loss are common because chronic diseases bring life restrictions
that others don't have to face. These may include no longer being able to participate in activities once
enjoyed, like eating a favorite meal or playing catch with a grandchild. Grief can cause feelings of
inadequacy and lead to withdrawal and isolation. Focusing on activities that remain unaffected by an
illness can help people overcome these feelings. Those who refuse to think of themselves as 'sick' will
have a more positive outlook.

5. Acceptance-Though managing a long-term illness can bring emotional upheaval, it also

brings the triumphant feelings and strength that come with overcoming obstacles.

Health is a product of culture and social structure. The routine organization and constraints of
everyday settings shape our health- the way we seek help and relate with the care givers . Socio-
economic status is of major importance in determining exposure to disease risk and in shaping health
and illness behavior responses. Lay explanations of illness affect illness appraisal, self-treatment,
decisions to seek care and changes in daily regimen. Somatization of psychosocial stressors is a
common concern in primary care systems throughout the world, and doctors are commonly frustrated
by such patients. Somatizing patients are often enmeshed in environments of great psychosocial
difficulty or are depressed, and many cultural and social factors affect how depression is expressed.
Although depression has devastating disabling effects on patients, it is often neither recognized by
doctors nor treated. But doctor-patient relationships are often the context for appropriate management
of such problems, and how they are handled affect the future trajectory of illness and disability.
Doctors' responses are conditioned by their attitudes, training, interviewing and psychosocial skills,
and organizational and financial factors. Patient flow is an important intervening variable affecting
the management of psychosocial difficulties and depression.

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In order to understand how patients respond to ill-health it is useful to appreciate the differences
between illness and disease.

Disease refers to a pathological or biological condition, for example kidney failure or cholera. Illness,
on the other hand, concerns individuals responses to symptoms: how they feel, experience and make
sense of their sickness. Illness and disease are not therefore synonymous it is possible to feel ill
without suffering a disease and to suffer a disease without feeling ill. Disease is therefore objective
and illness is subjective. For instance, a patient who has cancer may feel perfectly healthy, and not
even seek treatment until it is too late, while someone who is ill through excessive stress may not
exhibit a pathological disease. The distinction between illness and disease is important because it
emphasizes the fact that the way in which people respond to symptoms is often as important as the
disease state itself. However, it should be noted that sometimes the difference might be misleading in
that what is considered to be a disease in one area might be viewed differently in another area. this
distinction can be misleading because disease itself is not unequivocal. Pathological norms have
changed over time and are not universally accepted. Comparative studies indicate that what counts as
disease in one setting may be considered normal in another (McElroy and Jezewski, 2000). The
boundary between sickness and health is not clear-cut.

Illness is a variance from normality, and what is normal varies between societies, cultures, and
groups within society. In this sense illness is a socially defined concept that is, the implicit meaning
of illness is not universally shared but is peculiar to specific cultures and societies

ILLNESS BEHAVIOR

Human beings respond to symptoms in different ways. There are those who will buy medicine over
the counter, others will just wait while others will seek help from health care systems; whether
conventional or traditional. Illness behavior describes these different ways in which people respond
to the symptoms or changes in their bodies and how they come to view them as abnormal. It
involves the manner in which the individuals monitor their bodies, define and interpret the
symptoms and decide how, when and where to seek help. Studies of illness behavior seek to
understand how an individual's perceptions, experience, and expression of symptoms, as well as
their decisions concerning the appropriate course of action, are influenced by and interact with
professional models of illness, provided primarily by physicians, to determine how the illness career

50
 is structured. Indeed, one of the most intriguing and important aspect of illness behavior models has
to do with understanding compliance and the identification of those individual, cultural, and social
factors that lead individuals to ignore or to follow medical advice.

In studying illness behavior, one of the major assumptions is that illness, as well as illness experience,
is shaped by sociocultural and social-psychological factors, irrespective of their genetic, physiological
or other biological bases. The boundaries of illness and its definitions are potentially very broad, and
the illness process can be used to negotiate a range of cultural, social and personal tensions in the
home, at work, and in the community at large.
Illness behavior is also concerned with how people the changes in symptoms e.g. how pain increases
or subsides over the course of illness. When one is diagnosed with different diseases, the behavior of
the same patient is likely to be different in the same patient. If a wealthy patient was diagnose with a
disease like gout he is likely not to hide the fact that he is suffering from gout to his friends and
relatives because gout is associated with eating meat and alcohol which reinforces the fact that he is
rich. On the other hand, if the same patient was to be diagnosed with a sexually transmitted disease,
he is likely to hide that fact completely.

The experience of illness and illness itself is shaped by socio-cultural and psycho-social factors.
Indeed, the process can and has been used for negotiating a lot of social and personal situations at
home, work or schools. A worker can use the process to avoid a certain duty or night shift by
presenting as ill to the health care providers and negotiating for off duties; a wife/husband can fake
illness when she/he is not ready to perform conjugal rights; a student can fake illness when not ready
for an examination etc. The variability in patient behaviour in a given subculture, despite the
similarity of symptoms, also reflects major differences in psychological orientations and
predispositions. People vary in their tolerance for discomfort, in the knowledge, information and
understanding which they have about the illness process, and in the specific ways in which bodily
indications affect needs and ongoing social roles. People seem to vary a great deal in their subjective
response to pain and discomfort, although there appears to be much less difference in physical
thresholds. Patients brought up in communities which put a lot of emphasis on stoicism, are likely to
persevere even if they have severe pain. Illness behavior has been used to refer to the responses that
individuals engage in after they become ill, as they engage in measures to help them get well.

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DETERMINANTS OF HEALTH
Human health is determined not only as result of absence of the microbes and toxins that directly
cause Illness from our bodies, but also by other biological and social factors. The terms risks and
determinants are often used interchangeably. Health inequalities arise from unequal distribution of
underlying determinants, including income and assets, knowledge and literacy. Achieving health
equity will therefore, involve an understanding of social structures and the socially determined
conditions these create in which people grow, live, work, and age and not merely the understanding
of biomedical causes of disease. These are the social determinants of diseases, in other words the
causes of the causes (Marmot)

The social determinants of health are the conditions in which people are born, grow, live, work and
age, including the health system. A persons income, wealth, educational achievement, race and
ethnicity, workplace, and community can also have profound effects on human health. When the
distribution of these determinants, including income and assets, knowledge and literacy is uneven,
then health inequalities arise.
Many of the social factors that affect health have both independent and interactive effects. For
example, people with low incomes are likely to live in congested neighbourhoods, where social
services like water and sewage are unavailable. They are also likely to have less to have good health
care facilities which more often than not are located in the affluent areas. Indeed in Kenya most of the
population lives in the rural areas where we have about 20% of the health care facilities as opposed to
the urban centers where about 75 80% (Wamai, 2009) of the health care facilities are found.
Studies have shown that people who live in poorer neighborhoods have higher mortality rates, worse
birth outcomes, more chronic illnesses, and poorer reported health status than people living in higher
income neighborhoods.

The determinants of health can broadly be divided into three groups

1. Social and economic environment factors

These include

a) Income and social status

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Socioeconomic factors play a major role in the determination of an individual as well as a community
health and well-being. People with a more favourable socioeconomic position have better health
compared to those who are less well off. Disease creates poverty and can on the other hand be created
by poverty. People who are poor for instance can not afford to feed on balanced diet, not get
education, can not be able to access as well as afford health care (Cairey, 2000). These, among many
other factors can lead to malnutrition and frequent attacks of illnesses due to reduced immunity. On
the other hand when they are sick, they cannot afford to go to their places of work where they earn
their leaving. This leads to more poverty and exacerbates their ill health. Personal health status can
therefore be both contributed to and be an outcome of poor socioeconomic status. The gap between
the rich and the poor is also important he greater the gap between the richest and poorest people, the
greater the differences in health. Generally speaking, the wider the gap between the rich and the poor,
the greater the inequity in health. In one study found that people with a lower SES were more likely
to report poor health. Those who reported poor health were more likely to neglect personal health
care, such as going to the doctor.

2. Physical environment- safe water and clean air, healthy workplaces, safe houses, communities
and roads all contribute to good health. Employment and working conditions people in employment
are healthier, particularly those who have more control over their working conditions. Certain
diseases are for instance common in certain locations eg Schistosomiasis in Mwea. This is because
the environment in which the individual is living in contributes immensely in the disease patterns and
how the patients respond to the illnesses. Epidemiologists have found a link between the host factors,
agent and the environmental factors in the diseases causation process.

Other factors include housing and infrastructure. Infrastructure both in terms of roads and health
facilities also contributes immensely in disease and disease patterns. For instance, people living in
congested and poorly ventilated houses are likely to have a high level of transmission of TB than
those living in well ventilated and spacious rooms.

When people are sick, the accessibility to health care is also important. In some areas in this country
the health facilities are many kilometers apart and the roads to the facilities are also sometimes
inaccessible making it difficulty for patients to access the facilities.

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3. Individual characteristics and behaviours

a) Genetics - inheritance plays a part in determining lifespan, healthiness and the likelihood of
developing certain illnesses.

Personal behaviour and coping skills balanced eating, keeping active, smoking, drinking, and
how we deal with lifes stresses and challenges all affect health.

Social factors

Education low education levels are linked with poor health, more stress and lower self-confidence.

Social support networks greater support from families, friends and communities is linked to
better health. Culture - customs and traditions, and the beliefs of the family and community all
affect health.
Genetics - inheritance plays a part in determining lifespan, healthiness and the likelihood of
developing certain illnesses. Personal behaviour and coping skills balanced eating, keeping
active, smoking, drinking, and how we deal with lifes stresses and challenges all affect
health.
Health services - access and use of services that prevent and treat disease influences health
Gender - Men and women suffer from different types of diseases at different ages.

SICK-ROLE BEHAVIOR

Illness has been conceived by some sociologists as a deviant state, in that to be ill implies a
departure from normality. The notion of illness as deviance developed in the 1950s out of critiques of
the biomedical model of illness which explained illness behaviour purely as a breakdown of the
normal functioning of the body.

The concern of behavioural scienceis the understanding of how the sick persons relate to the whole
social system, and what the person's function is in that system. Ultimately, the sick role and sick-role
behavior could be seen as the logical extension of illness behavior to complete integration into the

54
medical care system. Parsons' argument is that sick-role behavior accepts the symptomatology and
diagnosis of the established medical care system, and thus allows the individual to take on behaviors
compliant with the expectations of the medical system. Present-day health education has been heavily
influenced by the research on illness and sick-role behavior

Talcott parsons (1951), a structural functionalist identified four obligations to be fulfilled by both the
physicians and the patients. He defined illness not as a biological state but as a social role namely,
the sick role. This role distinguishes those who are healthy from those that society, and the medical
profession in particular, classifies as being ill. The purpose of this distinction, Parsons argues, is to
ensure the cohesion and stability of society. In playing out our everyday conventional roles for
example, as employees or employers, as unemployed, as members of families, or as pensioners the
social order is maintained.

The sick role maintains the cohesion of society since those who are incapacitated are granted the
privilege of having their conventional day-to-day responsibilities and duties suspended in order to
allow them to restore themselves to health and expedite their return back into the social system, with
its obligations, duties and roles.

In the biomedical perspective, only a medical practitioner can legitimize entry into the sick role. Once
admitted to this role, the patient gains two benefits:

1. Patients are temporarily excused their normal roles. Gaining a sickness certificate from the doctor
is the obvious way in which this expectation is met. Merely visiting the doctor, however, confers
some legitimacy on the claim to be sick. Whereas feeling unwell might be treated sceptically by
friends and colleagues, a visit to the doctor may be sufficient to gain credibility.

2. Patients are not held responsible for their illness. Not being held responsible for the illness relieves
the patient of a considerable burden in our society. In some other societies the patient may be held
responsible in that, for example, the illness may be believed to be a punishment for some past crime,
sin or transgression.

However, in return for these benefits, patients are in turn expected to fulfill two obligations:

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1. Patients must want to get well and should recognize that the sick role is only a temporary state
which they must want to leave behind. If they apparently do not want to get well then instead of the
sick role being conferred by the doctor, they may be categorized as malingerers or hypochondriacs.

2. Patients must co-operate with technically competent help. The fact that it is only medical
practitioners who can legitimately confer the sick role in our society ensures that the technically
competent help tends to be confined to the official medical services. Patients who choose to defer to a
lay person with claims to medical knowledge, in preference to a medical practitioner, are judged as
not fulfilling one of the basic obligations of the sick role.

THE THEORETICAL BASIS OF PATIENT EDUCATION

The goal of patient teaching is to influence behavior change, yet changing habits is extremely difficult
for most of us. Health care providers ask patients to make enormous changes in their lives in order to
prevent disease and promote health. For example, we ask diabetic patients to lose or maintain weight
by staying on a diet 365 days a year, every year, for life. Diabetic patients must also carefully control
their intake of dietary fat and cholesterol to decrease their increased risk of heart attacks and stroke.
Constant and accurate self-monitoring of blood glucose is required by finger sticks and urine testing.
Exercise is part of the treatment as well, but it must be planned to avoid causing elevations or severe
drops in blood glucose levels. In addition, the patient must inject insulin several times a day or take
oral medications. Self-management of diabetes is very complex, yet we ask ordinary people to take
on all these tasks and, at the same time, carry on their normal life of work, school, and social
relationships.

Theories that explain human behavior change serve as guidelines for teaching. Theories are a
generalized set of rules that can help us find answers for patient learning and motivation, and help
predict the consequences of specific health education interventions. The more you know about
educational theories, the more tools you will have for building strong, effective patient education
interventions.2 Theories that can be applied to patient education come from the disciplines of
communication, organizational development, sociology, psychology, and adult education. Theories
used for patient teaching include the Health Belief Model, self-efficacy theory, locus of control

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theory, cognitive dissonance theory, diffusion theory, stress and coping theory, and adult learning
theory.

Human behaviour is experienced throughout an individuals entire lifetime. It includes the way they
act based on different factors such as genetics, social norms, and attitude. The traits vary from person
to person and can produce different actions or behaviour from each person. Social norms determine
which behaviours are acceptable or unacceptable. This determines how they will view their
symptoms, seek help from the health care workers, the way they relate with the workers and indeed
the way they will take medication and respond to treatment.

HEALTH BELIEF MODEL (HBM)

A person's motivation to undertake a health behavior can be divided into three main categories:
1. Individual perceptions: Factors that affect the perception of illness or disease and address the
importance of health to the individual, perceived susceptibility (perception of the likelihood of
experiencing a condition that adversely affects one's health), and perceived seriousness (perception of
the difficulties the disease would cause) such as pain, disability, loss of work time, financial burden,
or death.
2. Modifying factors: These factors include demographic variables such as age, gender, ethnicity and
educational level; perceived threat of the disease; and cue to action created through such events as
mass media campaigns, advice from others, illness of friend or family member, diagnosis of a
disease, or a newspaper article. The ultimate decision to engage in the behavior is influenced by these
modifying factors. These account for a person's "readiness to act."
3. Likelihood of action: Addresses the perceived benefits minus perceived barriers in undertaking the health
action. The learner conducts an unconscious cost-benefit analysis that must weigh the positive aspects of the
action against the potential negative aspects of the action such as dangerous, unpleasant, inconvenient,
expensive, time-consuming, etc.

The Health Belief Model (HBM) was one of the first theories of health behavior, and remains one of the most
widely recognized in the field. It was developed in the 1950s by a group of U.S. Public Health Service social
psychologists who wanted to explain why so few people were participating in programs to prevent and detect
disease. For example, Mobile X-ray units sent out to neighborhoods to offer free chest X-rays (screening for
tuberculosis) were not being fully despite the fact that this service was offered without charge. The question

57
Social psychologists wanted to what was encouraging or discouraging people from participating in the
programs. They theorized that peoples beliefs about whether or not they were susceptible to disease, and their
perceptions of the benefits of trying to avoid it, influenced their readiness to act. In ensuing years, researchers
expanded upon this theory, eventually concluding that six main constructs influence peoples decisions about
whether to take action to prevent, screen for, and control illness.

The model soon changed shape when applied to another set of problems concerning immunization
and more broadly to people's different responses to public health measures and their uses of health
services. In these wider applications, the model substituted a belief in susceptibility to a disease or
health problem for the more specific belief that one could have a disease and not know it, as the most
important belief accounting for seeking screening examinations.

In the mid-1970s, a monograph devoted to the wide-ranging applications of the model described its history and
experience (Becker, 1974). This was soon followed by a review of the standardized scales for measuring its
several dimensions (Maiman et al., 1977). The model continued to evolve into the 1980s, largely by Scholars
like Marshall Becker at Johns Hopkins University and later at the University of Michigan School. A recent
addition to the HBM is the concept of self-efficacy, or one's confidence in the ability to successfully perform an
action. This concept was added by Rosenstock and others in 1988 to help the HBM better fit the challenges of
changing habitual unhealthy behaviors, such as being sedentary, smoking, or overeating.

They argued that people are ready to act if they

Believe they are susceptible to the condition (perceived susceptibility)

Believe the condition has serious consequences (perceived severity)

Believe taking action would reduce their susceptibility to the condition or its severity (perceived benefits)

Believe costs of taking action (perceived barriers) are outweighed by the benefits

Are exposed to factors that prompt action (e.g., a television ad or a reminder from ones physician to get a
mammogram) (cue to action)

Are confident in their ability to successfully perform an action (self-efficacy)

The Health Belief Model relates largely to the cognitive factors predisposing a person to a health
behavior, concluding with a belief in one's self-efficacy for the behavior. The model leaves much still

58
to be explained by factors enabling and reinforcing one's behavior, and these factors become
increasingly important when the model is used to explain and predict more complex lifestyle
behaviors that needs to be maintained over a lifetime.

Since health motivation is its central focus, the HBM is a good fit for addressing problem behaviors that evoke
health concerns (e.g., high-risk sexual behavior and the possibility of contracting HIV). Together, the six
constructs of the HBM provide a useful framework for designing both short-term and long-term behavior
change strategies. When applying the HBM to planning health programs, practitioners should ground their
efforts in an understanding of how susceptible the target population feels to the health problem, whether they
believe it is serious, and whether they believe action can reduce the threat at an acceptable cost. Attempting to
effect changes in these factors is rarely as simple as it may appear. 13

Concept Definition Application

Perceived Beliefs about the Define population(s) at risk, risk levels;

susceptibility chances of getting a personalize risk based on a person's features
condition or behavior; heighten perceived
susceptibility if too low.

Perceived severity Beliefs about the Specify consequences of the risk and
seriousness of a the condition
condition and its
consequences

Perceived benefits Beliefs about the Define action to take; how, where,
effectiveness of taking when; clarify the positive effects to be
action to reduce risk or expected.

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 seriousness

Perceived barriers Beliefs about the Identify and reduce barriers through
material and reassurance, incentives, assistance.
psychological costs of
taking action

Cues to Action Strategies to activate Provide how-to information, promote

"readiness" awareness, reminders.

Self-Efficacy Confidence in one's Provide training, guidance in

Health
ability to take action performing action.
care
provider
s can
effectively change patients behavior by using a variety of techniques A number of conceptual
models (classical conditioning, cognitive social learning theory, health belief model, theory of
reasoned action, stages-of-change or transtheoretical model, and social action theory) are available to
guide behavior change interventions that address various behavioral attributes These models are
useful constructs for thinking about behavior change and can be applied to a variety of desirable
changes, actively seeking breast cancer screening, reducing risk-taking sexual activities, and general
maintenance of health.

Learning and conditioning models are among the oldest and most widely researched models.
Conditioning models are of particular importance for various aspects of health-related interventions,
such as reinforcement, stimulusresponse relationships, modeling, cues to action, and expectancies.
Medical students should particularly learn the stimulus-control concept, which posits that patients
vary their responses according to the situation in which they find themselves. For example, a person
may be in the habit of smoking after a meal and may crave cigarettes only after eating lunch or
dinner.

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Positive reinforcement (being rewarded) and negative reinforcement (getting rid of something
unpleasant) are also important concepts for medical students to understand.

Review questions

1. How do the behavior models help us understand health seeking behavior?

2. Describe five types of behavior that a patient can exhibit

References

DiClemente, R. J, Crosby, R. A. & Kegler, M.C., Eds. (2002). Emerging theories in health
promotion practice and research: Strategies for improving public health. San Francisco:
Jossey-Bass.

Glanz, K., Viswanath, K. & Rimer, B. K. (2008). Health education and health behavior, 4th ed. San
Francisco: Jossey-Bass.

Lynch, E. & Medin, D. (2006). Explanatory models of illness: A study of within-culture variation.
Cognitive Psychology, 53(4), 285-309.

Lupton, D. (1995). The imperative of health: Public health and the regulated body. Thousand Oaks,
CA: Sage.

Levanthal, H. (2008). Health psychology: The search for pathways between behavior and health.
Annual Review of Psychology, 59, 477-505.

Redding, C. A., Rossi, J. S., Rossie, S. R., Velicer, W. F., & Prochaska, J. O. (2003). Health behavior
models. The International Electronic Journal of Health Education, 3(Special Issue), 180-193.

Singer, M. (2009). Introduction to syndemics: A critical systems approach to public and community
health. San Francisco: Jossey-Bass.

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 CHAPTER SEVEN

HEALTH BEHAVIOR CHANGE

At the end of the unit the learner should be able to

1. Describe what behavior change is.

2. Describe the relevance of good physician patient communication

Health behaviors are shaped through a complex interplay of determinants at different levels. For
example, physical activity is influenced by self-efficacy at the individual level, social support from
family and friends at the interpersonal level, and perception.

In clinical settings, strategies to change health behaviors usually focus on individual-level factors
such as knowledge, beliefs, and skills.

Behaviors directly influence the risk of disease and are among the few modifiable risk factors that
exist for some diseases.

Health behaviors usually occur in combination. A long distance driver will most likely engage in
drinking, illicit sex and drugs to keep himself busy which influences his risk of sexually disease.
While all human behavior is learned, it quickly becomes habitual and less accessible to modification.

Because of the importance and yet the difficulty of modifying behavior, great attention has been paid
to conceptual approaches to understanding health behavior. Theories include the Health Belief Model
(Becker, 1980), the Theory of Reasoned Action (Ajzen, 1980), and many others, most of which focus
on the forces that maintain behavior and how these may be changed. Several models propose stages
of changing health behaviors, generally beginning with a period of precontemplation in which the
person is not interested in change; interventions such as a smoking-cessation program would be
premature and wasted (Prochaska, 1983). In the contemplation stage, preparatory cognitive changes
are occurring and interventions can support the person's decision making process. The actual behavior

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is not altered until the stage of initiating change, and during this fragile phase there may be frequent
relapses. There follows a long-term phase of maintenance of the change, during which the new
behavior must be reinforced until it is finally incorporated into the person's normal behavior pattern.
Such theories underscore the long-term nature of the process of altering health behaviors, and of the
need to make a detailed behavioral diagnosis for each person and to tailor interventions to match his
or her current stage of readiness to change.

PHYSICIAN INFLUENCE ON PATIENT BEHAVIOUR

Health care providers who practice healthy habits play a key role by helping their patients to adopt
healthy lifestyles for primary prevention of chronic diseases. The behavior of health care provider is
of utmost importance because health care providers act as health role models. They are more likely to
counsel their patients about health behaviour change if they practice healthy habits themselves. One
of the strongest predictors of health promotion counseling by primary care physicians is practicing a
healthful behaviour oneself it is clear that many physicians report difficulty counseling patients
about behaviours they themselves do not practice.

Health promotion counseling by providers is more effective than outsourcing counseling to a

counselor in part because patients view the persons dealing directly as the most trusted source of
health information.

It has also been observed that have found that simply talking to your patients about your personal
practices improves your health promotion delivery. Providers who disclose their healthy personal
health practices are perceived as more credible and motivating. This has been shown by others as
well: rates of prevention counseling increase and patients become more receptive to health promotion
counseling from physicians who demonstrate healthy behaviours themselves. Kreuter et al. found
that when physicians discussed health promotion with their patients, even when the patients had
already received printed materials on the same topic, those that were directly counseled by their
physician were 3555% more likely to quit smoking, make changes to their diet and begin exercising
compared with those who only received literature encouraging the same thing

Physicians can positively influence patients' health habits by counseling them about prevention and
health-promoting behaviours. The effectiveness of health care providers counseling has a direct link

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to one's own health practices. Thus, addressing providers' own health behaviours is key to
substantially increasing health promotion counseling in general practice. Providers benefit from
interventions that help them adopt healthier lifestyles this benefit is not only for their personal
health, but for the health of their entire patient population, which is likely to profit from more
efficient and effective health promotion.

EMPATHY AND HEALING PROCESS

Empathy heals

Therapeutically, it can be a very healing experience for someone to empathize with you. When
someone effectively says 'I care for you', it also says 'I can do that, I can care for myself.'

Empathy builds trust

Empathy displayed can be surprising and confusing. When not expected, it can initially cause
suspicion, but when sustained it is difficult not to appreciate the concern. Empathy thus quickly leads
to trust.

Empathy closes the loop

Consider what would happen if you had no idea what the other person felt about your
communications to them. You might say something, they hated it, and you continued as if they
understood and agreed. Not much persuasion happening there!

The more you can empathize, the more you can get immediate feedback on what they are
experiencing of your communications with them. And as a consequence, you can change what you
are saying and doing to get them to feel what you want them to feel

Comparison of Sympathy with Empathy

Sympathy emphasizes sharing distressing feelings whereas empathy does not emphasize any
particular type of feeling. The listener using empathy shares (experiences) whatever feelings the
talker is expressing at the moment, regardless of whether the feelings are distressing (grief, for
example) or pleasant (love, for example).
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Sympathy may also involve agreeing with some aspects of the other person's feelings, beliefs, etc.
whereas empathy emphasizes understanding all of them with no interest in either agreeing or
disagreeing.

The person using empathy tunes into the entire inner world of the other person whereas the person
using sympathy typically tunes into only those aspects with which he agrees.

The listener using empathy usually responds more comprehensively to the talker as compared with
the listener using sympathy.

Sympathy focuses on sharing (experiencing) a person's bad news or feelings, feeling sorry for the
person suffering the bad news/feelings, and whether the sympathizer agrees with any of the person's
beliefs, opinions, or goals whereas empathy focuses on sharing (experiencing) a person's bad and
good news or feelings and understanding the bad or good news/feelings rather than feeling sorry for
the person's bad news/feelings or agreeing or disagreeing with the person's

Review questions

1. What is empathy and what is its importance?

2. What is health behavior change?

3. How is the health care providers good communication skills help in changing patients behaviour

References

1. Marian Pitts (1996), The psychology of preventive health, Routledge, London

2. The Encyclopedia of Public health

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