Behavioral determinant

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Target of public health approaches.
The shifting role of behaviour ( simple-complex)
Behavioural risk factors (itself- determinant-consequent)
determinants of behaviour
Public health strategies to influence determinants of behaviour
The interaction of socioeconomic status (SES), environments, and behaviour
Denormalizing behaviour
Public health interventions and conclusion

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  • Simple, discrete behaviours account for many of the infections and injuries of the past. Today's growing chronic disease burden relates more to complex behaviours. We use the term ‘complex behaviour’ to refer to combinations of interrelated practices and their environmental contexts, reflecting patterns of living influenced by the family and social history of individuals and communities, their environmental and socioeconomic circumstances, and their exposure to cultures and communications. We know that discrete behaviours can be influenced directly by health education targeted at individuals and groups. Complex behaviour changes more slowly and usually requires some combination of educational, organizational, economic, and environmental interventions in support of changes in both behaviour and conditions of living. This combination of strategies has defined health promotion and public health programmes addressing complex behaviour change (Green & Kreuter 2005; Smith et al. 2006).
    Obesity and HIV/AIDS present the obvious contemporary examples of health-related conditions and diseases awaiting technological solutions, for which behaviour, in the meantime, is a necessary route of intervention and change. Virtually every public health breakthrough has had a behavioural change process that served the public until the technology was at hand. Then, behavioural change processes were needed to diffuse, adapt, and apply the new technology to varying cultural and social circumstances. Unless and until an obesity prevention vaccine or HIV vaccine is developed, society must depend on behavioural preventive measures to curb the spread of obesity and AIDS. These include, of course, policies, environmental changes, and health educational programmes that support behavioural changes.
    Much of the early success in controlling HIV infections through change in sexual practices (especially use of condoms) among men in urban gay communities appear to have been in response to health education programmes (Petrow 1990). Reviews also show increases in the use of clean needles for at least 15 years among intravenous drug users (e.g. Wodak 2006), which has required a combination of policy and educational interventions to make clean needles accessible and more acceptable than the culture of needle-sharing. Evidence that health education leads to the regular use of condoms among sexually active adolescents, however, has not held up consistently (James et al. 2006; Koniak-Griffin & Stein 2006; Walker et al. 2006). The parallel lessons from the success of tobacco control programmes also point to the need for combined policy,
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    regulatory, organizational, environmental, and educational interventions to influence population changes in tobacco consumption (Eriksen et al. 2007) and many of the same types of interventions are under consideration for obesity control (Mercer et al. 2005).
  • Single cause
    Multiple
  • actions people take, consciously or unconsciously, that can have an immediate or cumulative effect on their health status. The effect on health may be intended (health-directed) or unintended (health-related), but the behaviour is nevertheless direct in its effect. The most dramatic of these are the violent injury-causing actions people may take behind the wheel of an automobile, with weapons, or unintentionally with the careless use of tools or toxic substances or merely walking absent-mindlessly on a slippery or cluttered surface. Less dramatic, but no less lethal, are the cumulative little actions people take each time they light a cigarette, imbibe or inject an addictive or mind-altering substance, or abide by neglect of physical activity or healthful foods.
  • the three most important predictors of infant mortality rates to be percentage of households with sanitation, total literacy rate, and the percentage of households without safe water. The major public health goals in developing nations have related to the provision of immunization, access to a sufficient supply of clean water, and the installation of proper sanitation facilities (WHO 1981). But the more recent Millennium Development Goals (MDG) aim to cut global poverty by half by the year 2015
  • Both positive and negative behaviours are predisposed, enabled, and reinforced by forces in the culture and the environment. This broad categorization has proved useful in public health programme planning (with more than 970 published applications, see www.lgreen.net for bibliography)
  • Predisposing factors that reside in the individualThey include the cognitive and affective dimensions of knowing, feeling, believing, valuing, and having self-confidence or a sense of self-efficacy.
    Enabling factors are often conditions of the environment that facilitate (or impede) the performance of a predisposition or motivated action by individuals or groups
    Reinforcing factors are strengthening a behavioural tendency through encouragement and motivation. We have to shift fro extrinsic to intrinsic reinforcement
  • but these often involve individual and group decisions and actions about which policies to support, since they limit degrees of freedom in choice of behavioural options.
  • Behavioral determinant

    1. 1. Lawrence W. Green and Robert A. Hiatt Oxford Textbook of Public Health
    2. 2.         Target of public health approaches. The shifting role of behaviour ( simple-complex) Behavioural risk factors (itself- determinantconsequent) determinants of behaviour Public health strategies to influence determinants of behaviour The interaction of socioeconomic status (SES), environments, and behaviour Denormalizing behaviour Public health interventions and conclusion
    3. 3.    control or cajole the healthrelated behaviour of individuals. protect individuals from the behaviour of others, and mobilize the behaviour of groups to influence healthrelated social and physical environments.
    4. 4.  Simple or discrete behaviours ( injuriesinfections)  complex behaviour (chronic diseases)
    5. 5.  the simple and discrete behavior can be influenced directly by health education targeted at individuals and groups.  complex behavior required combination of educational, organizational, economic, and environmental interventions in support of changes in both behaviour and conditions of living.
    6. 6.     Some behaviour clearly increases the risk of developing disease. Other behaviours correlate with and precede better health, but their causal link is more tenuous. many behaviours are, in fact, contributing causes (causal risk factors) of specific diseases. the easiest examples of clear causal linkages are those established for single action behaviours such as ingesting a contaminated food
    7. 7. Sep 20, 2007 issue of the New England Journal of Medicine, Dr. Steven A.
    8. 8. Sep 20, 2007 issue of the New England Journal of Medicine, Dr. Steven A.
    9. 9. Physical, social and environmental causes Health, Disease, Injuries or Death Behavioral Causes Health-care environmental causes
    10. 10.  intentionally most dramatic (automobile, gun)  Unintentionally most dramatic (toxic substances, slippery surface)  Less dramatic , but no less lethal (DI, smoking, alcohol, inactivity)
    11. 11.  behaviour remains a critical mediator of the relationships between environmental measures and health outcomes.  improvement of the socioeconomic condition is accompanied by a shift in mortality  the three most important predictors of infant mortality rates were households sanitation, literacy rate, and safe water.
    12. 12.  Genes, via their influences on morphology and physiology, create a framework within which the environment acts to shape the behavior of an individual.  Genes also create the scaffold for learning, memory, and cognition that can be used in shaping behavior.  The environment can affect morphological and physiological development; in turn behavior develops as a result of that mechanism.
    13. 13.  Predisposing factors  Enabling factors  Reinforcing factors
    14. 14. 13 1 6 11 12 7 14 2 5 8 4 10 15 3 9
    15. 15. 1- Educational strategies inform and educate the public about issues of concern such as :  the dangers of drug misuse,  the benefits of automobile restraints,  the relationship of maternal alcohol consumption to foetal alcohol syndrome.  …..
    16. 16. 2- Automatic-protective strategies are directed at controlling environmental variables, that minimize the need for individual decisions in structuring each behaviour, such as:  milk pasteurization,  fluoridation,  infant immunizations, and  the burning of marijuana crops.  ……………….
    17. 17. 3- Coercive strategies employ legal and other formal sanctions to control individual behaviour, such as:  required immunizations for school entry, mandatory tuberculosis testing of hospital employees,  compulsory use of automobile restraints.  arrests for drug possession or use.  …………
    18. 18.    Population behavioural and educational diagnoses enable public health to intervene strategically on the behaviour of populations. But health problems have other determinants in the environment and in genetics. Behaviour also can play a role in influencing those determinants.
    19. 19.    Through Human Genome Project genetics information became available to individuals. The first assumption remains to be supported by true evidence of effectiveness (susceptibility to illness-sensitivity to drug) The second assumption, that having such information would motivate more concerted effort to change one's behaviour
    20. 20.   the limited influence of the genes so far implicated in specific mortality or morbidity outcomes, and their interactions with the environment . the ethics of offering such information to the individual with anything more than a cautionary note of possible relevance to their reproductive decisions or their behavioural choices
    21. 21.   The threshold effects are sometimes found beyond income or other SES indicators. The gradient adheres whether the SES measure is education, income, occupational status, or place of residence
    22. 22.       SES as a predisposing determinant of behaviour SES as an enabling determinant of behaviour The educational enabling influence of SES on behaviour The cultural-environmental predisposing influence of SES SES as a reinforcing determinant of behaviour The ‘status identity factor’ and social norms
    23. 23.  ‘denormalization’ of smoking behaviour in public places. legal restrictions- social norms  The combination of new smoke-free or ‘clean air’ ordinances and by-laws with mass media emphasizing the carcinogenic properties of second-hand smoke and the rights of nonsmokers
    24. 24.    These differences cannot be attributed solely to biological determinants related to sexual differentiation The social construct of gender, as opposed to the biological categories of sex, was conceptualized to refer to cultural and social conventions, roles and behaviours assigned to men and women The gender interactions with SES and health have been variously attributed to differential occupational experiences
    25. 25.  The dynamic relationships among the specific measures creates a complex system of social, economic, cultural, and behavioural factors.  The system interwoven with disease risk factors and health status, and influenced by the healthcare and physical environments.
    26. 26.  public health programmes shuold plan for behaviour change in three categories of determinants:
    27. 27.  direct communications to influence the knowledge, attitudes beliefs, and perceptions of the population concerning the behaviour-health relationship;  indirect communications through social organizations, parents, peers, employers, and others who control rewards and approval that would reinforce behaviour.  legal, engineering, financial, organizational levers and resource development that would enable or prohibit the behaviour.
    28. 28.  Behaviour is an inescapable link in the chain of causation between most environmental and genetic determinants and the health outcomes in which they are implicated.  The social environment presents a further complexity in the mediating and moderating of behaviour and environment in their determination of population health.  The individuals are acting upon, and in reaction to, each other as their health outcomes are being shaped by their actions.

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