Download Explaining Health Behavior with the Health Belief Model and more Schemes and Mind Maps Public Health in PDF only on Docsity!
SOCIAL AND BEHAVIORAL SCIENCES EXERCISE 1:
Explaining Health Behavior with the Health Belief Model- Screening for Latent Tuberculosis Infection INSTRUCTOR’S GUIDE VERSION 1.
Date last modified: November 16, 2009 1
SBS Exercise 1: Explaining Health Behavior with the Health Belief Model (HBM) Screening for Latent Tuberculosis Infection Estimated time to complete this exercise: 35 minutes LEARNING OBJECTIVES At the completion of this exercise, participants should be able to: ¾ Describe the 5 principal constructs of the HBM ¾ Describe a public health problem using HBM constructs ¾ Apply HBM constructs to a health promotion intervention ¾ Identify the main limitations of HBM and how they may limit the model’s applicability to some health behaviors
ASPH SOCIAL AND BEHAVIORAL SCIENCES COMPETENCIES ADDRESSED ¾ E.1. Identify basic theories, concepts, and models from a range of social and behavioral disciplines that are used in public health research and practice
ASPH INTERDISCIPLINARY/CROSS-CUTTING COMPETENCIES ADDRESSED F. 4. [Communication And Informatics] Apply theory and strategy-based communications principles across different settings and audiences G.10. [Diversity And Culture] Develop public health programs and strategies responsive to the diverse cultural values and traditions of the communities being served J.10.[Professionalism] Appreciate the importance of working collaboratively with diverse communities and constituencies (e.g., researchers, practitioners, agencies, and organizations) K.1. [Program Planning] Describe how social, behavioral, environmental, and biological factors contribute to specific individual and community health outcomes
Please evaluate this material by clicking here: http://www.zoomerang.com/Survey/?p=WEB229TEVBZPB http://www.zoomerang.com/Survey/?p=WEB229G8666NJG
Suggested citation: New Jersey Medical School Global Tuberculosis Institute. /Incorporating Tuberculosis into Public Health Core Curriculum./ 2009: Social and Behavioral Sciences Exercise 1: Explaining Health Behavior with the Health Belief Model- Screening for Latent Tuberculosis Infection INSTRUCTOR’S GUIDE Version 1..
This material was developed by the staff at the Global Tuberculosis Institute (GTBI), one of four Regional Training and Medical Consultation Centers funded by the Centers for Disease Control and Prevention, in collaboration with the Charles P Felton National Tuberculosis Center. It is published for learning purposes only. Author: Julie Franks, PhD Charles P Felton National Tuberculosis Center
For further information, please contact: New Jersey Medical School GTBI 225 Warren Street P.O. Box 1709 Newark, NJ 07101-1709 or by phone at 973-972-
SOCIAL AND BEHAVIORAL SCIENCES EXERCISE 1:
Explaining Health Behavior with the Health Belief Model- Screening for Latent Tuberculosis Infection INSTRUCTOR’S GUIDE VERSION 1.
Date last modified: November 16, 2009 2
Students should complete the required reading and Introduction section before the class session and have these items available as references while they complete the exercise.
Required Reading: Champion VL and Skinner CS. “The Health Belief Model.” In: Glanz K, Rimer BK, Viswanath K, eds. Health Behavior and Health Education. Theory, Research, and Practice. 4th ed. San Francisco, CA: John Wiley and Sons, Inc.; 2008: 45-65.
Introduction
Models of health behavior attempt to identify individual and social factors that influence health behaviors and to explain their interaction. Individual factors include beliefs, attitudes, motives, and expectations, as well as observable behaviors. Similarly, social factors include group values connected with and responses to particular behaviors, and material factors such as the availability of health care services.
One of the oldest and most widely applied models of individual health behavior is the Health Belief Model (HBM). The HBM emphasizes the normative, perceptual bases of behavior that are embedded in social relations and values, and which may influence individual health-related decisions as much or more than medical considerations. The model identifies perceptual dimensions related to judgments about personal health and health threats, and about the relative value and cost of contemplated health behaviors. Applied to health promotion and health education efforts, the HBM suggests that attempts to influence behavior will be successful to the degree that they effectively address the values and priorities of target populations, as well as providing information with sound scientific and clinical bases. As the required reading explains, the values and priorities are operationalized in the central HBM constructs: perceived susceptibility, perceived severity, perceived benefits, and perceived barriers.
Key Concepts and Definitions of the Health belief Model^1
Concept Definition Application
Perceived Susceptibility
One’s opinion of chances of getting a condition.
Define population(s) at risk, risk levels.
Personalize risk based on a person’s characteristics or behavior.
Make perceived susceptibility more consistent with individual’s actual risk.
SOCIAL AND BEHAVIORAL SCIENCES EXERCISE 1:
Explaining Health Behavior with the Health Belief Model- Screening for Latent Tuberculosis Infection INSTRUCTOR’S GUIDE VERSION 1.
Date last modified: November 16, 2009 4
Generally, people are most likely to progress from infection to active TB disease just after they are infected; the risk of developing the disease within 2 years of infection is from 5% to 10%. Thereafter, there is about a 10% lifetime risk of progression to disease if LTBI is not treated. Progression is significantly accelerated among certain groups, including young children and the immunocompromised, especially individuals infected with HIV.
One vaccine to prevent TB is currently available: the bacille Calmette-Guérin vaccine, or BCG. BCG is sometimes effective in preventing childhood TB and is given to very young children in many countries where TB is prevalent. It is not routinely given in the United States, because its effectiveness in adults is highly variable and because the vaccine may interfere with the reactivity of the most widely used test for TB infection, the tuberculin skin test (TST).
Given the difficulty in preventing transmission of TB, it is critically important that people who are infected with TB be identified early and when appropriate, be treated before the disease progresses to its symptomatic and usually infectious phase. TB-infected individuals for whom treatment is appropriate include: children under 5 years of age; close contacts of infectious TB cases; those who are at high risk for progression from infection to TB disease because of immuno-suppression due to disease, therapeutic drug regimen, or lifestyle considerations such as injection drug use and severe alcoholism; those in congregate settings, including prisons and jails, homeless shelters, and long-term care facilities; and recent immigrants from countries where TB prevalence is high. Effective treatment of LTBI can halt the development of TB disease in patients and may reduce the infections that would result from contact with an active disease case, infections that could become additional cases of TB disease.
The difficulties of identifying people with LTBI before they become symptomatic and infectious and seeing them successfully complete treatment have challenged health care providers and policy makers since effective treatment was made available. The preferred treatment for LTBI consists of 9 months of isoniazid (ī-sə-nī-ə-zəd; also referred to as INH) taken daily. INH is inexpensive and easily administered; however, it can produce toxic side effects, the most common of which is hepatitis. Alcohol use may increase the risk of hepatotoxic side effects from INH.
Recognizing the importance of LTBI treatment to TB control efforts in the United States, the US Department of Health and Human Services has established a target of an 85% completion rate among high-risk individuals prescribed LTBI treatment. 3 However, most reported completion rates fall well below that target.^4
SOCIAL AND BEHAVIORAL SCIENCES EXERCISE 1:
Explaining Health Behavior with the Health Belief Model- Screening for Latent Tuberculosis Infection INSTRUCTOR’S GUIDE VERSION 1.
Date last modified: November 16, 2009 5
In-Class Case Study Activity:
The instructor will divide the class into small groups (4 to 6 students per group), distribute the Case Study that begins on the next page, and ask students to read it. The instructor will then provide a blank HBM table handout (Pg 9 – 10) for each student, and explain that students will use the case study to complete the table.
When the class has finished reading the case study, the instructor should lead the entire class through completing the first row of the table, Perceived Susceptibility, as a group. Content that should be included in this row is found in the answer key at the end of the exercise.
The students will then complete the remaining rows working in their groups. Completion of the table will take about 20 minutes.
Case Study: Bringing LTBI Testing to Migrant Farm Workers
Migrant workers make up most of the seasonal agricultural labor force in the United States. Many migrants enter the country with temporary work permits and move in regional patterns according to the demands of the agricultural cycle. Most come from countries where TB is prevalent, especially Mexico, and thus are at high risk of having LTBI. While in the United States, workers often live in crowded group settings, in which there is an elevated probability that anyone who does become sick with TB will infect others living and working in close proximity. Migrant workers are therefore good candidates to test for LTBI and to begin treatment to prevent those who are infected from becoming sick with TB disease.
A community-based organization (CBO) in the heart of a western agricultural region is planning an initiative to educate Mexican migrant workers about LTBI, perform testing for LTBI, and refer infected workers for appropriate treatment at the regional public health clinic, located in the largest urban center of their region. Anticipating that workers who begin LTBI treatment through the program may return home before completing treatment, the CBO has established relationships with several providers in the regions of northern Mexico that most workers come from. The Mexican providers have agreed to follow patients on treatment for LTBI who are referred to them from the CBO. The CBO hopes that this initiative will increase the number of migrant farm workers who receive appropriate treatment for LTBI, and thus contribute to a reduction in cases of TB disease in the region.
SOCIAL AND BEHAVIORAL SCIENCES EXERCISE 1:
Explaining Health Behavior with the Health Belief Model- Screening for Latent Tuberculosis Infection INSTRUCTOR’S GUIDE VERSION 1.
Date last modified: November 16, 2009 7
lasted and had to make as much money as possible while work was available. Several workers asked about the regional public health clinic that the CBO planned to partner with, and commented that they had no experience getting health care in the United States. They asked about the cost of treatment and seemed doubtful when the CBO staff explained that LTBI treatment would be provided at no cost. One worker said that he did not need to go to American doctors because he brought herbal teas from home to help him stay healthy. If he did fall ill, he said, he would think back to what the women in his family had done to treat illness at home and replicate their remedies when needed.
Incorporating Patient Perspectives into Planning the Education and Testing Initiative
The CBO staff members have gathered to discuss how to use the information collected from the migrant workers to design their education and testing efforts. To help analyze the information, they will use the HBM. -----------------------------------------End of Case Study--------------------------------------------------
SOCIAL AND BEHAVIORAL SCIENCES EXERCISE 1:
Explaining Health Behavior with the Health Belief Model-
Screening for Latent Tuberculosis Infection
INSTRUCTOR’S VERSION 1.
Date last modified: November 16, 2009
10
The HBM: Migrant Workers and LTBI
HBM Construct
Construct Appliedto LTB Testing
Examples of Construct from theMigrant Farm Workers Case Study
Construct Addressed in the CBO’s LTBIEducation, Testing, and Referral Initiative
PerceivedBenefits PerceivedBarriers Cues to Action
SOCIAL AND BEHAVIORAL SCIENCES EXERCISE 1:
Explaining Health Behavior with the Health Belief Model-
Screening for Latent Tuberculosis Infection
INSTRUCTOR’S VERSION 1.
Date last modified: November 16, 2009
11
The HBM: Migrant Workers and LTBI Answer Key
HBM Construct
Construct Appliedto LTB Testing
Examples of Construct from theMigrant Farm Workers Case Study
Construct Addressed in the CBO’s LTBIEducation, Testing, and Referral Initiative
PerceivedSusceptibility
Personal risk of beingexposed to andinfected with TB.
Migrants had a generally low sense ofsusceptibility due to low awareness ofhow TB is transmitted.There was little awareness of thedistinction between TB and LTBI.Many felt protected by childhoodvaccine.Some may have felt that TB is ahereditary disease and judgesusceptibility on that basis.
Education should highlight how TB is transmitted.Remind workers of the high prevalence of TB inMexico.Emphasize the high prevalence of LTBI amongMexicans tested in the United States. Examplesshould be drawn from populations similar toworkers.If possible, engage spokespeople with personalexperience with TB to facilitate personalizing risk.
Perceived Severity
Consequences ofLTBI
Perceived severity of LTBI was lowbecause it is asymptomatic and was notassociated with progression of TBdisease. However, TB disease wasperceived to have severeconsequences, including isolation fromfamily and social networks.
Reiterate that infection can remain latent foryears before progressing to active disease.Describe the progression from infection todisease in terms that workers understand, usingexamples familiar to them.
SOCIAL AND BEHAVIORAL SCIENCES EXERCISE 1:
Explaining Health Behavior with the Health Belief Model-
Screening for Latent Tuberculosis Infection
INSTRUCTOR’S VERSION 1.
Date last modified: November 16, 2009
13
medicine prescribed at the regionalclinic.Treatment may extend beyond thetime that migrants can legally remainin the United StatesPositive result may lead toassociation with TB disease andimplied risk of social isolation.
treatment.Bring Mexican providers to camps todescribe process for transfer of care toMexico if needed.Reduce negative associations about TB byemphasizing that it is a common, curableinfection.
Cues to Action
Strategies tofacilitate LTBItesting and follow-up care amongthose who arewilling to undergotest.
Existing cues to action were weakbecause there was no precedent inthe camps for accessing health care,including LTBI testing and treatment.In the Mexican health system withwhich workers were familiar, LTBI isnot routinely treated.Workers had little contact with theclinic that the CBO engaged toprovide treatment.
Build TB education and testing into existingCBO activities, such as literacy programs.Ensure that the education is culturally andlinguistically appropriate.Engage a spokesperson for LTBI treatmentwho is from the same background as themigrant workers and who has undergonetreatment him/herself.Escort workers to regional clinic to facilitateappropriate follow-up.
SOCIAL AND BEHAVIORAL SCIENCES EXERCISE 1:
Explaining Health Behavior with the Health Belief Model- Screening for Latent Tuberculosis Infection INSTRUCTOR’S VERSION
Date Last Modified: November 11, 2009
When student groups have finished the table, the instructor will lead a class discussion of their results. The instructor will then pose the Questions for Further Discussion, below, to the whole class. The discussion period may last 15 minutes.
Questions for Further Discussion
What important aspects of designing the initiative are not addressed by the Health Belief Model?
- The model cannot definitively stipulate an optimal order in which to sequentially address dimensions of health behavior.
- While the HBM is useful for understanding many factors that influence health decision-making and health behavior, it is not a detailed guide to constructing interventions. The model does not provide direction on ascertaining and incorporating workers’ preferences for the format and content of educational activities and interaction with health care providers, which may affect the efficacy of the initiative.
- The HBM is well developed and well researched in its explanation of health decision-making (via perceived threat, benefits, and barriers) and health behavior initiation (via cues to action). However, as Champion and Skinner point out, the model devotes less attention to how health behaviors, once initiated, are maintained over time. Thus the model would not provide adequate guidance if the CBO wishes to ensure that workers who are referred to the regional public health clinic for evaluation and LTBI actually complete the initial visit and follow the prescribed course of therapy. Similarly, the model is largely silent on how to help ensure that referrals to collaborating providers in Mexico are completed. If workers cannot complete referrals and follow-up visits and complete prescribed treatment, the education and testing initiative will not achieve its ultimate goal of promoting treatment for LTBI and reducing the incidence of TB disease among migrant farm workers in the region.
What weaknesses in the initiative might result if the CBO relies solely on the information they have gathered to design the initiative?
- The information collected to guide the initiative is qualitative and needs to be assessed to determine its generalizability across all groups of migrants. In the
