Global Health
Applications
Health Promotion: Individuals and Communities
Learning objectives for this lesson:
- Explain why global and domestic health are increasingly merged, using globalization, HIV/AIDS, and influenza as the evidence.
- Describe the five ecological factors that make health problems follow different trajectories in different countries, and explain the epidemiologic transition and what blurs it.
- Identify the main types of actors in the global health system and predict which combinations come into play in a short-term crisis versus a long-term prevention effort.
- Carry out a PRECEDE-PROCEED style assessment of a global health problem, naming the data sources for each phase and the political constraints a planner must weigh.
- Judge which social and behavioural theories travel to a global setting, what must be adapted on the way (constructs, assumptions about the individual, ethnomedical systems), and why participatory collaboration is the recurring answer.
- Analyze four program examples (avian influenza communications, social marketing in Cameroon, family planning in Albania, mobile phone games for HIV prevention) to identify the theories each one used.
- Describe Canada's contribution to global health promotion, from the Ottawa Charter to Grand Challenges Canada and Canadian non-governmental organizations.
This course was developed by Dr. Kiffer G. Card, Faculty of Health Sciences, Simon Fraser University, to accompany Edberg, M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Jones & Bartlett Learning. This lesson follows Chapter 12 of the text.
Glossary: Key Terms, People & Concepts
📚 Reference page, available throughout the lesson
This glossary collects the key concepts, people, and ideas you will meet in this lesson. Use it as a reference while you work through the material, or as a review before assessments. Type in the search box to filter entries.
The Setting: Health in the Global Context
⏱ Estimated reading time: 15 minutes
Global health is no longer somewhere else
Learning objectives for this section
- Explain why it is less and less useful to separate global health from domestic health, using HIV/AIDS and avian influenza as evidence.
- Define globalization in its broad sense and list its implications for public health.
- Describe the five ecological factors that make health problems follow different trajectories in different countries.
- Explain the epidemiologic transition and say what blurs it.
- Apply the refugee and migrant example to a Canadian newcomer setting.
This lesson opens with a disclaimer. What follows is a brief and selective introduction to one arena in which social and behavioural theory can be applied, and readers who want a full account of global health should turn to a dedicated global health course or a source such as Richard Skolnik's Essentials of Global Health. The scope here is narrower. The question is how the theories you have met in earlier lessons behave when the setting is a district in Cameroon or Albania rather than a school district in British Columbia, and what has to change on the way.
Two settings that have become one
The first substantive claim of this lesson is that it has become less and less useful to think about global health as separate from domestic health. The HIV/AIDS pandemic and the influenza threats of the early 2000s, avian flu and swine flu, show that the two settings have merged into one, at least in terms of epidemiology. That is a claim about disease, but it is grounded in economics. Globalization is typically discussed as an economic term, yet it refers to much more. Movements of people, of images and information, of resources, and of environments have all reduced the distinction between global and domestic.
The definition of globalization is worth reading closely, because the example that illustrates it is deliberately ordinary. A clothing item is produced in a factory in the Philippines using cotton from Egypt, sold under different brand names in shopping malls in Tokyo, London, and Los Angeles, run by a company headquartered in the United States, with customer service and data processing outsourced to India. One shirt, six countries. The broader sense of the term covers the social and political consequences of that integration, and views differ on whether those consequences are positive or negative. For public health, there are five implications. Open each one.
When one product passes through factories in several countries, each under its own labour law and inspection regime, no single authority is responsible for the conditions under which it was made. The 2013 collapse of the Rana Plaza garment factory in Bangladesh, which killed more than a thousand workers producing clothing for Western retailers, is the case most students will know.
Food and pharmaceuticals are exported and imported across a wide range of countries and regions, and often transshipped through intermediate destinations, so the point of contamination can be several borders away from the point of harm. The Canadian Food Inspection Agency's import controls and Health Canada's drug inspections exist because of exactly this complexity.
When facilities and production are segmented and located in different countries under different regulations and conditions, pollution can be moved to wherever it is cheapest to produce. The health consequences land on the population nearest the facility, who may have had no say in its location.
Air travel means an infection can cross the world inside its incubation period. Toronto learned this in 2003, when severe acute respiratory syndrome arrived from Hong Kong and produced the largest outbreak outside Asia. COVID-19 later made the same point to every reader of this lesson.
The same networks that carry a virus carry information about it. Health Canada's Global Public Health Intelligence Network, an early-warning system that scans news sources in many languages, picked up early signals of the SARS outbreak before it was formally reported. Communication channels are also the raw material of the behaviour change programs in Section 4.
Two diseases carry the argument. HIV/AIDS is prevalent where there are international transportation and trade routes; where rapidly developing economies create a divide between urban and rural areas and people flow into cities to find income; where migrant worker flows separate men and women from their families for long periods; and where people travel to seek pleasure. Every one of those conditions is a product of the global economy. HIV is also prevalent in economies that are hard-pressed and lack the resources or capacity to mount prevention efforts or to provide antiretroviral therapies that are manufactured and controlled in wealthier economies, a situation that has been addressed in a number of countries through the United States President's Emergency Plan for AIDS Relief, PEPFAR.
Avian influenza makes the point from the other direction. As a virus that could infect humans it first surfaced in Hong Kong in 1997 and then spread to Thailand, Vietnam, Indonesia, China, Japan, and South Korea, with later outbreaks in Europe. In some of those countries poultry is both a major export product and a cultural tradition: most rural homes keep chickens, and fighting cocks are prized possessions. And because the disease is carried by birds, its spread also follows the flight paths of migratory birds, which have nothing to do with national borders. A behaviour change program about poultry handling in rural Thailand is therefore also a program about what arrives in Vancouver.
Why "global" rather than "international"?
The older term, international health, usually meant health work that wealthy countries did in poorer ones: health somewhere else. Global health, as a group of practitioners proposed in a widely cited definition, is concerned with issues that transcend national boundaries and with the determinants and solutions that populations share (Koplan et al., 2009). The opening argument of this lesson is the same idea stated through epidemiology. If HIV, influenza, and the shirt on your back all move along the same routes, then the setting of this lesson includes Canada.
Why health still follows different paths
If globalization has merged the two settings, why do health problems still follow different trajectories in different nations and regions? The answer is ecological: countries vary in at least five kinds of factors. Click each card for the definition and examples.
risksClick to learn more
and infrastructureClick to learn more
conditionsClick to learn more
conditionsClick to learn more
cultural traditionsClick to learn more
Two of these categories deserve a second look because they will return in every later section. System capacity is the reason the same theory-based program can succeed in one district and fail in the next: a program that tells people to boil water assumes fuel, time, and a stove. Social patterns and cultural traditions are the reason the constructs of a theory have to be filled in locally, which is the subject of Section 3.
The epidemiologic transition
The overall pattern of illness also differs between industrialized and less developed countries. As countries develop in broad socioeconomic terms, life expectancy rises and the pattern of morbidity and mortality shifts from being mainly associated with infectious disease to lifestyle-related conditions such as chronic disease, heart disease, and cancer. This is the epidemiologic transition, also called the health transition, first described by the demographer Abdel Omran in 1971 (Omran, 1971). Use the slider to see the schematic shape of the transition and the two things that blur it.
The transition is no longer a clean line. Widespread diseases such as HIV/AIDS and several forms of influenza have blurred the distinction between the two patterns, and lifestyle-related diseases such as heart problems have increasingly appeared in the developing world, for two reasons: longer lifespans, and differential economic development among population sectors within countries, so that some groups live in more developed conditions than others. A single country can sit at two points on the slider at once.
A well-known example takes the transition across a border. When migrants or refugees move from a rural or less developed country to a more developed one, obesity can follow. In the home country food may be scarce, the diet may include few processed foods, and physical work is built into food preparation. Because food is scarce, the few people who are wealthy, eat plenty, and are large in stature may carry high prestige. When migrants arrive somewhere food is abundant, processed, and high in sugar and fat, and at the same time enter at a low socioeconomic level, a pattern of obesity may ensue, and the prestige attached to being large as a sign of well-being may be retained and contribute to it. Canadian research on the healthy immigrant effect describes a related pattern: newcomers often arrive healthier than the Canadian-born population, and the advantage fades with years in the country.
Case study: A newcomer family in Surrey
A family arrives in Surrey, British Columbia, from a rural district where they farmed and where food was sometimes short. Both parents take shift work at low wages. The nearest grocery store to their apartment is a convenience store; a supermarket is a bus ride away. Within three years, a community health nurse notes rapid weight gain in the children and the father's new diagnosis of type 2 diabetes. When the nurse raises diet, the grandmother says the children finally look well fed, which in the village was a sign of a family doing well.
Which of the five ecological factors are at work here, and on which side of the border does each one sit? Is this a global health problem or a domestic one, and does the distinction help the nurse?
More layers of the onion
Thinking about global health highlights the idea of an ecology of health. Such ecologies are always the case, but in a global context there are more concentric circles, or layers of the onion, involved. The diagram adds the outer layers to the ecological model you met in Lesson 1. The person, family, community, and national policy layers are still there. Around them sit the global economy, the international agencies and funders of Section 2, and the cross-border flows of people, goods, pathogens, and information that this section has described.
The layers of the onion in a global ecology of health. The inner rings are the ecological model of Lesson 1; the outer two are what a global setting adds.
Keep the onion in mind through the rest of the lesson. Section 2 describes the outer ring in detail, because the agencies and funders that occupy it decide which behaviour change programs get built. Section 3 asks what happens to a theory built for the inner rings of one country when it is carried to another. Section 4 shows four programs that made the trip.
Reflection
Return to the newcomer family in Surrey. Sort what you know about them under the five ecological factors (environmental risks, system capacity and infrastructure, socioeconomic conditions, political conditions, and social patterns and cultural traditions), noting for each whether the influence originated in the home country, in Canada, or in the move between them. Then answer the opening question of this section in your own words: is it useful for the community health nurse to think of this as a global health problem, a domestic one, or neither?
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Key Takeaways
- The opening claim of this lesson is that it has become less and less useful to separate global health from domestic health: HIV/AIDS and influenza follow the same routes as trade, migration, and travel, and those routes run through Canada.
- Globalization means the integration of production and markets across borders and its social and political consequences; for public health it complicates workplace, food, and drug safety and environmental responsibility, and speeds up both disease transmission and communication.
- Health still follows different trajectories in different countries because of five ecological factors: environmental risks, system capacity and infrastructure, socioeconomic conditions, political conditions, and social patterns and cultural traditions.
- The epidemiologic transition shifts a country's burden from infectious to chronic and lifestyle-related disease as it develops, but HIV/AIDS, influenza, longer lifespans, and uneven development within countries have blurred the line, and migrants can carry the transition across a border.
- A global setting adds outer layers to the ecology of health: the global economy, international agencies and funders, and cross-border flows of people, goods, pathogens, and information.
1. A public health officer in Vancouver argues that a poultry-handling education program in rural Thailand is a Canadian concern. Which of the following arguments best supports her?
2. A country depends on two export crops whose world prices swing from year to year, so its health budget is unpredictable and long-term planning is rare. Under which of the five ecological factors does this fall?
3. A ministry of health finds that heart disease and diabetes are rising sharply in the capital's middle class while rural districts still lose children to diarrhoeal disease. How can a country show both patterns at once?
4. In the refugee and migrant example, why might the prestige attached to a large body contribute to obesity after migration?
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The Global Health System and Assessing the Context
⏱ Estimated reading time: 18 minutes
Who does what, and how you find out what is going on
Learning objectives for this section
- Name the seven types of actor in the global health system and give an example of each.
- Predict which combination of actors is likely to come into play in a short-term crisis and in a long-term prevention effort.
- Explain how funding and delivery arrangements shape which behavioural interventions get built.
- Walk through a PRECEDE-PROCEED style assessment for a global health problem and name a data source for each phase.
- Analyze the Country X scenario as an administrative and policy assessment.
Before asking which theory applies, pause on the systemic context. Interventions in global health are conducted or funded through a complex system with many levels, and a program designer who does not know that system will not know who pays, who delivers, or who decides. This section sorts the actors into types, then walks through the assessment phases in PRECEDE-PROCEED style. Both halves are about the same thing: reading the setting before choosing a theory.
The actors
The global health actors sort into seven types. Click any node on the map to read a description of it, a Canadian counterpart, and what it means for a behaviour change program. Then use the scenario buttons to see which actors come into play for a disaster and for a long-term infectious disease effort.
Select an actor
Click a node on the map. The centre node is the country's own health ministry, local organizations, and communities, through which almost every program is finally delivered.
Three things about the map matter for behaviour change programs. First, the money and the delivery usually sit in different boxes: a bilateral agency or a public/private partnership funds, an NGO implements, and a ministry approves. Second, the outer actors change. Any list of agencies is a snapshot, and the names above date from the early 2010s. Germany's GTZ merged into GIZ in 2011, the United Kingdom's DFID was folded into the Foreign, Commonwealth and Development Office in 2020, and in 2025 the United States government dismantled USAID, the funder behind at least two of the programs in Section 4, and moved its remaining functions into the Department of State. Third, the centre node is where behaviour actually changes, and the insistence on partnership with local organizations that runs through this lesson follows from that.
Common confusion
Lists of global health NGOs often include the International Committee of the Red Cross and Red Crescent (ICRC). Strictly, the ICRC is the International Committee of the Red Cross, a Geneva-based body with a mandate under the Geneva Conventions; national societies, including the Canadian Red Cross, belong to a separate International Federation of Red Cross and Red Crescent Societies. A second confusion: the Global Fund does not run programs. It finances them, and a funder and an implementer are different actors.
Which actors, for which situation
Different combinations of these actors come into play depending on the situation. Two contrasting cases are summarized here with a Canadian illustration of each.
| Situation | Typical actors | Canadian illustration |
|---|---|---|
| Disaster or short-term health crisis | The ICRC, CARE, or Médecins Sans Frontières on the ground, with funding and logistical support from national agencies such as USAID or regional bodies such as the European Community or the Association of Southeast Asian Nations. | The Canadian Red Cross deploys field hospitals and personnel to disasters abroad with Government of Canada funding; Global Affairs Canada often matches public donations to Canadian NGOs after a major earthquake or flood. |
| Long-term effort to prevent the spread of an infectious disease | WHO coordinates and collaborates with public/private actors such as the Ford Foundation and with national health agencies such as the NIH and the ministries of health of affected countries. NGOs such as CARE distribute medications and in some cases implement prevention programs. | The Public Health Agency of Canada's National Microbiology Laboratory in Winnipeg developed the Ebola vaccine later licensed as Ervebo and tested in a WHO-coordinated ring vaccination trial in Guinea in 2015, with Médecins Sans Frontières among the field partners. |
Notice what the second row implies for a behaviour change program. A long-term prevention effort has a coordinator, several funders, a ministry, and one or more implementing NGOs, each with its own reporting requirements and ideas about what works. The theory a program uses is often negotiated among these parties rather than chosen by one planner, which is one reason global programs tend to be pragmatic and to combine theories.
Assessing the context: a PRECEDE-PROCEED style walk
What kinds of theory might apply in a global context? This is a complex question, because many of the theories in this course originated in a Western, industrialized setting. The approach taken here is to run a brief assessment in the style of the PRECEDE-PROCEED model from Lesson 6, identifying the issues to address, and only then to discuss theory. Work through the five phases in the tabs.
Social assessment
Take all the situational diversity you would find across communities in one country and multiply it a hundredfold. The division between rich and poor nations is a major structural factor, as is the division of wealth within nations. The character of the global economy, its patterns of production, labour, capital, finance, regulation, and markets, helps determine how resources are distributed and how industrial and agricultural production affects people and environments. High mobility and international flows of labour move health problems from place to place. Cultural traditions, health beliefs, and practices form part of the context: Western biomedicine, viewed globally, is one of many competing paradigms for understanding and treating illness, alongside Chinese medicine, the Vedic traditions of India, spiritist traditions from Africa, Latin America, and the Caribbean, and shamanic practices from Eurasia and the Americas. Sites of conflict such as Sudan and Somalia have their own effects. Data sources: demographic and health surveys from the United Nations Population Fund, Population Bulletins and fact sheets from the Population Reference Bureau, and the USAID-funded Demographic and Health Surveys.
Behavioural and environmental assessment
Risks vary widely by disease, region, and country, and there is no complete source of information. The risk factors in WHO's Global Burden of Disease reports are important indicators of broad global patterns, and gray literature, the unpublished reports from specific projects available through project or organizational websites, is another important source. A sampler of risks runs from industrial development without environmental control, limited rural access to care, flood, drought, and deforestation, through forced marriage and early childbearing, female genital cutting, injection drug use, unsafe sex, child labour and trafficking, tobacco, poor diet, poor water and sanitation, and immunization practices. A planner reads such a list for the items a program can reach and the items that are conditions to work around.
Epidemiological assessment
Getting data on global health is both easy and problematic. WHO compiles its World Health Report and manages the Global Burden of Disease database, originally developed at Harvard University, but the degree to which mortality and morbidity data are kept varies greatly by country, and conditions are often not defined uniformly. The Demographic and Health Surveys are particularly useful, UNICEF collects data through its Multiple Indicator Cluster Survey, and ministries and university research centres are sources where surveillance exists. The major global issues include HIV/AIDS, tuberculosis, malaria, child survival, emerging chronic conditions, reproductive health, immunization, lower respiratory infection, cholera and diarrhoeal disease, and severe weather events. Immunization shows the stakes: in 2008 WHO estimated that 1.5 million deaths among children under five, 17 percent of all under-five deaths, were from diseases that routine vaccination could have prevented. And these risks interact to form a web.
Educational and ecological assessment
Here you face the diversity of knowledge, attitudes, norms, and cultural and social factors that influence behaviour around the world, and all their implications for applying theory. There is no key source: national ministries are one starting point, international health behaviour research another, and reports from NGOs that focus on a health area a third. A warning is needed here. In a short summary it is dangerously easy to stereotype examples of diverse attitudes and norms as something that other people have, as if diversity were not characteristic of all people. What matters is that you cannot make quick assumptions about the attitudes and knowledge that influence behaviour. Effective intervention on knowledge, belief, or norms means partnering with individuals and organizations familiar with local capacity, knowledge, beliefs, norms, and culture, taking the time to conduct research, and working with communities in a participatory collaboration. In that process you learn the structure of incentives and motivation, the predisposing, enabling, and reinforcing factors, so that you can build them into the program. Health promotion is inherently human; a willingness to learn, to understand, and to respect will take you a long way.
Administrative and policy assessment
Books have been written on the policy and administrative environment of global health. There are many layers in any intervention, and the complexity of the political situation is typically a factor. The illustration is the Country X scenario in the case study below: two funders with different rules, two possible partner NGOs with different connections, and a vocal group of opponents. The lesson lies in two questions. How would you negotiate the situation? And what if you did not know about all these political crosscurrents? Canadian funders have rules too. Global Affairs Canada's Feminist International Assistance Policy, adopted in 2017, directs Canadian assistance toward gender equality, which shapes what a Canadian-funded program can propose in the same way that the restricted American funds in Country X shape what can be delivered.
Social inequalities and emerging infectious diseases
Pause here for Paul Farmer, founding director of Partners In Health, whose 1998 essay drew the connections between poverty and infectious disease. Look at the trajectory of a disease, Farmer argued, in terms of the conditions that contribute to its emergence rather than the agent alone, because human action has done so much to drive mutation, resistance, and spread. The structure of poverty is one of the key political ecologies of emergence. Malaria was once a disease of the United States, controlled as a by-product of agricultural development, better housing, drainage, repellents, and nets; those things were not available to the poor, so malaria lingered among them. Tuberculosis has effective therapies but was never eradicated in many poorer nations, because therapies still have to be delivered, stored, and used according to protocol, and it gained new prominence as an opportunistic infection in people with HIV. A behaviour change program that ignores the structure of poverty is treating the agent and leaving the conditions alone.
The data at a glance
| Source | What it offers | Assessment phase |
|---|---|---|
| United Nations Population Fund; Population Reference Bureau | Demographic and health surveys; Population Bulletins and fact sheets | Social |
| Demographic and Health Surveys (the DHS Program) | Comparable national household surveys; one of the most comprehensive data sets. Long USAID-funded, and disrupted when USAID was dismantled in 2025. | Social, epidemiological |
| WHO Global Burden of Disease; World Health Report | Risk factor rankings and mortality and morbidity estimates, with uneven data quality by country | Behavioural and environmental, epidemiological |
| UNICEF Multiple Indicator Cluster Survey (MICS) | Child and household indicators from numerous countries | Epidemiological |
| Gray literature; NGO reports; USAID project listings | Unpublished evaluations, often the only source on local knowledge, attitudes, and norms | Behavioural and environmental, educational and ecological |
| Country health ministries; university research centres | Surveillance data where surveillance exists; local studies | Epidemiological, educational and ecological |
Case study: Sexually transmitted infections in Country X
You are trying to address sexually transmitted infections in Country X, where a growing STI problem may raise the risk of HIV/AIDS if nothing is done. Funds are available from a United States agency, but they are restricted to parent education or school-based education. You also have funding from a global nonprofit without those restrictions, which requires that you partner with an in-country organization. Two NGOs in Country X address STIs among other issues. One is closely tied to family members of the Minister of Health. The other is independent and has better access to schools around the country, which would let you draw on funds from both sources. A small but vocal group of Country X medical professionals opposes any direct education of youth about sexuality, on moral grounds.
Which partner do you choose, and what do you give up either way? Which of the five ecological factors from Section 1 does this scenario turn on? And how would the choice of partner constrain the theory and channels your program could use?
The scenario has no clean answer, and that is the point. The independent NGO reaches more schools and unlocks both funders, but a ministry with family ties to the rival organization approves programs and can make a school-based program unwelcome. The vocal opponents are a political condition in the sense used in Section 1, and they shape what a program says long before any theory is chosen. Section 3 asks which theories can survive those constraints.
Reflection
You are the program officer in the Country X scenario. Write a short memo that (1) names the partner NGO you would choose and the funder or funders that choice unlocks; (2) identifies which of the five assessment phases produced the information you relied on, and which piece of information you would most fear not having; and (3) states one way the political crosscurrents (the ministry connection and the vocal opponents) would change the theory or the channels your STI program uses, compared with a program in a Canadian school district.
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Key Takeaways
- Global health actors sort into seven types: government-level (bilateral) agencies, regional organizations, multilateral organizations such as WHO and the UN agencies, public/private partnerships such as the Global Fund, financial institutions, NGOs and foundations, and parastatal organizations.
- Different situations call up different combinations: NGOs with bilateral or regional funding in a disaster; WHO coordinating foundations, national agencies, ministries, and implementing NGOs in a long-term prevention effort. Funding and delivery usually sit in different organizations, so the theory a program uses is often negotiated.
- A PRECEDE-PROCEED style assessment comes before naming any theory: social, behavioural and environmental, epidemiological, educational and ecological, and administrative and policy, each with its own sources (UNFPA, PRB, DHS, WHO Global Burden of Disease, MICS, ministries, and gray literature).
- The educational and ecological phase carries the central advice of the lesson: you cannot make quick assumptions about attitudes and knowledge, so partner with people who know the local capacity, beliefs, norms, and culture, take time to do research, and work in participatory collaboration.
- The Country X scenario shows the administrative and policy layer at work: funder restrictions, partner connections, and vocal opponents shape what a program can say and through which channels, before any theory is chosen.
1. A cholera outbreak follows an earthquake, and within days Médecins Sans Frontières and the Canadian Red Cross are running treatment centres with Government of Canada and European funding. Which situation type does this match, and which actor type is doing the delivery?
2. A planner needs comparable national data on fertility, child health, and household socioeconomic status across several countries for the social and epidemiological phases of an assessment. Which source stands out as one of the most comprehensive?
3. A short summary of global attitudes and norms makes a particular error dangerously easy. What is the error, and what is the remedy?
4. In Paul Farmer's account, why did malaria linger among the poor in the United States after it had been controlled elsewhere in the country?
5. A Canadian NGO's funding from Global Affairs Canada is tied to the Feminist International Assistance Policy, and a partner country's ministry is wary of any program that discusses sexuality with adolescents. In the assessment framework, where do these two facts belong, and what do they most directly shape?
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Theory in the Global Setting
⏱ Estimated reading time: 18 minutes
Which theories travel, and what has to change on the way
Learning objectives for this section
- Explain the two adjustments required before an individual-level theory is used globally: filling in the constructs locally and checking whether the individual is the primary decision-making unit.
- Define an ethnomedical system and explain how it connects to the constructs of behavioural theory.
- Describe Behavior Change Communication, its theoretical roots, its eight steps, and its goals.
- Match organizational change, community mobilization, and political-economic theories to the kinds of global health problems they address.
- Analyze the AIDS Risk Reduction Model as a multitheory approach and identify its parallels with earlier theories.
The answer to the question of which theories apply in a global context is neither that none of them travel nor that all of them do. Much of the theory reviewed in this course concerning knowledge, health beliefs, intentions, social norms, and culture is potentially applicable, at least in its basic form. The work lies in what we can call filling in the blanks with different kinds of information, and in noticing the assumptions a theory carries with it. This section takes the families of theory in turn and asks of each: what has to change on the way?
Cultural knowledge and practices
Take the Health Belief Model. If you use it to guide an intervention, what you address as barriers must be relevant to the population you are working with. That is always the case, but in a global context it may take extra effort to make the intervention meaningful and relevant. A barrier to condom use in one place is price; in another it is what a condom is understood to do to the body. The construct is the same; its content is local.
The second adjustment is deeper. Much individual theory makes assumptions about individuals as decision makers that may not apply in societies where the individual is not understood as the primary social unit or primary decision-making unit, as it generally is in Western societies. A model built around one person weighing costs and benefits and forming an intention has to be rethought when the decision belongs to a couple, a household, elders, or a community.
Cultures and peoples across the world also have varying ethnomedical systems: systems of knowledge and practice that tie together culturally shared ideas about what causes illness and disease, how to treat or cure it, and who the appropriate healers are. These systems are closely tied to the elements of many behavioural theories. They shape people's understandings and expectations about using health care, the norms for patient and healer behaviour, and the values and meanings attached to particular health outcomes. An ethnomedical system is, in the language of earlier lessons, where a population's perceived causes, perceived severity, and cues to action already live.
None of this is a deficit to be corrected. Cultural variety can be a strength from which to build interventions, because diverse living patterns are often the foundation of resilience, built on the experience of generations. Indigenous communications practices, breastfeeding, and other traditions have already been incorporated effectively into public health programs.
A Canadian frame: Two-Eyed Seeing
Mi'kmaw Elder Albert Marshall of Unama'ki (Cape Breton) described Etuaptmumk, or Two-Eyed Seeing, as learning to see from one eye with the strengths of Indigenous knowledges and from the other with the strengths of Western knowledges, and to use both together. Canadian health researchers have adopted it for programs that work with an Indigenous ethnomedical system rather than around it. Offered here as a schematic teaching idea, it is one Canadian answer to the question of how a theory built in one knowledge system can be used respectfully in another.
Case study: Gender, sexuality, and HIV risk in India
Consider a 2004 study of condom use among married couples in India, where most AIDS cases at the time were attributed to sexual transmission and the epidemic had spread into the general population. Several traditions cut across religious lines. Family name and inheritance pass through the male line, and a wife lives in her husband's father's house. Female purity before marriage is prized while men are encouraged to have premarital sex, so men may be infected before marriage, and a bride who knows about HIV prevention may be suspected of premarital sex. Because wealth is inherited by men, women find it hard to leave a marriage even where there is abuse or infidelity. The duty to bear children conflicts with condom use; condoms are stigmatized by association with sex workers, and sterilization is the more common contraceptive. Beliefs about the balance and flow of body fluids lead some to see condoms as a threat to male health. There is a strong belief that marriage itself protects a woman from HIV, an acceptance of fate as part of karma, and a pattern of married men having sex with men.
Suppose a program in this setting used the Health Belief Model unchanged. Which constructs would need new local content, and where does the model's assumption about who decides break down? Which of the other theory families in this section would you add, and why?
The case makes the two adjustments concrete. Perceived barriers include stigma, the belief about bodily flow, and suspicion of an informed bride; perceived susceptibility is undermined by the belief that marriage protects. And the decision about a condom belongs to the couple, which points toward theories of gender roles and social norms and toward communication that reaches husbands and mothers-in-law. The program examples in Section 4 use exactly that kind of combination.
Communication with diverse populations
Communications theories address the process of encoding, sending, receiving, and decoding messages, where encoding and decoding refer to how a message is packaged so that a particular group will understand its meaning as intended and find it intuitively sensible. In a global context this takes careful thinking and a decent knowledge of the many possible audiences. Consider one example: how would you target information to migrant Latina mothers in the United States? What would you need to know about themes, about words and symbols to use or avoid, and about channels? Replace the audience with newcomer mothers in Brampton or Richmond and the questions are unchanged.
Communications programs are one of the areas of global health where theory is used most explicitly. They draw on communication theory, social marketing, diffusion of innovations, and community mobilization, and there is a term used almost exclusively in global health: behavior change communication, or BCC. The accordion summarizes the approach.
BCC was developed primarily in the global health context, originally in nutrition and later widely in HIV/AIDS. Its roots are in several theories from this course and some that are not: diffusion of innovations; stages of change from the Transtheoretical Model; self-efficacy from Social Cognitive Theory; social marketing and its consumer research; and the Behavior Change Continuum from the World Bank, which this course does not cover. Like many global health programs, it uses a combination of theories.
Very similar to any communications campaign: (1) state program goals; (2) involve stakeholders; (3) identify target populations; (4) conduct formative BCC assessments, meaning formative research designed to understand risk behaviours, their context, attitudes, and understandings; (5) segment target populations; (6) define overall behaviour change objectives; (7) design a BCC strategy covering current behaviour, concepts and themes, key messages, channels, barriers and supports for change, implementation partners, and monitoring and evaluation; (8) implement and evaluate the strategy. Compare this with the campaign process in Lesson 8: the sequence is the same, and step 4 is where the local filling-in happens.
The goal is to change behaviour and so address a health problem, through these processes: increase knowledge; stimulate community dialogue; promote essential attitude change, for example regarding perception of risk; reduce stigma and discrimination; create demand for information and services; advocate; promote services for prevention, care, and support; and improve skills and sense of self-efficacy. Read against the theories: knowledge and risk perception belong to the Health Belief Model, dialogue to diffusion and mobilization, demand to social marketing, and skills and self-efficacy to Social Cognitive Theory.
Organizations, communities, and political economy
Three further families of theory address problems no message can solve on its own. The tabs give an account of each and the situation it fits.
When the problem is an organization or a policy
These approaches may be needed when an organizational or policy problem has to be solved before a health problem can improve. For example, resources may not be directed to a population that needs them because the public health agency, or network of agencies, has no system for identifying who is affected and feeding that information to decision makers. An organizational change effort is also needed when a new system linking epidemiological data to program planning is put in place and meets internal resistance. The same theories matter when change has to come from within a community: people have to be aware of a problem and motivated to take collective action, holding public awareness events, gathering signatures for a petition, or organizing a mail, telephone, or email campaign directed at a legislator.
Participation in the tradition of Freire
Advocacy and mobilization approaches are very much part of public health work in a global context, particularly the participatory approaches that come from Paulo Freire, in which there is a collaboration with the community in defining the problem and identifying solutions. This is the theory behind the advice repeated in Section 2: partner with local organizations, take the time to do research, and work with communities in a participatory collaboration. It is also the answer to the second adjustment above. Where the individual is not the decision-making unit, the community that is the unit has to be in the room.
When the cause is upstream
There is often a macro-level political-economic context that shapes the trajectory of a health condition. A country's pattern of economic development may create vulnerabilities in specific populations; the rural-to-urban transition may result from political decisions about which industries to favour. If those decisions create a geographic class of rural people with less and less access to work, cash income, resources, education, and medical care, an intervention targeting the political-economic context will identify the key elements of that context and then use a range of approaches, including community mobilization, advocacy, and direct programmatic action. The object might be to redirect economic activity to rural areas, organize rural health collaboratives to make the most of scarce resources, or pass a law that makes it hard for businesses to relocate from rural to urban areas without providing some compensatory service. The microcredit approach of the Grameen Bank, founded in Bangladesh by Muhammad Yunus, falls in this category: it changes what poor households can do before it changes what they know.
Multitheory approaches
Global health programs are often pragmatic responses to real situations, and the emphasis on theory is not always as pronounced as in domestic programs. Theory-based programs may combine approaches or constructs from different approaches. A good example is the AIDS Risk Reduction Model, or ARRM (Catania, Kegeles, and Coates, 1990). It focuses on sexual transmission of HIV and incorporates elements of the Health Belief Model and efficacy theory from Social Cognitive Theory, together with the role of emotion and interpersonal processes. It also shows the influence of stages of change, because the change process it envisions has three stages. Do these stages sound familiar? The table answers.
| ARRM stage | What happens | Parallels in earlier theories |
|---|---|---|
| Stage 1: Recognition and labelling | Recognizing and labelling one's own behaviour as high risk | Perceived susceptibility and severity in the Health Belief Model; the move from unaware and unengaged to deciding in the Precaution Adoption Process Model; precontemplation to contemplation in the Transtheoretical Model |
| Stage 2: Commitment | Making a commitment to reduce high-risk sexual contact and to increase low-risk activities | Intention in the Theory of Planned Behavior; the preparation stage of the Transtheoretical Model; outcome expectations and self-efficacy from Social Cognitive Theory |
| Stage 3: Taking action | Seeking information, obtaining remedies, and enacting solutions | The action stage of the Transtheoretical Model; enabling factors in PRECEDE-PROCEED; skills and self-efficacy in Social Cognitive Theory |
What ARRM adds that its parents lack is emotion and the interpersonal: fear, desire, and the negotiation between two people, which the India case showed to be decisive. That is the pattern of multitheory work in global health: the combination is chosen for the problem, and the theories are judged by whether they cover the situation.
Does this theory travel?
The decision tree turns this section into questions you can put to any program idea. It follows the logic of this section: identify what stands between people and the behaviour, check the assumptions the candidate theory carries, and find out whether you know enough locally to fill in its constructs. Every path ends with a theory family and a caution.
Whatever ending you reach, the closing advice of Section 2 applies. Globally, as domestically, health promotion is inherently human, and a willingness to learn, to understand, and to respect will carry a program further than any single theory. Section 4 shows what that looks like in practice.
Reflection
A Canadian NGO proposes a condom promotion program for married couples in the setting described in the India case study. The first draft uses the Health Belief Model unchanged: messages raise perceived susceptibility and severity, list the benefits of condoms, and address the barrier of cost. Using this section, write a critique in three parts: (1) which constructs need different local content, and what that content is; (2) where the model's assumption about who decides breaks down, and which theory family you would add as a result; and (3) what formative research you would do first and why.
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Key Takeaways
- Much of the theory in this course is applicable in a global setting at least in basic form, but its constructs must be filled in with locally relevant content, and the assumption that the individual is the primary decision-making unit must be checked, because in many societies a couple, household, elders, or community decides.
- Ethnomedical systems, shared ideas about the causes of illness, its treatment, and the appropriate healers, are closely tied to the constructs of behavioural theory, and cultural variety is a strength to build on rather than a deficit to correct.
- Communication is the area of global health where theory is used most explicitly. Behavior Change Communication draws on diffusion, stages of change, self-efficacy, social marketing, and the World Bank's Behavior Change Continuum, and its eight steps put formative research before strategy.
- When the obstacle is an organization, a community that has not acted, or the structure of the economy, the answer lies in organizational change and advocacy, Freire's participatory community mobilization, and political-economic approaches such as microcredit.
- Global programs are pragmatic and combine theories; the AIDS Risk Reduction Model joins the Health Belief Model, self-efficacy, emotion, and interpersonal processes with three stages that echo the Transtheoretical Model and the Precaution Adoption Process Model.
1. A planner imports a Theory of Planned Behavior questionnaire, validated in Ontario, to predict whether women in a rural district will attend antenatal care. Local staff report that mothers-in-law decide when a pregnant woman may leave the household. Which caution applies most directly?
2. Which statement best captures how ethnomedical systems relate to behavioural theory?
3. A campaign to promote oral rehydration solution follows these steps: state goals, involve stakeholders, identify and segment target populations, run formative research on how caregivers understand diarrhoea, define objectives, design messages and channels with monitoring built in, then implement and evaluate. Which approach is this?
4. In the AIDS Risk Reduction Model, a man recognizes and labels his own behaviour as high risk. Which construct or stage from earlier theories is the closest parallel?
5. A rural district loses clinics and jobs after national policy favours coastal industry, and diarrhoeal disease rises among children left behind. Which family of theory should frame the intervention, and what might it aim to do?
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Program Examples and Canada’s Role
⏱ Estimated reading time: 18 minutes
Four programs that made the trip, and Canada’s part in the system
Learning objectives for this section
- Describe the components of four program examples: avian influenza communications, social marketing in Cameroon, family planning in Albania, and mobile phone games for HIV prevention.
- Identify the theories each program used and the evidence it produced.
- Explain Trials of Improved Practices and why it learns more from what people cannot do than from what they can.
- Compare a top-down and a participatory program and predict which is more likely to change behaviour.
- Describe Canada's contribution to global health promotion through the Ottawa Charter, government agencies, Grand Challenges Canada, and Canadian NGOs.
This lesson closes with a few examples of behaviour-related global health programs, none presented as a model to copy. Each shows theories chosen for a setting, channels chosen for an audience, and, usually, formative research that filled in the constructs locally. Read them with Section 3's decision tree in mind, then test yourself with the theory spotter.
Four program examples
Avian influenza communications program
USAID developed a communications program to inform target audiences about avian influenza and preventive strategies. Its components are the channels of a campaign. Interpersonal communication used agriculture and veterinary extension agents, counselling by clinic staff, and peer educators such as farmers and vendors. Organizational and community channels included workplaces, schools, village meetings, and affinity groups such as farmers' associations. Mass media covered television, radio, and print. Public relations and advocacy included leader conferences, press briefings, and training of public spokespersons. Private sector partnerships completed the set. Recall from Section 1 that the audience was rural households for whom poultry is both livelihood and tradition. Extension agents and peer farmers are diffusion of innovations in practice: trusted early adopters through whom a new practice spreads.
Social marketing for STI prevention in Cameroon
Population Services International ran a social marketing campaign against sexually transmitted infections and unwanted pregnancies among urban youth in Cameroon, reaching about 600,000 sexually active young people aged 15 to 24. Young Cameroonian peer educators, journalists, comic-strip artists, radio personalities, and scriptwriters helped develop the messages. The campaign was built around the 100% Jeune (100% Young) condom brand, with messages promoting images of youth who challenged social norms and protected their health; more than 40,000 of these condoms were sold in 2002. A serial radio drama and a call-in talk show were part of the effort, and face-to-face sessions for youth in and out of school reached about 10,000 a month. Evaluation showed that knowledge increased, attitudes about buying condoms became more positive, and condom use rose with regular partners. A branded product, a price, distribution, and promotion are social marketing's four Ps; the drama and talk show are entertainment-education; the young message developers are participation as well as consumer research.
Albania family planning project
In Albania, the Manoff Group, a research and program consulting organization, took part in a USAID-supported family planning project led by John Snow, Inc. It designed a BCC strategy based on cognitive anthropology, social interaction theory, behaviour change theories derived from commercial market research, and gender role and status theory, to help Albanians adopt and use modern family planning methods. The work ran through twelve steps: a literature review; formative qualitative research; Trials of Improved Practices; a behaviour change strategy; a national baseline survey; two television spots portraying, symbolically and socially, the cognitive domains found in the research and advocating locally feasible behaviours from the TIPs results; broadcasting; a media recall survey; community outreach; a call-in show, because the research had shown that most modern methods were unknown; a press workshop for journalists; and a follow-up survey. The formative research elicited cognitive domains through a projective technique in ethnographic interviews, assuming that fertility and family planning are parts of culture inextricably linked to gender roles and status and to the couple's relationship. More than 65 percent of women in the audience and more than half of men saw the spots, and the great majority discussed them with others. That last finding is the theory at work: models of culture change hold that discussing information with others is key to producing knowledge, and all BCC steps from design to evaluation were based on culture theories.
Mobile phone games for HIV/AIDS prevention
An example of mHealth, the use of mobile devices in health promotion, is Freedom HIV/AIDS, developed in Africa by ZMQ, an India-based social enterprise, with partners, building on an earlier effort in India, using two awareness games on mobile phones. AIDS Fighter Pilot is an adventure game about a village boy, Juma, and a village girl, Wanjiku, peer educators who spread knowledge about HIV/AIDS in every corner of their village using their glider. AIDS Penalty Shoot Out is based on soccer: players save and shoot penalties, receive messages on awareness, prevention, and myths, and the score reflects how much was learned and triggers feedback. For Eastern Africa the games were developed in English, Kiswahili, and Sheng, the urban mixed language of Nairobi. The approach is based on Social Cognitive Theory: the score measures knowledge change, and the interactive play is intended to build self-efficacy and motivation for prevention.
Trials of Improved Practices
The Albania project's third step is the clearest example in this lesson of a method built to fill in a theory's constructs locally. Trials of Improved Practices, or TIPs, was developed by the Manoff Group and first used in 1979. From formative qualitative research, the researcher develops a menu of behaviours that would improve audience members' health or help them reach their fertility goals more safely; the behaviours may differ from the ideal recommendation because they are tailored to local norms. The researcher then draws a sample of at least 15 people per audience segment, observes and interviews them at home or in clinics, negotiates a behaviour for the person or couple to try during the coming week, obtains a commitment, and returns after a week.
The line to remember: the aim is to learn what behaviours are locally feasible, so researchers often learn more from what people were unable to do than from what they could do. Results are analyzed as barriers and as supports or motivators, the same categories as the Health Belief Model's barriers and PRECEDE's enabling and reinforcing factors. TIPs is based on both culture theory and behaviour change theories: a week-long, household-level test of whether a theory's construct has the content you assumed.
The programs side by side
| Program | Lead actors (Section 2 types) | Theories named or clearly used | Evidence reported |
|---|---|---|---|
| Avian influenza communications | USAID (bilateral), with extension services, clinics, private partners | Communication theory; channels consistent with diffusion and mobilization | Components described; no outcome data |
| 100% Jeune, Cameroon | Population Services International (NGO) | Social marketing; entertainment-education; peer participation in message design | Knowledge up, attitudes to buying condoms better, condom use up with regular partners |
| Albania family planning | Manoff Group and John Snow, Inc., with USAID support | Cognitive anthropology; social interaction theory; commercial market research; gender role and status theory; BCC; TIPs | Most women and more than half of men saw the spots; most discussed them with others |
| Freedom HIV/AIDS mHealth games | ZMQ (social enterprise) with partners | Social Cognitive Theory: knowledge, self-efficacy, motivation | Score as a measure of knowledge change; no population outcomes |
Two patterns stand out. Every program used several theories, as Section 3 predicted. And the most explicitly theoretical programs, Albania and Cameroon, are the ones with formative research and local participation in message design: partnership restated as method.
Top-down or participatory: two districts, one program
Case study: Handwashing in two districts
A Canadian NGO receives a bilateral grant to reduce diarrhoeal disease among children under five in two rural districts of a partner country. In District A, the program is designed at head office from a package used elsewhere: posters and a radio jingle on handwashing with soap after the latrine and before feeding children, translated into the national language, distributed through clinics, with a knowledge recall survey at six months. In District B, the field team spends two months on formative research with a local women's association, then runs TIPs with 20 households. They learn that soap is kept for laundry, that water is carried from a well twenty minutes away, that a local language is spoken at home, and that grandmothers, not mothers, decide how children are fed. The negotiated behaviours are washing with ash or soap at two key moments using a hanging water container made from local materials, promoted through the women's association, grandmothers' meetings, and local-language radio. At six months, District A's survey shows high message awareness; District B's household observations show more handwashing stations in use.
Which theories underlie each design? Why did District A measure awareness while District B measured behaviour? Using the assessment phases and the advice on partnership from Section 2, explain why District B was more likely to change behaviour, and name one cost of its approach.
District A is a message campaign whose constructs were filled in somewhere else: it assumes soap is available for hands, water is nearby, the national language reaches the home, and mothers decide. Each assumption is a barrier an educational and ecological assessment would have found. District B is BCC with TIPs, mobilization through the women's association, and the right decision-making unit. Its costs are real: two months of research, a smaller reach, and a program that cannot be copied to District C without repeating the research. Those costs are the price of changing behaviour rather than awareness.
Canada in the global health system
The program examples above are American and European. Canada occupies the same boxes on the actor map, and its contribution to health promotion runs back to the document that defined the field.
The first International Conference on Health Promotion, hosted in Ottawa in 1986 by WHO, Health and Welfare Canada, and the Canadian Public Health Association, produced the charter (WHO, 1986). Its definition of health promotion and its five action areas became the reference point for a series of WHO global conferences, from Adelaide in 1988 through Bangkok in 2005, whose charter addressed health promotion in a globalized world directly, to Shanghai in 2016. When Section 3 says that mobilization, advocacy, and policy change are part of global public health work, it is describing the Ottawa Charter's action areas in practice.
Canada's bilateral agency was the Canadian International Development Agency, created in 1968 and merged into the foreign affairs department in 2013; its work now runs through Global Affairs Canada, whose priorities have included the 2010 Muskoka Initiative on maternal, newborn, and child health and the Feminist International Assistance Policy of 2017. The International Development Research Centre, a Crown corporation created in 1970, funds research in low- and middle-income countries. Canada is a member of WHO and, since 1971, of the Pan American Health Organization, and hosted the Global Fund's fifth replenishment conference in Montreal in 2016.
Grand Challenges Canada, founded in 2010 and funded largely by the Government of Canada, funds innovators in low- and middle-income countries and in Canada. Its Integrated Innovation approach holds that a scientific or technological idea reaches people only when paired with social innovation, the community and behavioural work this lesson describes, and business innovation that makes it sustainable. Its programs have included Stars in Global Health and Saving Brains, and it co-founded Saving Lives at Birth in 2011. In the actor categories of Section 2 it is closest to a parastatal organization, and it shows how a funder can require theory-based behavioural work as a condition of support.
Canadian NGOs occupy the implementation box on the actor map. CARE Canada was founded in 1946, a year after CARE itself. Cuso International, founded in 1961, places volunteers with partner organizations. The Stephen Lewis Foundation, founded in 2003, supports community-based organizations responding to HIV/AIDS in sub-Saharan Africa; its Grandmothers to Grandmothers Campaign, launched in 2006, is community mobilization on both sides of the partnership. Nutrition International, based in Ottawa, works on vitamin A supplementation and salt iodization, where a behaviour change component decides whether a technology is used. Right To Play, based in Toronto, uses sport and play in health and education programs. Médecins Sans Frontières and the Red Cross have Canadian sections, and Canadian James Orbinski accepted the 1999 Nobel Peace Prize on behalf of Médecins Sans Frontières as its international president.
For a student, the entry point to any of this is the advice that runs through this lesson: partner with people who know the local capacity, beliefs, norms, and culture, and do the research before designing the program. The final review draws the threads together: a global setting that includes Canada, a system of actors that decides what gets built, theories that travel with adaptation, and programs that succeed when they fill in their constructs locally and treat the community as a partner.
Reflection
Grand Challenges Canada invites proposals for a behaviour change component to accompany a new low-cost water filter in a rural region of a partner country, and requires social innovation alongside the technology. Using the four program examples from this section as your models, design the component in outline: (1) name the theories you would combine and say which program example each is borrowed from; (2) describe the formative research and any Trials of Improved Practices you would run before the first message is written; (3) choose your channels and justify them for a rural audience; and (4) say what you would measure at six months and why a media recall survey alone would not be enough.
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Key Takeaways
- The four program examples each combine theories chosen for a setting: a USAID communications program on avian influenza built from interpersonal, community, mass media, advocacy, and private sector channels; PSI's 100% Jeune social marketing campaign in Cameroon; the Manoff Group's culture-theory based BCC strategy for family planning in Albania; and ZMQ's Social Cognitive Theory based mobile games for HIV prevention in East Africa.
- Trials of Improved Practices, first used in 1979, negotiates with a small sample of households a behaviour to try for a week and returns to learn what was locally feasible, sorting results into barriers and supports; researchers learn more from what people could not do than from what they could.
- The programs with the most explicit theory, Albania and Cameroon, are also those with formative research and local participation in message design, and the evaluations that mattered measured behaviour rather than message recall.
- A top-down program fills in its constructs somewhere else and tends to measure awareness; a participatory program fills them in locally, identifies the real decision-making unit, and measures behaviour, at the cost of time, reach, and easy replication.
- Canada occupies every box on the actor map: the Ottawa Charter of 1986 shaped health promotion worldwide, Global Affairs Canada and IDRC fund, Grand Challenges Canada requires social innovation alongside technology, and Canadian NGOs from CARE Canada to the Stephen Lewis Foundation implement.
1. Which feature of the Cameroon campaign most clearly marks it as social marketing rather than a general health education program?
2. In the Albania project, television spots portrayed the cognitive domains found in ethnographic interviews, and the recall survey found that most viewers discussed the spots with others. Why does the discussion finding count as evidence that the theory worked?
3. A TIPs researcher recommends that a mother add an egg to her toddler's porridge daily and returns a week later to find she managed it twice, because eggs are sold for cash and the family keeps only two hens. What should the researcher do with this result?
4. Two districts receive a handwashing program. District A gets a translated poster and jingle package delivered through clinics and measures message recall. District B runs formative research and TIPs with local women's groups and measures observed handwashing. Which argument best explains why District B is more likely to change behaviour?
5. Which statement about Canada's place in the global health system is accurate?
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Final Review & Assessment
⏱ Estimated time: 25 minutes
Bringing It All Together
This lesson moved from a claim to a method. The claim is that it has become less and less useful to think about global health as separate from domestic health. HIV/AIDS travels along trade routes, urban migration, labour flows, and tourism; avian influenza followed poultry markets and migratory birds from Hong Kong across Asia to Europe; and the shirt on your back passed through six countries on its way to you. Health still follows different paths in different countries because of five ecological factors, environmental risks, system capacity and infrastructure, socioeconomic conditions, political conditions, and social patterns and cultural traditions, and because countries sit at different points of the epidemiologic transition, a line that HIV, influenza, longer lifespans, and uneven development within countries have blurred. The global ecology of health is the same onion as the domestic one, with more layers.
The outer layers are the global health system: bilateral agencies, regional and multilateral organizations, public/private partnerships, financial institutions, NGOs and foundations, and parastatal bodies, combined differently for a disaster and for a long-term prevention effort, and always delivering through a country's ministry, local organizations, and communities. Because funding, coordination, approval, and delivery sit in different boxes, the theory a program uses is often negotiated, and a PRECEDE-PROCEED style assessment comes before choosing one. The educational and ecological phase carries the central advice of the lesson: make no quick assumptions, partner with people who know the local capacity, beliefs, norms, and culture, take time to do research, and work in participatory collaboration. The administrative and policy phase, in the Country X scenario, shows funder rules and political opposition shaping a program before any theory is named.
The method follows. Most theories travel in basic form, but their constructs must be filled in locally and the assumption that the individual decides must be checked against the ethnomedical system and the real decision-making unit. Communication is where theory is most explicit, and Behavior Change Communication, with formative research as its fourth step, is the working approach. Organizational change, Freire's participatory mobilization, and political-economic theories address obstacles no message can move, and real programs combine several, as the AIDS Risk Reduction Model does. The four program examples, avian influenza communications, 100% Jeune in Cameroon, family planning in Albania with Trials of Improved Practices, and Social Cognitive Theory based mobile games, show the combination in practice, and Canada occupies every box on the map, from the Ottawa Charter to Grand Challenges Canada and Canadian NGOs.
Key Takeaways from this lesson
- Global and domestic health have merged epidemiologically: the routes that carry trade, migration, and travel carry HIV/AIDS and influenza, and they run through Canada.
- Health still follows different trajectories because of five ecological factors and a country's position in the epidemiologic transition, and system capacity and cultural tradition decide whether a theory-based program can work at all.
- The global health system has seven types of actor whose combinations vary by situation; because funding and delivery sit in different organizations, theory is negotiated, and a PRECEDE-PROCEED style assessment comes first.
- The central advice of the lesson is participatory: make no quick assumptions, partner with people who know the local capacity, beliefs, norms, and culture, and take the time to do formative research before designing a program.
- Theories travel with adaptation: fill in the constructs locally, check whether the individual is the decision-making unit, respect the ethnomedical system, and combine theories as Behavior Change Communication and the AIDS Risk Reduction Model do.
- The program examples succeed where they filled in their constructs locally, used local voices and channels, and measured behaviour rather than recall; Trials of Improved Practices is the clearest method for doing so, and Canadian actors from the Ottawa Charter to Grand Challenges Canada work in the same tradition.
Reflection
A Canadian NGO with a three-year grant from Global Affairs Canada is asked by a partner ministry of health to reduce diarrhoeal disease among children under five in a rural region where water is carried from distant wells, a local language rather than the national one is spoken at home, grandmothers decide how children are fed, and a group of local clinicians believes the real problem is that mothers are ignorant. Integrating the whole lesson, write a plan that (1) places the problem in the ecology of health, naming the ecological factors and the layer of the onion each belongs to; (2) maps the actors involved and says who funds, who approves, and who delivers; (3) runs the assessment phases in order and names the source or method for each; (4) chooses and adapts theories, showing where you filled in constructs locally, who the decision-making unit is, and which of the four program examples you are borrowing from; and (5) says what you will measure and why, and what the clinicians' view would lead you to measure instead.
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Final Knowledge Assessment
This assessment covers all material from this lesson. You must score 100% to complete the lesson. Review the feedback for any incorrect answers and try again.
1. Which of the following best states the reason for opening a lesson on global health with a discussion of globalization?
2. A country's rural clinics exist on paper, but most have no trained staff and are located far from the villages they serve, and there is no system for collecting mortality data. Under which of the five ecological factors does this cluster of problems fall?
3. What does it mean to say that HIV/AIDS and several forms of influenza have blurred the epidemiologic transition?
4. Which of the following is an example of a parastatal organization?
5. For a long-term effort to prevent the spread of an infectious disease, which actor is likely to coordinate, and with whom?
6. Why is getting data on global health both easy and problematic?
7. In the Country X scenario, the independent NGO has better access to schools, which would let the program draw on both funders. What is the main risk implied in choosing it?
8. In a global context, using the Health Belief Model may require extra effort. What specifically has to be done?
9. Which of the following are the theoretical roots of Behavior Change Communication?
10. A district health office collects good surveillance data, but the information never reaches the planners who allocate clinic staff, and the staff resist a new system that would link the two. Which family of theory fits this problem?
11. Which statement about the AIDS Risk Reduction Model is correct?
12. In the avian influenza communications program, agriculture and veterinary extension agents and peer educators such as farmers and vendors were used. Which communication channel category do they belong to, and which theory do they most resemble in practice?
13. What did the evaluation of the 100% Jeune campaign in Cameroon find?
14. The Albania project's formative research used a projective technique in ethnographic interviews to elicit cognitive domains. What assumption underlay this design?
15. Which feature of Grand Challenges Canada's approach most directly reflects the argument of this lesson that a technology reaches people only through behavioural and community work?
✦ Complete the final reflection above before submitting