Some years ago I was in Portugal having a conversation with a physician colleague about teenage pregnancy in Brazil. After showing some numbers she asked me “why do you have so many young women getting pregnant? Don’t you have pills to offer?”. I tried to show her that the picture was a bit more complex and an easy answer (or an easy intervention) to that issue would not be helpful and, probably would be detrimental for everyone. It is not easy to give up on our biomedical interventionist and stop prescribing solutions for everything.I agree that the problem is “probably basic” only if you mean “Fundamental” or “Central”, but not if you mean “easy”. Actually, it is far from “easy” to understand and, as a policymaker, to deal with. This can be applied to your example (poor communities) as well as to corporations, health teams, hospitals.
About your question “What can we do, in order to behavior change?”, I would suggest to get a step back and try to understand what “behavior”, “change” and “do” mean.
About Behavior
In the literature, the term commonly used today is Health Seek Behavior and you can find some good articles like this one from Ethiopia published this year at the African Journal of PHC and FM or this one about diarrhea in Adis Ababa from 2017. Those articles help to understand more about HOW people behave.
In order to understand WHY people do things the way they do, there is a very good book from the British medical anthropologist Cecil Helman called Culture, health and illness: an introduction for health professionals. It is a very good reading, full of colorful examples, wrote aiming health care providers and policymakers. You can find it in Portuguese – I’m assuming you’re a Portuguese speaker.
About Change
Here things get more complicated because we will start again to “prescribe”.
From a clinical (health care provider) perspective, I’d recommend the reading of Roger Neighbour, Moira Stewart and her book about patient-centered care and Francesc Borrell (in Spanish). From a policymaker and management perspective, I’d recommend the Quality Improvement literature, most of that comes from business and management, but from a health care perspective, the Quality Improvement program at the Department of Family and Community Medicine from Toronto has great material and it helps a lot to understand that there’s no silver bullet, while gives you tools to can be used every day in planning and management. To give you an example, we “stole” their idea of training residents in Family Medicine to develop a QI project during the first year of training. For the whole year, they have courses, workshops and develop their project. As a result, we have residents in the second year complaining less about how things are and questioning more about how can they help to make things improve for everyone.
Maybe the article A continuous quality improvement intervention to improve the effectiveness of community health workers providing care to mothers and children: a cluster randomised controlled trial in South Africa addresses something similar to your problem.
About Do (or not to do)
Health Economists are in love with the idea of Nudge, after Richard Thaler Nobel prize in 2016. I think it is interesting to know about and understand behavior from an economic perspective, but use it in health care services can be a panacea. This article about Tuberculosis in Viet Nam helps to understand how health services design can be harmful to the patients (and communities) and make their lives a nightmare. I met the author Knut Lönnroth last week and he is a fantastic researcher with many stories about how we design health systems trying to help people, but taking only our perspective into consideration. The outcomes are always disastrous.
Hope this will be helpful.
Have a nice weekend,
Adelson Guaraci Jantsch
Médico de Família e Comunidade
Doutorando em Epidemiologia pelo Instituto de Medicina Social (IMS) da UERJ
Coordenador Técnico do
Programa de Residência Médica em
Medicina de Família e Comunidade da
SMS – Rio de Janeiro
Family Physician
Ph.D. Candidate at the IMS/UERJ, Rio de Janeiro, Brazil
Director of the Family Medicine Residency Program at the Rio de Janeiro Health Department