REPORT OF A CONSIJLTATIVE GROUP MEETING ON

APPLICATION OF BEHAVIOURAL SCIENCES IN

HEALTH SERVICES IN DEVELOPING COUNTRIES

Alexandria, Egypt, 2-5 September 1985

WORLD HEALTH ORGANIZATION REGIONAL O F F I C E FOR THE EASTERN MEDITERRANEAN

1985

W O - E M / M E M T / ~ ~ ~

October 1885

REPORT OF A CONSULTATIVE GROUP MEETING ON APPLICATION OF BEHAVIOURAC SCIENCES IN HEALTH SERVICES IN DEVELOPING COUNTRIES

Alexandria, Egypt, 2-5 September 1985

(Meeting ME.: EM/CGM.RBS.HS.DVC/~)

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE EASTERN MEDITERRANEAN

1985

EDITORIAL MOTE

The issue of this document does not constitute formal publication.

The manuscript has only been modified to khe extent necessary for proper comprahsnsion. The views C H ~ P C S ~ C ~ , howcver, do not necessarily reflect the official policy of the World Health Organization.

The designations employed and the presentation of the material in this document do not imply the expression of any opinion whatsoever on the part of the Secretariat of the Orkanization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiere or boundaries.

1. INTRODUCTION

A Consul ta t ive Group Meeting on Applicat ion of Behavioural Sciences i n Health services in Developing Countries was convened i n the WHO Eastern Mediterranean Regional Off ice , Alexandria, on 2-5 September 1985. The meeting was at tended by temporary advisers from f o u r coun t r i e s from the Region and a number of.EMR0 s t a f f members. A l i s t of p a r t i c i p a n t s i s given i n Annex 11. Representat ives of major behavioural sc ience d i s c i p l i n e s were present a s we l l as r ep re sen ta t i ves of major WHO programme a r e a s ( i . e . Disease Prevention, Environmental Wealth, Heal th Manpower Development, Maternal and Child Health, Nutrition, Occupational Health, Essential Drugs, Research Promotion and Development).

The meeting was opened by D r Hussein A. Gezairy, Regional D i r ec to r , who welcomed t h e p a r t i c i p a n t s , no t ing t h e important r o l e of t he behavioural scicnccs i n the skruggle towards the goal of Health f o r All.

D r Gezairy s t q t ed :

"... it i s slowly becoming apparent t h a t no amount of research i n phys ica l sc iences can ever make us understand t h e complexi t ies of human behaviour, t h e motivat ion of t h e i nd iv idua l , h i s a s p i r a t i o n s , and h i s fears, which ultimately decide why a health programme succeeds o r f a i l s . The s ign i f i cance of human behaviour i n mat te rs of hea l th and d i sease i s obvious t o anyone who ca re s t o examine t h e i ssues ."

Dr Gezairy remined t h e p a r t i c i p a n t s of t h e Koranic v e r s e which r e f e r s t o t h e b a s i c p r i n c i p l e which should guide behaviour : "Lo! Allah changeth not t h e condi t ion of a people u n t i l they change t h a t which is i n t h e i r hear t s" .

Following h i s address , Dr Gezairy proposed t h a t D r W.A. Hassouna se rve a s t h e Chairman of t h e Meeting. D r A. Marsel la and D r H. A b e d were appointed as Rapporteurs. The Meeting then adopted t h e Agenda (see Annex I) , and the proposed programme.

2 . OBJECTTVES

The fol lowing ob jec t ives of t h e Meeting were approved:

2 . 1 . To review recent developments i n t h e app l i ca t i on of behavioural sciences i n h e a l t h s e rv i ce s , p a r t i c u l a r l y a s i t r e l a t e s t o WHO co l l abo ra t ive programmes i n developing count r ies .

2.2. To i d e n t i f y behavioural and mental h e a l t h i n t e rven t ions which can improve the quality of hea l th services i n the Region and t o develop an outline of p ro j ec t proposals r e l a t e d t o i d e n t i f i e d behavioural in te rvent ions .

2 .3 . To i d e n t i f y reg ional f a c i l i t i e s and manpower resources i n behavioural sciences research r e l a t e d t o hea l th problems.

2.4. TO recommend s t eps t o promore research and t r a i n i n g i n t h e behavioural sciences as r e l a t e d t o h e a l t h i n t h e coun t r i e s of t h e Eastern Mediterranean Region.

3. REVIEW OF RECENT DEVELOPMENTS IN THE APPLICATION OF BEHAVIOURAL SCIENCES TO HEALTH SERVICES IN DEVELOPING COUNTRIES

3.1. Behavioural sciences

The behavioural sciences were defined as " t h a t hranrh nf nrganized knowledge

t h a t seeks t o desc r ibe , understand, modify and p red i c t t h e determinants and func t ions of human behaviour". The primary behavioural sc iences a r e anthropol~~~,psychiatry, psychology, and sociology. Cer ta in aspec ts of economics, geography, p o l i t i c a l sc ience , and pub l i c hea l th may a l s o be considered a s behavioural sc iences .

1.2. T ~ P rontribut ion o f behavioural sciences -

The behavioural sc iences have developed an impressive knowledge base which can be used t o s t r u c t u r e and f a c i l i t a t e t h e de l ive ry of h e a l t h s e rv i ce s i n developing coun t r i e s . S c i e n t i f i c da t a a r e a v a i l a b l e t h a t address problems regarding t h e ae t io logy , expression, course, outcome, t rea tment , and prevention of a broad spectrum o f hea l th problems, including cardiovascular d i s eases , rnnrer and stress problems. There is also considerable behaviournl science knowledge on such top i c s a s f e r t i l i t y - r e g u l a t i n g behaviour, pa in , pa t i en t - doctor r e l a t i onsh ips , compliance, p a t i e n t s ' conceptions of d i s ease , se rv ice- u t i l i z a t i o n p a t t e r n s , indigenous conceptions of d i s ease and indigenous hea l e r s .

But perhaps most important ly, the behavioural sc iences a r e concerned with t h e i n t e r r e l a t i o n s h i p s among t h e p a t i e n t , t he p ro fe s s iona l , and t h e bureaucratic- s y s t e m that provide the basis of health services. These sciences d e a l with t h e p a t i e n t ' s perspec t ive regarding h i s /he r i l l n e s s , , including t h e ways i n which t h e pa t i en t conceptua l izes , experiences, and , manifests t h e i l l ne s s , and t h e ways i n which the p a t i e n t seeks he lp and deci'des t o accept and comply wi th t h e c a r e prescr ibed , The behavioural sciences a r e a l s o involved i n t h e ways i n which t h e profess iona l - indigenous hea l e r o r un ivers i ty- t ra ined physician - perceives t he i l l n e s s and t h e p a t i e n t , and t h e way he/she formulates, proposes and provides therapeutic services. Lastly, the behavioural sciences a r e concerned with the s t r u c t u r e and process o f hea l th care and se rv i ce s . Behavioural sciences d e a l not only with t h e behaviour of c l i e n t s but equal ly wi th t h e behaviour of t h e providers of hea l th serv ices .

3 . 3 . Some b a s i c p r i n c i p l e s of behavioural sties

To understand t h e poss ib l e app l i ca t i ons of the behavioural sc iences t o t h e h e a l t h ca re and se rv i ce s of developing coun t r i e s , i t i s necessary t o d is - cuss some b a s i c t e n e t s o r p r inc ip l e s of these sciences.

The behavioural sc iences assume t h a t human h e a l t h and d i s ea se are determined by a spectrum of fo r ce s which extend f a r beyond simple b io log i ca l functioning. T h i s assumption, w h i c h same people have termed " h o l i ~ t i c " , acknowledges t he f a c t t h a t every i nd iv idua l func t ions a t many l e v e l s and t h a t these l e v e l s a r e interdependent . Fur ther , t h i s assumption concedes t h a t we cannot t r e a t only t h e ind iv idua l but must a l s o t r e a t t h e broader s o c i a l and phys ica l environment i f we a r e t o be success fu l . Although t h i s perspec t ive obviously complicates t he t a s k s and r e s p o n s i b i l i t i e s of the medical p rofess ion as i t cu r r en t l y e x i s t s , it a l s o o f f e r s t h i s pro- fessian a n e w v i n i o n of human health and digease which holds more promise f o r t he t reatment , con t ro l , and prevent ion of d i sease and t h e promotion of human h e a l t h and well-being.

Too o f t e n medical s c i e n t i s t s and p r a c t i t i o n e r s , pursuing t h e causes of a d i sease , focus on one s i n g l e phys ica l agent (e.g. v i r u s , bacterium, aneurism, hern ia ted d i s c ) and concentrate t h e i r energ ies on i t s removal. T h i s apprnach runs counter t n t h e causa l epistemology t h a t characterizes t he behavioural sc iences , Behavioural sciences incorpora te t he be l i e f t h a t , w h i l e some f a r c e s a r e formative t o t h e problem (i.e. they he lp c r e a t e the context f o r i t s occurrence), o the r s se rve t o p r e c i p i t a t e , exacerbate , o r maintain a problem.

According t o t he ~ r i n c i p l e s of behavioural sc iences , involvement of hnth and community i n hea l t h services i s required for succeoo. Such involvement i n h e a l t h s e rv i ce s i s not a p r i v i l e g e t o be awarded by hea l t h p ro fe s s iona l s bu t a ba s i c r i g h t which acknowledges human d ign i ty and human capab i l i t y f o r choice and s e l f - r e spons ib i l i t y . P a t i e n t and community involve- ment promotesindependence r a t h e r than dependence. Within t h i s framework, p a t i e n t s and communities can renew o r acquire a sense of pe r sona l mastery and competence which i s t he c r i t i c a l foundation f o r h e a l t h and well-being.

The movement toward p a t i e n t and community involvement has been encouraged by t h e primary h e a l t h ca r e (PHC) approach which has s t r e s sed s e l f - r e l i ance r a t h e r than dependency. This approach emphasizes maximum p a r t i c i p a t i o n i n planning, o rganiza t ion , opera t ion and con t ro l i n h e a l t h care . Although these p r inc ip l e s a r e as o ld a s any community, they required r e s t a t even t i n t he well- known Alma-Ata Document (1978) because h e a l t h s e rv i ce s i n developing count r ies had d i s in t eg ra t ed under cen t r a l i z ed contrnls whi.ch w e r e pramoting inappropr ia te goa ls , s e rv i ce s and technologies . The expected b e n e f i t s of "modern medkcine" failed t o f i l t e r down t o the limited-income urban f o l k and the r u r a l poor .

3 .4 , ~e levance of behavioural sciences f o r developing count r ies

It i s o f t en argued t h a t t h e poor develpoing count r ies have many urgent hea l t h problems of ma lnu t r i t i on , i n f ~ r t i n n s , pnnr s a n i t a t i o n , over-population, e t c . f o r which they need urgent p r a c t i c a l so lu t i ons ; t h e i r resources a r e s o l imi ted t h a t they cannot a f fo rd t h e "luxury" of g e t t i n g involved i n behavioural science t r a i n i n g and research f o r t h e i r hea l t h s e rv i ce s . This argument i s f a l l a c i o u s , In facc, developing count r ies need t h e input of behavioural sciences even more than developed ones. As experience during t h e l a s t few decades has a l ready shown, t h e h e a l t h problems of developing count r ies cannot be resolved only by r e l i a n c e on t h e h i m n ~ d i r a l s t r a t e g i e s and technologies

FIGURE 1. Behavioural in te rvent ion s t r a t e g y f o r h e a l t h se rv ices i n developing count r ies (from Marselia and Higginbotham, 1985)

m

1 3 . 3 S

a

-

TARGETS

Reinforce e x i s t i n g p o s i t i v e b e h a ~ i o u r s and a t t i t u d e s

Exti?guish ex is t ing nega t ive behaviours and a t t i t u d e s

Promte new o s i t i v e

i e h a v i o u r s and a t t i t u d e s

Prevent new nega t ive behaviours and a t t i t u d e s

Policy- maker Pa t ien t

*

Community leadzr worker

Family Nurse Physician Health

Admlnis t r a t o r

used i n developed count r ies . The presence of d i f f e r e n t hea l th problems wi th in t h e context of r a d i c a l l y d i f f e r e n t c u l t u r a l and environmental circumstances d m a n d s the implpm~ntat ion of new approaches. The PHC approach based on a c t i v e community p a r t i c i p a t i o n f o r t he prevention of d i s ease and t h e promotion of hea l th has merged as t h e bas i c s t r a t egy of WHO'S e f f o r t s i n developing count r ies . The emphasis on PHC has given r i s e t o a unique need f o r a l t e r i n g behavioural pa t t e rns and l i f e - s t y l e s of both urban and I?Ural populations i n developing count r ies . This need has produced new and exc i t i ng p o s s i b i l i t i e s and chal lenges f o r l ink ing t h e behavioural and biomedical sciences i n t h e world- w i d p mnvpment tnward "Health f o r A l l by t he Year 2000".

3.5. Applicat ion of behavioural sciences

Given . the acceptance of an a c t i v e r o l e f o r t h e behavioural sciences i n addressing t h e hea l th s e rv i ce problems of developing count r ies and given t h e acceptance of behavioural science assumptions and methods, t h e chal lenge i s then t h e i r appl ica t ion . Clear ly , t h e r e i s a s i zeab le s t e p between conwinring policy-makers, technocrats and medical profess iona ls of t h e va lue of beha- v iou ra l sc iences and t h e a c t u a l implementation of t h e i r techniques f o r the preventionof d i s ease and t h e promotion of hea l th .

The appl ica t ion of t h e behavioural sc iences ' knowledge and techniques t o hea l th ca re and serv ices i n developing count r ies must proceed beyond theory t o p rac t i ce . However, i f t h i s i s t o occur, it i s necessary t h a t s t r a t e g i c plans be developed t o implement t he ac tua l app l i ca t i on processes. The formation of a s t r a t e g i c p lan requires t h e i d e n t i f i c a t i o n of goa ls , problems and resources. I t a l s o involves t he i d e n t i f i c a t i o n of s p e c i f i c implemencacion procedures. For rrhe l a t t e r , behavioural targets must be se lec ted and s p e c i f i c t a c t i c s m u s t be planned, A conceptual summary of t he l a t t e r process is displayed i n Figure 1.

Each c e l l i n ch i s f i g u r e i s charac ter ized by i t s own s e t of problems and needs and should be considered unique,

3 . 6 . Same examples o f behaviour-ortenred in te rvent ions i n healch servfces

Although medical s k i l l s and treatments w i l l always remain the mainstay of dea l ing with var ious d i s eases , t he behavioural sciences can provide a number of a l t e r n a t i v e s which can complement and enhance the s k i l l s and c a p a b i l i t i e s of hea l th profess iona ls including h e a l t h workers, nurses and physicians. These are b r i e f l y l i s t e d below.

(a ) Communication enhancement

Communication i s perhaps one of t he most v i t a l elements i n t h e r o l e of a hea l th provider . Yet so l i t t l e a t t e n t i o n i s paid t o t h i s aspec t i n our cur ren t system of h e a l t h s e rv i ce s . The app l i ca t i on of behavioural sciences can g r e a t l y improve h e a l t h education and t r a i n i n g i n t h i s regard.

(b) Behervi~ural modification

Although the idea of behaviour change through the systematic use of rewards, punishments, and incentives is not new, there has been a remarkable development of specific principles and techniques for behaviour description, management and control in recent years, through the work of B.F. Skinner and other behavioural theorists. This behavioural technology has come to be termed "behaviour modificatioel',

This technology can be used to systematically change and maintain behavioural patterns relevant to such health areas as nutrition, occupational safety, smoking, exercise, sanitation and many others.

(c) Stress management

Behavi~ural sciences research has demonstrated that stress management can effectively reduce disease and enhance psychological and physical well- being. Stress management refers to a broad arena of techniques for reducing levels of stress in high-risk individuals. They include: (1) meditation, (2) time management; (3) cognitive control of behaviour; (4) hypnosis; (5) coping skills; (6) muscle relaxation; (7) imagery; (8) systematic desensitization and (9) biofeedback.

All of these non-medical interventions can be used effectively to reduce stress and thus control disease, For example, research has indicated that stress is implicated in a spectrum of disease including imunological dis- orders, headaches, back pain, ulcers, asthma, diarrhoea, constipation, high blood pressure, impotence, frigidity, arrthymias, insomnia, etc. Stress management techniques can be easily learned and applied by a spectrum of health professionals, with great benefits.

(a) Compliance

One of the major barriers to the reduction of morbidity and mortality in the health services is n~n-compliance with prescribed biomedical regimens.

The medical approach to compliance is based on the assumption that the doctor knows best and that the patient should do exactly what the doctor prescribes - to do less suggests ignorance, laziness, or willful neglect, This approach has led to the labelling of patients as "compliers" or "non- cmpliers". In contrast, the behavioural science viewpoint emphasizes situational circumstances that nay influence "adherence" to a regimen and subjective or phencwnennlagical perceptions by the patient of his/hcr illness, its causes, severity and preferred treatment. Behavioural science research clearly indicates that treatment regimens and risk-reduction programmes which are sensitive to life circumstances and patient representations of illness result in adherence, whereas those which do not are largely failures. This fact leads us to another behavioural science finding, that can be applied to health service problems in developing countries - i.e. indigenous perceptions of causality, illness and treatment.

(e) Indigenous concepts of causality, illness and treatment

Whereas the biomedical approach to health care and services proceeds from an assumption of the universality of disease entities identified through scientific research, the behavioural sciences proceed from the viewpoint that the patient's perspective is a critical determinant of health services utilization and treamenr: as well as risk-reduc~ion compliance.

If the health workers were familiar with the indigenous categories of causality, illness and treatment, he/she would have more insight into the patient's perceptions and preferences for health services and this would enhance his/her credibility, comunication, technical skills, and general potency as a change agent. Although it does not need saying, it is useful to remember char no maccer how well-trained a health professional may be in technical skills, he/she is of no use if the patient will not seek care nor adhere to prescribed treatments. Knowledge of the indigenous perspective increases the latter possibilities and thus should be encouraged as a part of training and practice.

3.7. Some limitations of the behavioural science approach in developing countries

Several problems must be considered prior to any application effort. These are:

(a) Ethnocentricitv

Virtually all behavioural science knowledge has been developed in the indus~rial world and much of it may r loL be r e l e v a l l L i u L h e developing countries. A careful examination of what knowledge is relevant should be made.

(b) Research problems

Research materials will require careful attention with regard to translation, conceptual equivalence and methodological equivalence. 1r: will be necessary co devise new norms and to adjust standards ro local customs.

I

(c) Concepts of health and disease

Industrial countries have concepts of health and disease that are based on distinctions between body, mind and spirit. In many developing C U U I I L L i r s , L l l r s t : c l i s ~ i ~ ~ c ~ i u ~ ~ s s l ~ r I I U L m a d r .

(e) Behavioural science resources

The behavioural sciences are not well developed in non-industrialized countries and there are shortages in manpower, fiscal resources and technical support services. There are also problems in interdisciplinary cooperation. Considerable time, money and i~lstitution-building will b e necessary tu ensure development of these sciences.

The Eastern Mediterranean ACMR, which met in Cyprus in April 1983, discussed the role of biobehavioural sciences and mental health and proposed the following activities t

(a) A review and identification of resources for research and training.

(b) Strengthening of training activities and development of training material.

(c) Active participation in the planning and implementation of global a c t i v i t l c a ,

(d) participation in jntervention trials concerned with disease-prevention and health-prmotlon-

(e) Translation into local languages of appropriate material in order to increase awareness of decision-makers and the scientific cornunity about 'needs and opportunities for work in this area.

4. APPLICATTON OF REHAVIOURAL SCLENCES TO SPECIFIC WHO PROGRAMMES

WHO has committed itself to the goal of "~ealth for All by the Year 2000". PWC has been designated as the basic approach for achieving this goal and prograrnrnes have been developed to address the officially identified components of PHC efforts,

4.1. Some examples of the relevance of behaviour to human health and disease

The current meeting included presentations by workers involved in these efforts including environmental health, disease prevention, nutrition, occupational health, maternal/child health, essential drugs, health manpower development and research promotion and development. Based on these dis- cussions, a sample of health-relevant behaviours capable of being promoted or changed was identified. These sample behaviours are displayed in Table 1.

As Table 1 indicates, there is reason to believe that reductions in the ra tes of morbidity and mortality and increases in human health and well- being could be attained by modifying human behaviour patterns and life-styles regarding: (i) increase in breast-feeding and reduction in bottle-feeding; (ii) changes in domestic sanitation, including improved disposal of refuse and human waste; (iii) changes in personal hygiene including regular brushing of teeth and washing of hands; (iv) elimination of spitting and indiscriminate discharge of nasal secretions; (v) changes in diet including reduction in salt and fat intake and increase in that of vegetables and fruits; (vi) reduction in the use of alcohol, tobacco, and certain other substances: ( v i i ) increased use of innuunizations and other health services; (viii) wearing of shoes; (ix) proper use of medications, including essential drugs, and (x) (possibly most important of all) changing the attitude and style of functioning of the providers of health services.

,LA:ALILE 1: Some egamples of desirable behaviour change required f o r major h e a l t h problems i n the Eastern Mediterranean Region

HeaAth Problems

I. Comuniqable d i s e a s e s

1.1 Diarrhoea1 diseases

1 . 2 Malar ia

1.3 Hookworm

1.4 Ascar is

1 .6 Leprosy

2 . Non-communicable diseases

2 . 1 Cardiovascular d i s e a s e s

2 .2 Cancer

2.3 T r a f f i c a c c i d e n t s

2 . 4 Dental c a r i e s

2.5 Emotional d i s o r d e r s

2 .6 Malnu t r i t ion

Behaviour change requ i red

I

1.1 Promote breast-feeding, personal hygiene, domestic s a n i r a t i o n

1,2 Eliminate wate r -co l lec t ioq l~catiqne I 1 . 3 Promote use of shocs, uao u l lstrlnos

and r e f u s e d i s p o s a l

1 . 4 Eliminate use o f h u w n excreta as f e r t i l i z e r ; promote use of l a c v i n e s

1.5 El iminate u r i n a t i o n and defaeca t ion i n s t r e a m s

1.6 Eliminate s p i t t i n g and indiscriplinatp discharge of n a s a l s e c r e t i o n s

2.1 Reduce s a l t i n t a k e , f a t s , and a l c o h ~ l i n diets; reduce smoking; reduce s t r e s s ; i n c r e a s e e x e r c i s e

1 2 . 2 Promote consumption of vege tab les and f r u i t ; fibres1 reduce smoking, alcohol consumption and use of be te l nut

2.3 Reduce a l c o h o l use while driving; educate paren t s and c h i l d r e n

2.4 Promote brushing t e e t h and d e n t a l hygiene

2.5 Reduce s t r e s s ; increase coping s k i l l s

2.6 Promote proper n u t r i t i o n through education of lie p u b l i c and haalfh p r o f e s s i o n a l s

W H O - E M I M E N T J ~ ~ ~ page '11

It was observed t h a t these behaviour r ~ a t t e r n s were a l l amenable t o change through behavioural science technologies concerned wi th a t t i t u d i n a l and habit. funnaLion a l t e r a t i o n ( e . g , behaviour modif icat ion) . The r o l e of l e g i s l a t i o n i n behaviour modif icat ion was a l s o considered. It was pointed out t h a t l i t t l e i s ye t known about t he use of l e g i s l a t i v e r a t h e r than educat ional approaches t o behaviour change. For example. l e g i s l a t i o n has been used t o cont ro l c e r t a i n d i seases ; however, i t s exact r o l e i n h e a l t h promotion i s highly complex and remains t o be s c i e n t i f i c a l l y evaluated.

The u s e of educat ional methuds w i l l r e q u i r e the development of manpower, mater ia l s and potent communication channels. Many non-health profess iona ls , w i l l most probably have t o be involved, including teachers , t he po l ice , s a n i t a t i o n workers and mass-media s p e c i a l i s t s . I t w i l l a l s o be necessary t o inform both mid-level adminis t ra tors , l e g i s l a t o r s , policy-makers, and na t iona l l e ade r s regarding the important r o l e of behaviour i n human hea l t h and d isease .

4 . 2 . Some problems i n t he app l i ca t i on of t h e behavioural sciences i n t he Eastern Mediterranean Region

Throughout t h e meeting, problems regarding t he appl ica t ion of behavioural sciences t o hea l t h se rv ices i n t he Eastern Mediterranean Region were i d e n t i f i e d and discussed. These problems included t he following: ( i ) minimal manpower developrncnt in the behavioural sciences; (ii) limited oppor tun i t ies Lo incorporate behavioural sc ience ma te r i a l i n medical cu r r i cu l a ; ( i i i ) loca t ion of behavioural un ive r s i t y science programmes i n f a c u l t i e s of a r t s , education, o r humanities which a r e f a r removed from hea l t h problems; ( i v ) c o n f l i c t s wi th in the behavioural science f i e l d s (e.g. sociology versus psychology); (v) poor l inkages between behavioural s c i e n t i s t s and hea l th and education m i n i s t r i e s ; ( v i ) misperceptions regarding behavioural science knowledge, methods, and technologies; and (vii) outdated m a t e r i a l i n the bellaviuural sciences and lack of access t o contemporary information.

In addi t ion , it was observed t h a t t he behavioural sciences a r e of ten concerned with ba s i c r a t h e r than appl ied research , t h a t they a r e o f t en concerned with d i seases r a the r than broader aspec ts of hea l t h , and t h a t f ea r s e x i s t t h a t t he involvement of behavioural s c i e n t i s t s i n t he hea l t h field w i l l result i n competition with physicians for limited financial resources.

The meeting a l s o included d iscuss ion of the many hea l t h s e rv i ce problems of developing count r ies t o which behavioural s c i e n t i s t s must be a l e r t i f they a r e t o be success fu l in applying t h e i r knowledge and technologies . These problems {nclude: (i) low na t i ona l p r i o r i t i e s f o r hea l t h programmes, because o f a g r i c u l t u r a l , cons t ruc t ion , and m i l i t a r y p r i o r i t i e s ; ( i i ) lack of i n t eg ra t i on of hea l t h programmes with education, economic, p o l i t i c a l , c u l t u r a l , and technica l s ec to r s ; ( i i i ) bureaucra t ic systems which a r e i n e f f i c i e n t and ( i v ) c u l t u r a l customs and t r a d i t i o n s which may i n t e r f e r e with hea l t h behaviour changes.

WHO-EM/MENT/B 11 page 12

5 . REVIEW OF SPECIFIC INTERVENTIONS AND IDENTIFICATION OF RESEARCH PROPOSALS

The meeting considered v a r i o u s possible behavioural s c i e n c e i n t e r v e n t i o n s w h i c h c a n be moulded into specific research proposals. It was agreed that, wherever possible, such research p r o p o s a l s should involve mare than one country a d should be helpful in developing appropriate research methods for local use. The meeting reaffirmed the following criteria for selection of a research proj ect :

(a) The research problem is clearly defined.

(b) Lack of knowledge on the .topic is the main obstacle to programme delivery.

(c) The topic is suitable for collaborative effort (and for international collaboration) .

(d ) Research is likely to produce results in the short- and medium-term perspectives.

(e) The investigation will ~ u p p n r t grnwrh nf expertise and development of manpower.

( f ) The project allows productive collaboration between the researchers and Chose w h o will apply results, both in the conduct of research and i n the implementation of findings.

The fa1 l,nwing two mule <centric proposals were rec-ended for urgent implementation:

5.1. Psychosocial skills for improving effectiveness of PHC workers

M present most of the PHC staff in developing countries lack both the knowledge of behavioural sciences and the psychosociaL skills needed to deal with a multitude of health problems. It is believed t h a t i E PBC workers acquire certain tginimum psychosocial skills their performance will improve. These psychosocial skills would i n c l u d e ability to: (i) communicate better (e.g. by careful listening; by developing warmth, trust and non- judgemental attitudes); (iif assess health problems in a holistic and psycho- social way (not concentrating only on disease or symptoms); (iii) provide counselling and motional support when required; (iv) acquire cultural sen- s i e i v i t y to local needs, etc. T h e research proposal essentially consists of providing such trainiq in s h o r r courses, followed by a period of in-service supervision and consultarion. The results of such training would be measured by various parameters of work satisfaction, acceptability by the community, effects in programmes ( e . g . increase in imnization, reduction in cases of diarrhoea, etc.). Following a pilot phase demonstrating the feasibility of the project, the study would be conducted on an experimental and a control group.

WHO-EM/MENT/~ 11 page 13

5 .2 . ~sychosomat ic symptoms and psychosocial problems i n PHC se rv i ce s

I t 1s estlrnated t h a t a t l e a s t 15-LUX ot persons attending PHC t a c i L l t l e s and general ca re serv ices do n o t have s ign i f i can t physical pathology, although they present with mul t ip le somatic complaints. Such complaints a r e genera l ly regarded as mntinnnl in nriein, a t t r i b ~ ~ t a h l e to s t r e s s i n the p s y r h n s o r i a l environment. The study aims a t ident i fy ing these types of d i sorder and deveLoping in te rvent ion methods f o r deal ing with them. The l a t t e r w i l l include recognit ion of psychosocial elements i n the h i s to ry of the pa t ien t and use of s u p p o r t i v e techniques t o r management.

5 . 3 . Other research proposals

In addit ion t o t h e mu l t i cen t r i c p ro j ec t s , the following addi t iona l research proposals were recommended:

- Epidemiology of i n j u r y i n young chi ldren. - Psychosocialdimensionof r u r a l s an i t a t i on . - Effect iveness of medical education i n l oca l languages. - A rmparisnn nf ~ r l ~ i r a t i nn/l~gi c7a t i nn apprnarhms fnr rhanging

behaviour toward e s s e n t i a l drugs. - Effect iveness of problem-oriented medical education for PHC. - Influence of family counse l l ing on PHC work. - Survey of teaching and research i n behavioural sclences i n t he

hea l t h f i e l d i n t he E a s t e r n Mediterranean Region.

6 . P W S FOR STRENGTHENING BEHAVLOURAL SCIENCE RESEARCH AND TRAINING I N THE EASTERN MEDITERRANEAN REGION AND LINKING THESE WITH HEALTH SYSTEM DEVELOPMENT IN MEMBER STATES

As sec t ion 4 .2 . of t h e present r epo r t i nd i ca t e s , there a r e inany problems f ac ing the development and strengthening of behavioural sc ience research and t r a in ing i n t h e Eastern Mediterran@on R ~ g i a o . The present meeting gave

s p e c i f i c a t t e n t i o n t o t h e ques t ion of behavioural science research and t r a in ing resources i n t h e Region and t h e s t eps necessary for t h e i r e f f e c t i v e applica- t i on t o the problems of PHC.

It was pointed our t h a t cu r r en t resources a r e d i s t r i b u t e d across a v a r i e t y of s e t t i n g s and i n s t i t u t i o n s including u n i v e r s i t i e s , medical schools , research i n s t i t ~ i t ~ s , health ministry r e s ~ a r r h m i t s and natinnal health counci 1 s. This d ispers ion has led t o poor communication, dupl ica t ion of e f f o r t , l imi ted funding and lack of coordinat ion. Frequently, the resources which are ava i l ab l e have f a i l e d t o develop any sus ta ined i n t e r e s t i n hea l th problems. As a r e s u l t , re levant t r a in lng c u r r i c u l a and ma te r r a l s a r e v i r t u a l l y absent .

The d i scuss ion emphasized t h a t i t w i l l be necessary to develop resources i n hehsr~?invrrsrl s c i e n c e training and r Q s ~ a r r h by a coordinated program4 w h i c h must include: (i) increased communication among behavioural sciences educators and hea l th serv ices planners and p r a c t i t i o n e r s ; ( i i ) e d u c a t i o n and s e n s i t i ~ i n ~

WHO-EM/MENT/~ 11 page 14

of s e n i o r hea l t h services and p o l i c y o f f i c i a l s regarding the p o t e n t i a l con t r ibu- tions a£ behavioural s c i e n c e s t o h e a l t h programmes, p a r t i c u l a r l y by o r i e n r i n g these officials t o new advances in bchavioural science knowledge and technology: ( i i i ) the development of behavioural sc iences c u r r i c u l a and t r a i n i n g m a t e r i a l s ; and ( i v ) t h e f u r t h e r t r a i n i n g of behavioural s c i e n t i s t s w i t h h e a l t h in teres ts . A number of s p e c i f i c a c t i o n s were proposed t o implement t h e s e sugges t ions . T k s e are reflected i n the reconanendations and include the s t r u c t u r i n g of workshops, t h e t r a i n i n g of r e s e a r c h f e l l o w s , t h e i n i t i a t i o n of behavioural science r e s e a r c h , and t h e p r e p a r a t i o n of educa t iona l o b j e c t i v e s and region- sprciri4 o ~ a t e r i a l s .

7.1. In view o f t h e demonstrated importance of human k h a v i o u r i n t h e a e ~ i o l o g y , concco l and preven t ion of human d i s e a s e and t h e promotion of human health, it is cr i t i ca l that. appropriate bch~vioural science ZEnowZsrXge and r ~ h n o l o g y be immediately appl ied ta t h e h e a l t h serv ices of d e v e l o p k g countries.

7.2. Appropria te k h a v i o u r a l sc ience knowl4g.e and technology should be coweyed t o health service pol icy-makers , planners and p r o f e s s i o n a l health workers and laymen through t h e development o f new r e s e a r c h and training programmes and the strengthening of existing ones,

7 . 3 . E x i s t i n g c o o r d i n a t i o n and c o l l a b o r a t i o n between t h e +XI Mental Heal th Programe, which has r e s p o n s i b i l i t y f o r promoting behavioural s c i e n c e s , snd other WttO prcrgrarsnes and u n i t s should be c m c i n u e d and expanded.

7.4. WHO should continue to a s s i s t i n promoting c o l % a b o t a t i o n i n t h e behavioural sciences bctwccn univcroirics, rcacarrh ccncrec , and health m i n i s c r i e s .

8.1. Advocacy

8.1.1. inEotm r e g i o n a l countries of p o s s i b l e a p p l i c a t i o n s of the behavioural scie-s to heal th s e r v i c e s through t h e use of c o n s u l t a t i o n v i s i t s , n a t i o n a l m d r e g i o n a l workshops, and t h e d i s t r i b u t i o n of r e l e v a n t m a t e r i a l s ,

8.1.2. Prepare atKi d i s ~ r i b u t e a p p r o p r i a t e behavioural science b i b l i o g r a p h i e s and research and training m a t e r i a l s t o resea rch and t r a i n i n g i n s t i t u t i o n s i n chc Rcgion.

8.1.3. organize tm n ~ i o n a l workshops dur ing t h e nex t two years (1986/87) t o bring t o g e t h e r biomedical and behavioural s c i e n t i s t s t o exchange views on areas oE canrnon i n t e r e s t and t o develop n a t i o n a l p l ans f o r c o l l a b o r a t i o n in resea rch and t r a i n i n g i n t h e application of behavioural sc iences f o r t h e improvement of h e a l t h s e r v i c e s .

WHO-EM/MENT/III page 15

8 . 2 . I n f r a s t r u c t u r e

8.2.1. Tdentify centres and individuals who can collaborate in the developmcnt and expansion of programnes f o r t h e app l i ca t i on of behavioural sciences t o hea l t h s e rv i ce s i n t he Eastern Mediterranean Region.

8.Z.Z. Strengthen se lec ted cen t r e s by exchange v i s i t s , fe l lowships programmes and f i n a n c i a l support f o r research , t r a i n i n g , suppl ies and equipment.

R.3. Training

8.3.1. I d e n t i f y one or more i n s t i t u t i o n s i n t he Eastern Mediterranean Region t o func t ion as f o c a l c en t r e s f o r t h e promotion and improvement of behavioural sciences f o r h e a l t h personnel including t r a i n i n g , curriculum development, and t h e design and production of ma te r i a l s .

8 . 3 . 2 . Assemble three working groups in 1986/87 to develop instructional and organiza t iona l ob j ec t i ve s f o r t h e teaching of behavioural sciences t o medical students, nurses and s a n i t a t i o n professionals. Each working group should f u r t h e r design eva lua t ion s t r a t e g i e s t o a s se s s t h e achievement of these obj e c t ives . 8 . 3 . 3 . The EMRO clear inghouse should review t h e ava i l ab l e i n s t r u c t i o n a l mqter ial f o r the behavioural sc iences i n indigenous languages and take urgent s t eps t o develop appropr ia te t r a i n i n g m a t e r i a l i n behavioural sc iences f o r d i f f e r e n t ca tegor ies of hea l t h personnel.

8 . 4 . Research

8.4.1. WHO should provide t h e f i n a n c i a l and t echn i ca l support t o implement t he m a j o r research prnpnsaln d~velnpnd at this m e e ~ i n g , particularly those which have a rnu l t icen t r ic co l l abo ra t i ve design.

8 . 4 . 2 . To enhance t h e research p o t e n t i a l and s k i l l s of behavioural s c i e n t i s t s id t he Region, WHO should organize a workshop during t h e next two years t o provide t r a i n i n g i n behavioural sc ience research . WHO should f u r t h e r co l labora te with s e l ec t ed u n i v e r s i t i e s and o the r cen t r e s t o organize s imi l a r t r a i n i n g work- shops a t national level. S u i t a h l P yniing h*h~v io t i ra l scientists should also be provided fel lowships f o r advanced t r a i n i n g i n behavioural science research.

8.5. Fur ther p rog rame development

8.5.1. A s i m i l a r consul ta t ion meeting should be convened i n about two years ' time t o review the progress achieved i n t h i s f i e l d and t o suggest new avenues f o r f u t u r e development.

8.5.2. I n order t o provide add i t i ona l impetus and t echn i ca l input i n t o t h i s programme a r e a , it i s recommended t h a t t h e s e rv i ce s of consul tan ts f o r s i x t o nine months be provided f o r t h i s progrannne, s t a r t i n g from 1986.

WHO-EM/MENT/ 11 1 page 17

ANNEX I

AGENDA

Inauguration of thc mccting

Elec t ions of o f f i c e r s

Adoption of the Agenda

Review of r e c e n t developments i n t h e a p p l i c a t i o n of behavioural sc iences t o h e a l t h gcrviccs programmes relevant to developing countries.

Relevance of behavioural s c i e n c e s t o s p e c i f i c WHO programmes

Global view

Environmental h e a l t h

Disease prevent ion

N u t r i t i o n

Occupational h e a l t h

Maternal and c h i l d h e a l t h

E s s e n t i a l drugs

Health manpower development

Other programmes

Review of some s p e c i f i c t op i c s t o i d e n t i f y behaviuur-re la ted i n t e r v e n t i o n s t o improve the q u a l i t y of h e a l t h s e r v i c e s

6.1 Training in behavioural sciellces f o r general physicians and paramedical s t a f f

6.2 Psychosocial f a c t o r s i n c h i l d development

6.3 Role of family and s o c i a l network i n h e a l t h

6.4 L i f e - s t y l e , h e a l t h and i l l n e s s

6.5 Other areas

Development of o u t l i n e s of p r o j e c t p roposa l s r e l a t e d t o some of t h e i d e n t i f i e d i n t e r v e n t i o n s

Review of research f a c i l i t i e s and s ign i f i can t research i n behav ioura l sc iences i n the Eastern Mediterranean Region

Plans f o r s t r e n g t h e n i n g of behavioural s c i e n c e research i n t h e Eastern Mediter- ranean Region and l i n k i n g i t with h e a l t h system development i n Member S t a t e s

C o n s i d o r a ~ i o n and adopt ion of t h e d r a f t r e p o r t

Conclusions and recommendations.

EGYPT

PAKISTAN

ANNEX 11

L I S T OF PARTICIPANTS

WHO TEMPORARY ADVISERS

Dr W.A. Rassouna President S I N A I H e a l ~ 1 1 S y s t e r u s Curlsultation Group Dokki Cairo EGYPT

Dean Faculty of Medicine Suez Canal Universi ty

Professor of Psychiatry A l Azhar U n i v e r s i t y Cairo EGYPT

* P r o f . 0 . 3 l b r l n Faculty 06 Education University of Jordan

Prof. Waroon Ahmed Associate P r o f e s s o r of Psychiatry Jinnah Postgraduate Medical Centre Kararh i PAKISTAN

* d i d n o t artend

WHO-EM/MENT/~~~ page 19

TUNISIA

YEMEN

* D r Tigani Adem Hamad Lecturer i n Medicine (Psychiatry) Facul t y of Medicine Universi ty o f Gezira Wad ~ e d a n i SUDAN

Dr E. J e d d i Univ~rsi ty C l i n t c of Psychiatry Tunis - . TUN IS I A

Dr Abdo A . Othman Department of Sociology University of Yemn

OBSERVERS

Dr Nadia A . Taher Senior Researcher S INAI Hea l th Systems Consultat ion Group Dokki Cairo EGYPT

WHO SECRETARIAT

D r H.A. Gezairy Regional Di rec tor

D r A. Khogal i Di rec tor , Programme Management

D r J , Hashmi Di rec tor , Health P ro t ec t i on and Promotion

D r N . Sartorius Direc to r , Mental Health Division

D r N.N. Wig Regional Adviser on Mental Health and Secretary of the Meeting

WHO Eastern Mediterranean Regional Off ice

WHO Eastern Mediterranean Regional Of £ice

WHO Eastern Mediterranean Regional Off ice

WHO Headqusr tcrs

WHO Eastern Mediterranean Regional Off ice

;S d i d no t a t t end

WHO-EM/MENT/~I~ p a g e 2 0

D r D . R . B i l l i n g t o n Regional Adv i se r , WHO Eastern Med i t e r r anean Educa t iona l Development Regional O f f i c e and S u p p o r t

Dn: A. Nadim Regional Adv i se r , Research WHO Eas t e rn Medi ter ranean Promo t i o n and Development Regional Uftice

Prof. A . Marsella WHO Consu l t an t

Conference Officer

S e c r e t a r y

Director, WHO P s y c h i a t r i c Research C e n t e r . The C)tleenl Medical Center, HonoL.ulu, Hawaii

WHO Eas t e rn Medi ter ranean Regional Off ice

WHO Eastern Mediterranean Regional O f f i ce

WHO-EM/MENT/ 111 page 21

ANNEX 111

LLST OF BASIC DOCUMENTS

Programme

List of p a r t i c i p a n t s

Some a p p l i c a t i o n s of t h e behav ioura l s c i e n c e s t n h e a l t h care and services in developing c o u n t r i e s . P a r t I: Terms of r e f e r e n c e , conceptionaf/rnethodologicaL i s s u e s and theo- r e t i c a l foundat ions (A. J. Marse l l a , N.H. Higginbo tham)

Some a p p l i c a t i o n s of t h e behav ioura l s c i e n c e s t o health care and services in developing c o u n t r i e s . P a r t 11: Assumptions, p r a c t i c a l c o n s i d e r a t i o n s and a p p l i c a t i o n s (A . J . Marsel la)

Suggested resource m a t e r i a l s f o r a p p l i c a t i o n o f the behav ioura l sciences t o hea l th care and serv ices i n developing c o u n t r i e s (A. J. Marsel la , N.H. Higginbotham, L.H. Connor)

Relevance of behavioural s c i e n c e s t o the WHO programme i n h e a l t h manpower development (R. B i l l i n g t o n )

P r o j e c t t o implement an i n t e g r a t i o n of f i e l d work, educational research and h e a l t h service func t ions i n the combined teach ing and commu- n i t y and behav ioura l s c i e n c e s (M. Shaalan)

From symbiosis t o i n d i v i d u a t i o n : the bod i ly i n t e r f a c e between b i o l o g i c a l and c u l t u r a l - symbolic o r g a n i z e r s ( E . J e d d i )

L i f e - s t y l e , h e a l t h and i l l n e s s (H. Ahmed)

Review of r e s e a r c h f a c i l i t i e s and s i g n i f i c a n t r e s e a r c h i n behav ioura l s c i e n c e s i n t h e Eastern Mediterranean Region (W.A. Hassouna)

Teaching and rcccarch nctivitics in bchavioural s c i e n c e s i n Suez Canal Univers i ty (I. I z z a t ) .