Changing of Maternal Health behaviour through Health Belief Model of health communication in context...

Changing of Maternal Health behaviour through Health Belief Model of health communication in context of Bangladesh

By

Rahul Kumar Sanjowal

Content

Concepts Pages

Abstract 01

Introduction 02

Objectives 02

Understanding about Reproductive Health 03

Understanding about Maternal Health 03

Understanding about Health Belief Model 03

Understanding about Behaviour Change Communication 04

Changing of Maternal Health Behaviour through HBM and Behaviour Change Communication

04

Perceived Susceptibility 05

Perceived Severity 08

Perceived benefits 10

Perceived barriers 12

Cue to action 12

Self-efficacy 13

Concluding Remarks 13

References 14

Abstract:

The following change of maternal behaviour through Bangladesh condition. Observing the

maternal health through the health belief model, it could be say that, the individuals’ health

behaviour changes through the perceived beliefs. Individuals and peoples are getting their

susceptibility or perceptions about risk and level of risks. Individuals also aware about their

consequences of risky behaviour by their circumstances or known by behaviour change

communication process. Individuals perceived that, their acts of maternal health is in

susceptible condition and it results worse; then people intend to take actions to change their

behaviour toward maternal health. Individuals also considered the benefits of behaviour

change or taking action more valuable than the expenditure of taking action or change

behaviour.

The BCC helps to continuing the expose people to behaviour change and these all behaviour

change would not be possible without self-efficacy. Which refers the one’s confidence and

ability to change behaviour.

Introduction:

Population is a result of behaviour. Human population does not mentioned only numbers of

people rather, it refers to human conditions about society, culture, tradition, economic status,

health status etcetera. All of these, health is an important issue of human population and it

determined by various factors of group of people or a society. Health behaviour is a vital

issue of a population health. Health behaviour integrated the attitudes, beliefs, cultures,

perceptions and practices about their health.

In this paper, we are going to illustrate the maternal health behaviour of Bangladesh. If we

observe the trend and scenario of maternal heath of Bangladesh. We could see that, the

maternal health has promoted in recent years. The maternal mortality ratio has been

declining, the women are being conscious about their own health at the pregnancy period.

The maternal as well as child mortality rate has also declined for various health care action

such as; antenatal care, vaccination, iron toxicity, safe delivery, postpartum care for both

mother and child etcetera. These all are the matter of practicing health behaviour and we

could see the health behaviour through a theory, the theory of health belief model (HBM).

There has also a curiosity, that, why people motivated and change their behaviour or health

behaviour. Then the topic has come, that the health behaviour or people’s behaviour

influenced by their society, community, peers or circumstances then people or individuals are

motivated to change their behaviour. Peoples or individuals are also influenced by

organizations and mass media communication. These all are refer in one word which is BCC

or behaviour change communication. We also see the changing of maternal health behaviour

through behaviour change communication (BCC).

Objectives:

This paper’s objectives are as following;

1. Illustrate the changing of Maternal Health behaviour through Health Belief Model

(HBM) in context of Bangladesh.

2. Address the Behaviour Change Communication on maternal health of Bangladesh.

Understanding and Reproductive and Maternal Health:

Reproductive health: Reproductive health refers, the reproductive processes, functions and system at all stages of life.

Reproductive health relates to the maintenance of one's reproductive health system and

fertility. It includes a broad range of topics such as birth control, sexually transmitted

infections, ability to become pregnant and infertility. Reproductive health depends on many

factors such as age, lifestyle, and overall health. According to UNFPA, reproductive health

illustrated about; men and women’s access to safe sex, effective, affordable and acceptable

methods of birth control. Also added that, women go safely

through pregnancy and childbirth could provide couples with the best chance of having a

healthy child.

Maternal Health: Maternal health is the health of women during pregnancy, childbirth, and

the postpartum period. It encompasses the health care dimensions of family

planning, preconception, prenatal, and postnatal care in order to reduce maternal morbidity

and mortality.

Now, our concern about maternal health of Bangladesh which has come from the broad topic

reproductive health. We will see how people perceive their beliefs on maternal health through

the health belief model. But, we have to know about health belief model. Which is given

below.

Understanding about Health Belief Model & Behaviour Change Communication:

The Health Belief Model (HBM) is the prior theory of all the theories. It was originally

conceived by social psychologists in the public health arena of United States, in 1950s. It is

an individual level theory, the likelihood that someone will take action to prevent illness

depends upon the individual's perception that:

They are personally vulnerable to the condition;

The consequences of the condition would be serious;

The precautionary behaviour effectively prevents the condition; and

The benefits of reducing the threat of the condition exceed the costs of taking

action.

The health belief model has also contains six constructs:

1. Perceived Susceptibility: One’s evaluation of chances of getting a condition.

2. Perceived Severity: One’s evaluation of how serious a condition, its treatment, and its consequences would be

3. Perceived Benefits: One’s evaluation of how well an advised action will reduce risk or moderate the impact of the condition.

4. Perceived Barriers: One’s evaluation of how difficult an advised action will be or how much it will cost, both psychologically and otherwise.

5. Cues to Action: Events or strategies that increase one’s motivation.

6. Self-efficacy: Confidence in one’s ability to take action.

According to James O. Prochaska and Wayne F. Velicer the model's four key components are conceptualized as perceived: 1) susceptibility, 2) severity, 3) effectiveness, and 4) cost(20003, Special Issue: 180-193, The International Electronic Journal of Health Education)

Behaviour Change Communication: According to Disease Control and Prevention (CDC)

health communication as “the study and use of communication strategies to inform and

influence individual and community decisions that enhance health” Behaviour Change

Communication (BCC) is a process that motivates people to adopt and sustain healthy

behaviour and lifestyles. Sustaining healthy behaviour usually requires a continuing

investment in BCC as part of an overall health program. In this stage of this paper, I tried to

explain the change of maternal health behaviour of Bangladesh through Health Belief Model

(HBM) within the concept of Behaviour change communication. The explanation has given

below.

Changing of Maternal Health Behaviour through HBM and Behaviour Change

Communication:

Behaviour change is a process not a product. If we observe the maternal health condition in

the recent years of Bangladesh. We could see that, the maternal health condition of

Bangladesh has improved in last recent years. The maternal mortality ratio has decreased, the

antenatal care has been increasing, the safe and attendance with trained provider delivery has

been increasing day by day. But, these all are the result of practicing health behaviour. The

following figure addressing the trends of maternal health service.

Figure 01: Utilization of Maternal Health Services, 2004 – 2011.

Source: Bangladesh Demographic and Health Survey; 2004, 2007, 2011.

To see this figure we could sure that people accept the maternal health service more than past

and increasing day by day. As well as the maternal health of Bangladesh promoted for change

these behaviour. Now, a question has arisen generally, why and how people changing their

maternal health behaviour to promote maternal health condition in Bangladesh. Numerous

attempts have been made to develop explanatory frameworks for understanding health

behaviour. I have tried to get the answers as following to use health belief model (HBM)

through the behaviour change communication.

1. Perceived Susceptibility: Perceived susceptibility refers to the probability that an

individual assigns to personal vulnerability in developing the condition. It refers, what

individuals know about their risks of maternal health and level of known. In Bangladesh,

individuals or peoples may conceive their risks of maternal health as followings.

1.1 Adolescence motherhood or early marriage: Bangladesh has one of the world's highest

rates of adolescent motherhood, based on the proportion of women under the age of 20 giving

birth every year. 28% of adolescent women (age 15-19) are already mothers with at least one

child and another 5 % is pregnant (UNICEF, 2009;Maternal and Neonatal Health in Bangladesh). The number of deaths

among adolescent mothers is double the national average. Individuals or people get concepts

about adolescence or early marriage from their peers, local health care provider, NGO

workers or from mass-media advertisement. People may get the concept about adolescence

pregnancy from community clinic or health complex. The all things by which people or

individuals get concepts about considered as communication and then people perceived them

at risk level. The following figure mentioned the adolescent marriage in Bangladesh.

17 16 1622 21 20

2632

27

05

101520253035

ANC At least 4 Visits Delivery attended by a medically trained provider

PNC for mothers within 2 days of delivery from a medically

trained provider

Utilization of Maternal Health Services, 2004-2011

BDHS 04 BDHS 07 BDHS 11

Figure 02: Female Median Age at Marriage of Bangladesh

Source: Bangladesh Demographic and Health Survey

It evident from this figure that, the average age of marriage in Bangladesh was 15.9 years in

the recent year 2011. Which indicates the poor maternal health status of Bangladesh. Because

of, 15.9 years is involved in adolescent marriage and it directed at risks about pregnancy of

mothers as well as risks of infants for insufficient physical condition of mother.

1.2 Unconscious about vaccination and iron pill

tetanus vaccine for mother to prevent infant from tetanus also prevent from

mother child. People can know about this vaccine or iron tablet from local health care

provider, NGO workers and peers. He or she also can know about their risk if they did not

taken these things.

1.3 Unaware about Antenatal care:

important to monitor the status of a pregnancy and

the pregnancy. If we see the antenatal care service rate in recent decade of Bangladesh we

can see that a little number of people get ANC service. But the scenario has changed; people

get knowledge about antenatal care service during pregnancy by communicate with peers,

health worker, get by mass-media. People also get their risk level by these communication.

1.4 Malnutrition: Malnutrition is a great threat of maternal health. People or individuals can

knew about the malnutrition and its harmful effects on mother as well as infant, via behaviour

change communication. Then people perceived about their susceptibility of mal

they perceive their level of susceptibility.

1.5 Insufficient birth intervention:

child health. Insufficient gap between or among birth can call many risk appraisals for

mothers health. Now a days, many Govt. and NGOs are working about this policy, they

trying to know the people abou

14.213

13.514

14.515

15.516

16.5

1997 2000

Female Median Age at Marriage of Bangladesh

Bangladesh Demographic and Health Survey; 1997,2000,2004,2007, 2011.

that, the average age of marriage in Bangladesh was 15.9 years in



hers as well as risks of infants for insufficient physical condition of mother.

Unconscious about vaccination and iron pill: It is very important to take iron tablet and

tetanus vaccine for mother to prevent infant from tetanus also prevent from anaemia for both

child. People can know about this vaccine or iron tablet from local health care


1.3 Unaware about Antenatal care: Antenatal care from a medically trained provider is

r the status of a pregnancy and identify the complications associated with

. If we see the antenatal care service rate in recent decade of Bangladesh we

r of people get ANC service. But the scenario has changed; people


media. People also get their risk level by these communication.

Malnutrition is a great threat of maternal health. People or individuals can


change communication. Then people perceived about their susceptibility of mal

they perceive their level of susceptibility.

birth intervention: Birth intervention is necessary for both maternal and



trying to know the people about the matter. As a result individuals or peoples are getting

15 14.8 15.315.9

2000 2004 2007 2011

Average age at marriage

Average age at marriage

that, the average age of marriage in Bangladesh was 15.9 years in



It is very important to take iron tablet and

anaemia for both

child. People can know about this vaccine or iron tablet from local health care


l care from a medically trained provider is

identify the complications associated with

. If we see the antenatal care service rate in recent decade of Bangladesh we

r of people get ANC service. But the scenario has changed; people


media. People also get their risk level by these communication.

Malnutrition is a great threat of maternal health. People or individuals can


change communication. Then people perceived about their susceptibility of malnutrition and

Birth intervention is necessary for both maternal and



t the matter. As a result individuals or peoples are getting

15.9

2011

about the concept of birth intervention. As well as they can observe their condition and know

about their figure of risk.

1.6 Unaware about Safe delivery: Rest of the pregnancy period; safe delivery is an

important issue or process for both infant and maternal health. People or individuals

perceived their beliefs that, if the delivery would unprepared, it would be a risky factor for

mother and child. The unprepared delivery refers the unprepared about money, transportation

to clinic or hospitals, unaware about blood which may need for mother, not to inform a

trained health care provider.

People or individuals has perceived their beliefs, by their communities peers, health workers,

and advertisement of any behaviour change policies of Govt. or NGOs and they perceived the

unsafe delivery as a risky factor for maternal as well as child health. Not only that, the

unhygienic kits or tools for delivery and cord cutting also fall down at risk the mother and

child.

The following issues have discussed about perceived susceptibility. People or individuals of

Bangladesh perceived these as risky factors for maternal health. The implicated behaviour

change communication policies of govt. and NGOs help to know about the risky factors of

maternal health to the peoples of Bangladesh. People knew the risky factors by discussing

with their friends, relatives, family members. People or individuals also informed by local

health worker, electric or printing media advertisement, doctors and found them or own-self

at the risk and figure out their level of risk.

The health belief model and each theories and models contain their three key concepts.

1. Behaviour motivated by cognitions. What people know and think affect behaviour.

2. Knowledge is necessary for behaviour change.

3. Behaviour influenced by people’s perceptions, motivation, skills and social

environment.

If we see the maternal health through the HBM; at this level, people has got the risk

appraisals by BCC and it influence their thinking which affect the direction that what they act

or they perceived about their risk maternal health behaviour.

2. Perceived Severity: Perceived severity refers to how serious the individual believes the

consequences of developing the condition are. An individual is more likely to take action to

prevent risks of maternal health if she or he believes that possible negative physical,

psychological, and social effects resulting from developing the disease pose serious

consequences. According to health belief model, the severity of the maternal health of

Bangladesh has given below.

2.1 Anaemia: Anaemia is a condition in which the red blood corpuscles contain too little

haemoglobin, the iron-containing red pigment that carries oxygen from the lungs to all tissues

in the body. A mother who is iron deficient during her pregnancy has a greater risk of dying

during childbirth and of having a small baby. Anaemia, a serious and harmful diseases for

both mother and child, especially for mother. If a women conceive and not take the iron pills

properly she could fall in anaemia during pregnancy or postpartum period. As well as the

fetus or child could be fall in the shorten of blood.

2.2 Tetanus: By know the risk appraisal in the stage of perceived susceptibility individuals

are concern about the harmful results of the risks and tetanus is one of them. It is a harmful

disease for both mother and child. People or individuals perceived belief that, if mother do

not take the vaccine of tetanus and not used the hygienic delivery kits for cord cutting; then

there have a serious probability for mother and infant to dying in tetanus. If the fetus harmed

by tetanus the pregnant mother fallen in a dangerous health complexity.

2.3 Bleeding during delivery: In Bangladesh, over bleeding is a common problem of mother

health during delivery time. Individuals or women perceived their beliefs that, if the proper

readiness or preparation was not taken before the delivery time or not to manage a person

who donate blood for mother if the mother faces bleeding. Then mother can fall on death for

over bleeding. Adolescence mothers are faced the problem with a big number. The

traditional DAIs are also responsible for bleeding of mother. So, individuals perceived that, if

the trained health worker do not attend during delivery it would be dangerous for mother as

well as infant.

2.4 Underweight: Underweight during pregnancy and postpartum period is very harmful for

maternal health. By health workers, peers and other communities of individuals, individuals

or peoples know about that, the insufficient nutrition is consequences the underweight.

Pregnant with a little age adolescence pregnancy also causes the underweight of mother.

Mainly in Bangladesh; based on the proportion of women under the age of 20 giving birth

every year. 28% of adolescent women are already mothers with at least one child and another

5 % is pregnant (UNICEF, 2009;Maternal and Neonatal Health in Bangladesh). So that, the adolescence marriage and

motherhood causes a big threat of underweight in the maternal health of Bangladesh.

2.5 Maternal death: According to United Nations, maternal death is the death of a woman

who is pregnant or within 42 days of the end of her pregnancy, irrespective of the duration

and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its

management. There has a figure to addresses the mortality causes of women in Bangladesh

and it show that 14% of death caused by maternal reasons. And the occurrences of maternal

death

Table 01: Distribution of causes of deaths among women of reproductive age (15-49 years),

Bangladesh 2010.

Causes of Death Death Rate

Maternal 14%

Infection 9%

Cancers 21%

Circulatory Disease 16%

Injury 6%

Obstructed Labour 16%

Urinal Diseases 9%

Undetermined 9%

Source: Bangladesh Maternal Mortality Survey, 2010.

by the reasons of adolescence marriage and pregnancy, insufficient birth intervention,

malnutrition, unaware about vaccinations many mothers are fallen to death in Bangladesh.

Though people believe or perceived that, the ratio of maternal death are reducing day by day

in Bangladesh. The reasons behind the maternal mortality cannot be removed easily.

Maternal death is a final and worse consequences of not taking vaccination, antenatal care,

and unpreparedness of birth. People or individuals perceived their beliefs that, the risk

appraisals which are contain with them are harmful for their maternal health. They also

perceived by perceived severity that, their maternal health behaviour have many serious or

severe consequences, which can reach a mother till death as well as an infant.

Figure 03: Pregnancy Related Maternal Mortality

Source: BMMS Preliminary Result 2010.

According to the health belief model, the individuals perceived their cognitions about the

risky factors of the maternal health. Then individuals think to change the maternal health

behaviour. The behaviour change communication or BCC also helps to know about the risky

acts or factors of maternal health. BCC is very helpful to maintains people with right

information and perception about maternal health. Health workers, NGO workers, doctors,

mass-media advertisement, peers etc. directed the individual’s cognitions and perception in a

right way, the BCC is also very helpful to perceived people’s attitude toward maternal health

by reducing superstitions. After that, people or individuals believe that, if they take actions

against the risk factors or change their maternal health behaviour thus they can prevent the

maternal health from the risks as well as their level of susceptibility will reduced.

Now, the individuals think, what will the outcomes if they change their maternal health

behaviour. The health belief model addresses the stage as perceived benefits.

3. Perceived benefits: Perceived benefits refers to the benefits of engaging in the protective

behaviour. Motivation to take action to change a behaviour requires the belief that the

precautionary behaviour effectively prevents the condition. Individuals who are convinced

that there is a causal relationship between adolescence motherhood and maternal health are

likely to quit adolescence marriage because they believe that quitting adolescence marriage

will promote maternal health. The explanation with HBM and BCC with maternal health has

given below.

3.1 Reduce maternal & Child mortality: People or individuals perceived that, the maternal

susceptibility will results the severe or serious harmful effects on maternal health of

Bangladesh. Which also can be death of a mother. But if we look at the maternal services

71 36 21635 18 1420

50

100

150

200

250

During Pregnancy During Delivery Post Purtum

2001

2010

which get people and apply these and results the declined ratio of maternal mortality. The

maternal

Figure 04 : Maternal Mortality Ratio in Bangladesh

Sources: Bangladesh Maternal Mortality Survey 2010, BBS, 2011.

mortality ratio in 1990 was 5.74 and it reduced at 1.94 in the year 2010 (Bangladesh Maternal

Mortality Survey 2010) and this is the benefit of following behaviour change actions. Reduced

adolescent marriage and pregnancy, increase antenatal care, increase of vaccination and iron

pill taking, increase local health workers, increase delivery in service centres, increase the

attendance of

Figure 05: Delivery at Service Centres in Bangladesh

Source: BDHS 2007, 2011.

5.74

3.21.94 1.43

0

2

4

6

8

1990 2001 2010 2015

MMR(Per 1000 LB)

MMR(Per 1000 LB)

4%

12%

17%

29%

32%

0% 10% 20% 30% 40%

1994

2004

2007

2011

2012

Delivery Rate at Service Centers

trained health care provider at delivery time, increase postpartum care. Provide knowledge

about nutrition. Not only that, the actions taken in Bangladesh or change the maternal

behaviour the child mortality rate has declined as well. The neonatal health is closely related

Figure 06: Trends in Child Mortality in Bangladesh

Source: IEM Unit, Director of Family Planning.

with maternal health. Because it couldn’t be ensure the better neonatal health without better

maternal condition, and reason is; the postpartum health include both the serious maternal

and neonatal health and the infant live depend on mother’s breast milk. The following figure

addresses that, the NNMR has declined at 43 in 2011 which was very high in 1994 87. The

following consequences of the behavioural change are considered as the perceived benefits of

maternal health in Bangladesh. The BCC has motivate people to change their attitude toward

accept policies of promote maternal health and change the individuals maternal health

behaviour.Through the HBM, another benefit, “maternal morbidity” of Bangladesh reduced

for promote maternal health.

4. Perceived barriers: Perceived barriers refers to the barriers or losses that interfere with

health behaviour change. The combination of perceived effectiveness and perceived costs

constitute the notion of outcome expectation. Belief alone is not enough to motivate an

individual to act.

The perceived barriers of maternal health of Bangladesh would be, the expenditure of

vaccination, iron tablet, nutritious food for mother, antenatal care, transportation, safe

delivery etc. But, individuals are tend to change their behaviour to promote maternal health.

So that, they considered the proper maternal health is more valuable than the following costs

or doctors’ fees. The behaviour change communication improves people and individuals

consciousness about free services provided by Govt. or a little cost like tetanus vaccine, free

health service at community clinic at rural level etc. Which are also increase the individuals

intend to change the behaviour of maternal health in Bangladesh.

52 48 42 41 37 32

87 8266 65

5243

0

20

40

60

80

100

Neonatal Mortality

Infant Mortality

5. Cue to action: Cues to action involve stimuli that motivate an individual to engage in the

health behaviour. The stimulus that triggers action may be internal or external. This concept

of health belief model refers to help the individuals to continuing exposing on the behaviour

change of maternal health behaviour.

Cues to action on maternal health behaviour would be, provide the reminder calendar to

individuals for visiting doctors for antenatal care at least four time and to take iron pills

properly at the pregnancy period. Posters, mass-media advertisement, magazines about

consciousness of various maternal health behaviours. By these actions, individuals are

minded about the well-fear maternal health behaviour and practice a healthy live to promote

maternal health. Cue to action is very effective to change the people’s health behaviour and it

is not only about maternal health, it could be any health behaviour. Because, cues to action of

HBM directed peoples or individuals in a correct way through the behaviour change.

6. Self-efficacy: Self-efficacy is influenced by mediating variables and in turn influences

expectations. According to health belief model HBM, self –efficacy referred as one’s ability

to played the maternal health behaviour. Individuals must have to confidence to practice the

maternal health behaviour. Individuals have to take vaccines, iron pills, visit doctors at least

four time during pregnancy period with her own responsibility. Women who conceived, have

to concern always about herself and her infant/fetus.

Self-efficacy is an important issue to practicing behaviour, continue the practice then change

health behaviour of maternal health.

These are the following discussion of changing maternal health behaviour through health

belief model.

Concluding remarks: The maternal health situation of Bangladesh has explained thorough

the health belief model and by these following explanation, it could be understood that,

behaviour change communication policy, which implied by government or NGOs effectively

influenced on individuals and people’s behaviour, not only that, it also helps to change

people’s attitude toward maternal and other public health sectors. Bangladesh has promoted

the maternal health situation by reduce maternal death, increase antenatal and postnatal care

etc. But it could be understood that, Bangladesh has a high rated adolescent marriage and

pregnancy. Which is the main barrier to improving maternal health of Bangladesh. It is well

known that, the overall health condition of Bangladesh has improving day by day and

Bangladesh has achieved a MDG award for reducing child mortality. So that, we can expect

easily that, Bangladesh will contain a healthy population with healthy motherhood.

References:

1. Barbara K, Rimer, Glanz K, 2005, U.S. Department of Health and Human Services,

National Institutes of Health, Theory at a Glance; A Guide For Health Promotion

Practice (Second Edition).

2. National Institute of Population Research and Training; Bangladesh Demographic

and Health Survey 1997, 2000, 2004, 2007,2011. Dhaka, Bangladesh.

3. United Nations Children's Fund, 2010, Maternal and Neonatal Health in Bangladesh.

4. World Health Organization, Department of making pregnancy safer, 2010; Bangladesh Country Profile.

5. Bangladesh Bereau of Statistics;2010, Statistic Division, Ministry of Planning, October 2011, Report on Sample Vital Registration System.

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